In an inconspicuous control room at the Sioux Falls, S.D., headquarters of the , nurses keep round-the-clock watch on motion and humidity sensors in the living rooms, bedrooms and bathrooms of elderly men and women in five states.

The seniors — a handful in their own homes and the rest in assisted living facilities owned by Good Samaritan — are part of one of the most comprehensive remote health monitoring efforts anywhere. Using sophisticated sensors, computerized pattern recognition and human responders, Good Samaritan hopes to show it can detect and head off health threats to the elderly and thereby accomplish two important goals. The first is saving money on medical costs. The second is helping seniors feel secure enough to “age in place” at home or avoid moving from assisted living to a skilled nursing facility.

Whether this costly technology will ultimately prove clinically or economically effective remains uncertain. So, too, is whether a benign health care purpose can help overcome the unsettling “Big Brother” overtones for some potential users. What is clear, however, is that health care is joining a national trend toward greater surveillance of everyday life.

For example, more than 70 U.S. cities now use sensors to pick up the sound of gunfire and alert authorities even before 9-1-1 is dialed. Auto insurers are to a car’s computer system to monitor driving habits and, with the driver’s permission, calculate premiums accordingly. Even some farmers are with monitors allowing automated milking systems to track the cow’s milk production, amount of feed eaten and even how long it chews its cud. If the system detects a problem, it can call the farmer on his phone.

What benefits bovines might also help humans, albeit with appropriate modifications. Good Samaritan is the nation’s largest nonprofit provider of senior services, operating more than 240 facilities in 24 states. Working with the University of Minnesota, the system recruited 1,600 seniors in North Dakota, South Dakota, Minnesota, Nebraska and Iowa to test the impact on cost, quality of care and senior independence of a comprehensive set of monitoring tools. With an $8.1 million grant from the Leona M. and Harry B. Helmsley Charitable Trust, the LivingWell@Home study began collecting data at 40 of its assisted living facilities in January 2011, and will stop at the end of June 2013.

LivingWell@Home comprises three technologies. First, sensors from are distributed throughout the living space. (The company stresses that no cameras or microphones are involved.) When a senior is sleeping a motion sensor records how often he or she moves in bed. Showering, toileting and other activities of daily living are also analyzed by WellAware algorithms and scrutinized by nurses for changes that might signal health problems.

The second piece is a medical alert button from that includes an auto-alert function designed to detect a fall and call for help even if the user is incapacitated. Lastly, remote monitoring is provided by the through a clock radio-sized console in each apartment. It turns on each morning and prompts seniors to strap on a special blood pressure cuff, step on a special scale and transmit that and other information back to the monitors in Sioux Falls.

Jacci Nickell, who is Good Samaritan’s vice president of development and operation delivery systems, emphasizes that the technology is just a tool. “Unless you gather, integrate and interpret that data in a meaningful way to the client and to their formal and informal caregivers, a sensor hanging on a wall isn’t going to help anyone,” she says. “It’s what you do with that data, and how you optimize wellbeing.”

Good Samaritan isn’t waiting for the study results to be finalized to roll out the LivingWell@Home service, in which the system has a financial stake, as an option in all its assisted living facilities. It’s also putting parts of the technology into some skilled nursing facilities and even into seniors’ own homes.

The organization’s website tells the story of an elderly woman who agreed to have the sensors installed in the South Dakota farmhouse where she lived alone. Not long afterwards, the sensors detected a change in her toileting that prompted a call from a nurse.ÌýIn response, the woman sought out her doctor, who discovered a bladder infection. “Maybe it was God talking to me,” says 83-year-old Carol Tipton in a , seemingly near tears.

“We think the use of the technology can reduce the need for physical visits and will save expense and time,” Nickell says. Still, the high-tech security blanket doesn’t come cheap. The technology costs $500 to $750 per month per person at home and about $175 a month for residents in Good Samaritan assisted living facilities that already have a personal emergency response button service. By comparison, notes Mary Cain, managing director of consulting firm HC3, conventional disease management costs well under $100 per month per patient.

“It’s a very small percent of the population that’s going to benefit from [the Good Samaritan] level of monitoring,” Cain says. “How many will you monitor, and who is paying?”

A similar cautionary note comes from a spokeswoman for United Healthcare, the nation’s largest health plan. United already covers devices such as those used to detect abnormal heart rhythms or measure blood sugar.Ìý But “health insurers typically rely on guidance from the clinical community in making coverage decisions,” says the spokeswoman, and with sensors and similar technology “it’s too early to do so at this time.”

Privacy also remains a concern. Some critics may detect overtones of a 1983 song by The Police that warns, “Every breath you take, every move you make, we’ll be watching you.” As Christine Sublett, a health privacy and security consultant, put it: “Individuals should have the right to know exactly what information is being transmitted and that appropriate controls are in place.” Good Samaritan says it takes appropriate precautions, but the research study may not provide a rigorous test of protection against hackers. Nor has Good Samaritan or its vendors yet encountered feed, as has happened to makers of defibrillator monitors and similar technologies.

Still, other companies are jumping into this market. For instance, offers a radar beam to provide in-home monitoring of vital signs, activities of daily living and falls. The company suggests its equipment be placed inconspicuously behind a picture frame. And offers to collect data from motion, temperature, door, chair and bed sensors, in addition to pill box sensors for monitoring medication use and caller ID information to keep an eye out for telephone scams.

Choices are also proliferating for consumers willing to pay out of pocket for detailed quantification of their diet, exercise and sleep patterns. In just one example, sells wearable sensors said to gather 5,000 data points a minute on skin temperature, heat flux and galvanic skin response. The company says its aim is to provide users with a personalized assessment of health issues such as stress, fatigue and depression.

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The old axis of access ­in U.S. health care – insured or uninsured – is being replaced by the kind of gradations and complexity in determining who-gets-what-when-for-what-price for which the airline industry has become famous.

Some recent data and reactions to the provisions of the Affordable Care Act reinforce the trend. Here’s an overview:

Millenson

Being able to afford any kind of seat. While the number of Americans left standing at the gate because they can’t afford a health insurance “ticket” is declining, the scheduled takeoff in insurance coverage has run into mechanical difficulties. The Census Bureau announced this month that the number of uninsured dropped slightly in 2011 to 48.6 million, or 15.7 percent of the population. That slide is partly due to a health law provision allowing parents to keep children on their insurance plans until age 26.

But prospects of adding another 30 million Americans starting in 2014 and going forward under the health law’s various mandates and subsidies are now up in the air. The Supreme Court did not ground the entire law, but it did invalidate the penalty designed to compel states to expand Medicaid to many above the federal poverty line. That decision could void tickets to health insurance for an estimated three million people, says the , and possibly a lot more, according to a by two liberal legal experts.

A ticket isn’t the same as a seat. As airline passengers have learned, having a ticket isn’t the same as having a confirmed seat. In 2011, they wouldn’t accept new Medicaid patients because of payment issues; a smaller number of doctors have said the same thing about Medicare patients. Even with some private plans, you may be on permanent standby because the doctor of your choice does not accept your health plan.

Your private jet is ready. Of course, when money is no object, there are those who rate the equivalent of a private jet. That group would include individuals paying for “boutique” services like Guardian 24/7 (whose one-page public simply says, “By Invitation Only”), and . The latter promises “medical research…at your fingertips,” your complete health records instantly available online and “access to outstanding medical and emergency support anytime, anywhere.”

First class, commercial flight. What’s more interesting is what happens behind the curtain separating first class from other travelers on a commercial flight. Seated up front are the senior corporate managers who get “executive” physicals at places like the Mayo Clinic plus reimbursement checks for their out-of-pocket costs. One CEO with a total compensation package of about $9 million received another $23,000 to pay his medical bills, . These executive perks will be stopped by the health law in 2014 if loopholes can’t be found.Ìý

Business class. Unlike Medicaid “recipients,” Medicare ‘beneficiaries’ start off with a generous benefit at a modest price and can easily upgrade. They can choose a Medicare Advantage plan in which the average enrollee received more than $70 in additional benefits and reduced cost-sharing, . In addition, plans provide wrap-around coverage to pay costs traditional Medicare doesn’t. And even middle-class retirees may be able to upgrade to low-end concierge medicine, like .

Also traveling business class are those participants in the fast-dwindling number of health plans provided by unions, or private companies where the worker contribution is minimal and benefits are generous.

Coach, but some people get better seats and prices. Patients with traditional Medicare coverage, , are more likely than those with private health insurance to get needed care, to avoid access problems due to cost, to avoid medical bill problems and to be satisfied with their coverage. Medicare even in access and drug expenditures.

But being a high-wage worker with a good employer-sponsored plan also is a great way to get a good ticket. A new found that workers at businesses with more low-wage employees paid an average of nearly $1,000 more for their share of premiums than workers in a high-wage environment. That may not quite equal a free “executive” physical at the Mayo Clinic, but it’s not bad. (KHN is an editorially independent program of the foundation.)

Overall, workers at small firms face higher cost sharing, including higher copayments and higher deductibles, and may face a greater premium contribution, the KFF survey found. Think of it as a high-cost ticket and maybe a middle seat, to boot. In that same vein, the health overhaul’s ban on insurers using pre-existing condition information to refuse coverage or raise prices doesn’t take effect until 2014, which affects today’s self-employed workers who are older and have families. Those workers can find themselves paying much more than the  under an employer plan.ÌýState plans for high-risk individuals who are otherwise uninsurable typically are high priced and full of restrictions.

Sorry, your flight has been delayed. Of course, even sitting in first class doesn’t mean your flight won’t have mechanical problems or weather delays or a rough landing. Similarly, the most comprehensive insurance is no guarantee of high-quality, safe and appropriate care.

A new ticketing system? For all the inconveniences of the current health insurance system, it is at least familiar. However, both the public and private sectors have plans to shake up the shopping process as has happened in the era of deregulated airlines. It may come through easy-to-compare online shopping for basic health plans when the health law’s coverage mandate takes effect in 2014. It may be the use of vouchers and comparative shopping among insurers for Medicare beneficiaries, as in the Republican Medicare plan proposed by Rep. Paul Ryan, R-Wis., the GOP vice presidential nominee. Or it may be in the increased use of high-deductible health plans by the private sector that put the onus on employees to choose the best care value.

Unlike with airline tickets, however, consumer choices in health care can lead to consequences that truly are non-changeable and non-refundable. Whether the industry turmoil leads to more Americans getting a better “seat” at a better price remains to be seen.

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There is a corner of the health care industry where rancor is rare, the chance to banish illness beckons just a few mouse clicks away and talk revolves around venture deals, not voluminous budget deficits.

Welcome to the realm of Internet-enabled health apps. Politicians and profit-seeking entrepreneurs alike enthuse about the benefits of “liberating data” – the catch-phrase of U.S.ÌýChief Technology Officer Todd Park – to enable it to move from government databases to consumer-friendly uses. The potential for better information to promote better care is clear. The question that remains unanswered, however, is what role these consumer applications can play in prompting fundamental health system change.

, a physician, attorney and senior program officer at the Robert Wood Johnson Foundation, is optimistic. “We think that by harnessing this data and getting it into the hands of developers, entrepreneurs, established businesses, consumers and academia, we will unleash tremendous creativity,” Painter said. “The result will be improved and more cost efficient care, more engaged patients and discoveries that can help drive the next generation of care.”

The foundation is backing up that belief with an open checkbook. RWJF recently to , a multi-functional symptom checker for web and mobile platforms. Developed by two Johns Hopkins University medical students, the app determines a possible diagnosis far more precisely than is possible by just typing in symptoms as a list of words to be searched by “.” Symcat also links to quality information on different providers and can even direct users to nearby emergency care and provide an estimate of the cost.

Symcat received its check in early June at the , an event where the  upbeat tone was reflected in its official nickname, Datapalooza. Sponsored by the Department of Health and Human Services and the Institute of Medicine, the first such meeting in 2010 fit into a cozy auditorium. This year’s gathering drew nearly 1,500 attendees to the Washington Convention Center to discuss how consumer-friendly data could disrupt old ways of delivering health care information.

The federal government plays multiple roles in that effort as convener, innovator, cheerleader and facilitator, the latter through an aggressive program to open up data to the private sector. Symcat, for instance, draws on disease prevalence data from the Centers for Disease Control and Prevention. Other presenters and exhibitors showed off new efforts to apply these federal resources to help anticipate asthma attacks, make diabetes care more effective and improve survival estimates in cancer patents.

The intense interest in consumer health IT comes in response to “an increasingly health care ‘do-it-yourself’ world,” notes economist Jane Sarasohn-Kahn. now use health-related blogs, social networks, ratings websites or apps. Health and medical apps for the iPhone now target fitness, stress, chronic disease, mental health, smoking cessation and medication adherence, to name just some categories tracked by MobiHealthNews.

Funding has followed the crowd, with in just two years to $766 million, and the average start-up pulling in nearly $12 million. The medical app market, already growing faster than the general apps, will grow 25 percent annually over the next five years, according to .

Despite the buoyant marketplace, it remains to be seen whether the effectiveness of individual apps will . While MobiHealthNews health- and medical-related iPhone apps as of April, the reliability of any particular app or even category of apps is hard to determine. One research group that both content and user interface be tailored as necessary to respond to cultural differences among different racial and ethnic groups. Separately, another group of researchers examining web-based tools to help consumers control their diabetes that “few tools … met our criteria for effectiveness, usefulness, sustainability and usability.”

That uncertainty shadowing this fast-evolving field is one reason the Food and Drug Administration wants to regulate medical apps it believes could present a risk to patients if they don’t work as intended. That sentiment prompted a backlash among those fearful that bureaucratic caution would block innovation. In mid-July, that, among other provisions, calls on HHS to report to Congress on an “appropriate, risk-based regulatory framework pertaining to health information technology, including mobile medical applications.” FDA is expected to release guidelines reflecting its thinking by year-end.

Opening up new information sources to patients will also affect the traditional doctor-patient relationship. There is growing activism by some patients who don’t want to wait to become full, in their care. For instance, Hugh Campos, who has long-standing heart problems, for demanding access to the data feed from his pacemaker. At the same time, some physicians wonder whether this level of involvement truly represents a trend. In a , Dr. Arnold Relman, former editor of the New England Journal of Medicine, said he had “some reservations about the depiction of a future patient who is consumed by constantly watching [remote] sensors talk to his smartphone. I don’t think that patients are going to be motivated to do that all the time.”

A found that about one in 5 mobile phone users search for health information. And experts caution that lasting behavior change is often blocked by barriers as much psychological as informational. An app whose interface is appealing isn’t the same as one that’s effective.

Jessie Gruman, a four-time cancer survivor who heads the Center for Advancing Health, points out that “keeping ourselves alive and out of pain is a serious business.” Those who are sick don’t need apps that are fun, says Gruman. Rather, “we want a technology that is efficient and useful –one that will help us take care of ourselves so that we can live lives that are fun.”

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A radical change just getting underway in the U.S. health system could transform how medical treatment has been paid for since Hippocrates made his first house call. But the new payment method faces conflicting dangers: either it won’t be strong enough to upend entrenched incentives or it will be so successful it will prove too politically disruptive to survive.

The “accountable care organization” replaces the idea of reimbursing individual doctors and hospitals by procedure with a lump-sum payment to clinicians working as a formal ACO team. Under the terms of the Affordable Care Act, a Medicare ACO agrees to be responsible for all the care needs of a group of patients and to be paid based on those patients’ health outcomes, satisfaction and costs.

The federal government recently announced that Medicare ACOs are now serving more than a million elderly Americans in locales as diverse as Los Angeles County, the Mississippi Gulf Coast and New York City’s Chinatown. That number is expected to at least triple by year’s end. At the same time, most  are also experimenting with ACOs, leading to a potentially powerful convergence.

“This is a vast change,” said Dr. George Lundberg, editor-at-large of MedPage Today and former editor in chief of the Journal of the American Medical Association. “It is a credible way to move the health-care system.”

Millenson

But as Lundberg and others caution, that credibility will be tested as ACOs move from concept to reality.Ìý 

The drawbacks of fee-for-service reimbursement are hardly secret. In 1909, the playwright George Bernard Shaw wondered why “any sane nation, having observed that you could provide for the supply of bread by giving bakers a pecuniary interest in baking for you, should go on to give a surgeon a pecuniary interest in cutting off your leg.” A century later, McKinsey Global Institute identified “” as one reason U.S. medical spending is more than 25 percent higher per person than even in other industrialized nations.

ACOs explicitly target the “value versus volume” problem. In an ACO, a group of physicians and a hospital share clinical and financial responsibility for providing all care needed by a group of patients whether in the hospital or outside it. Rather than each procedure propping up the bottom line, the partnership prospers by keeping patients healthy and meeting clinical and cost-effectiveness goals. The intent is to reward quality, not quantity, of care.

ACOs differ in important ways from the last two major attempts to infuse cost-consciousness into American medicine. In the mid-1980s, with Medicare in crisis, Congress changed how hospitals were paid. The old “cost-plus” system, giving every hospital a guaranteed profit margin, was replaced by a “prospective payment system,” in which Medicare would pay a flat fee set in advance and based on each patient’s diagnosis, not each hospital’s costs. Following that change, the average length of a Medicare hospital stay plunged, and many private insurers adopted the same payment model.

In the mid-1990s, health maintenance organizations and other private insurers moved to more restrictive managed care contracts using a variety of fixed payment schemes meant to push providers to reduce unnecessary care, or lose money. At the height of managed care’s influence, the average rate of dropped to less than a third that of both general inflation and workers’ raises.

Both victories proved short-lived.

With Medicare, there was a backlash against patients being discharged “quicker and sicker” that subsided when initial anecdotes proved overblown. Still, hospitals soon found ways to move care to the outpatient setting or other places where prospective payment didn’t apply.

With managed care, the was more sustained. A spate of attributed to sharp cutbacks in genuinely needed care – such as new moms being discharged within 24 hours, ready or not – sparked a political uproar that ultimately persuaded insurers to loosen the rules.

ACO advocates have tried to learn the lessons of both too tight and too loose controls. For example, the “” designed by Blue Cross and Blue Shield of Massachusetts, considered a model for ACOs, addresses the cost-shifting that allowed facilities to work around prospective payment by including inpatient and outpatient treatment, pharmacy and behavioral health.Ìý At the same time, to protect providers from feeling unfair financial responsibility, the contract includes adjustments for factors such as general inflation and how healthy a particular group of patients has been.

Unlike prospective payment or managed care, ACOs also include a long list of rules meant to balance cost-containment incentives. Medicare requires ACOs to be run by hospitals or doctor groups – not insurers – and beneficiaries can seek care outside the ACO without financial penalty. Moreover, the government has mandated 33 publicly disclosed quality measures related to care coordination and patient safety, preventive health services, at-risk populations and the patient experience of care.

“You don’t get paid a dime if you don’t hit the quality metrics,” said Donald Fisher, president of the American Medical Group Association, a strong proponent of the concept.

Hopes run high. In a recent , Lundberg wrote that ACOs could help “build a new medical world based less upon … lucre, and more on … outcomes” such as keeping patients healthy and treating illness effectively. Providers would no longer profit from catering to the “worried well.”

But the potency of that profit potential is exactly what concerns ACO skeptics.ÌýEstablishing a Medicare ACO is voluntary and current financial rewards are modest, mostly due to fears that larger financial incentives might trigger accusations of “rationing” at a time when the political consensus for innovation is fragile. That raises the question of why providers should forego fee-for-service until forced to do so.

Lawrence Casalino and Stephen Shortell, two well-regarded academics, under the largest Medicare ACO program, “even an efficient, high-quality ACO will gain less money from sharing in savings than it would have earned if it had simply continued with business as usual.”

Going forward, the balance of ACO risk and reward will be crucial. Even if the health reform law is overturned, the concept has had . Moreover, the Medicare fee schedule for physicians and prospective payments to hospitals is failing to keep pace with medical inflation, even though Congress staved off a 27 percent reduction in physician fees that had been scheduled for March 1. In this continued era of fiscal austerity, Medicare can either pay all providers less and less money for all the care they give or slow costs by paying an adequate reimbursement to doctors and hospitals providing high-value care. .

“The system cannot and will not pay what it has in the past,” said economist Michael Chernew, a professor of health care policy at Harvard Medical School. “The boat is sinking, and they’ve built a reasonable life raft.”

Chernew says an ACO-type contract allows providers to reap the benefits from providing more efficient and effective care. That’s one reason he believes ACOs are now being offered by even high-profile and prosperous organizations, such as Harvard-affiliated Partners HealthCare System.

Medicare has authority to create incentives for all providers to join ACOs without having to go back to Congress for permission. That’s unusual. “If it works, it’s easy to expand,” said Andrew Croshaw, a partner in the health care practice of Leavitt Partners.

And if that indeed happens, says AMGA’s Fisher, “this is the beginning of the end” of fee-for-service medicine.

This article was produced by Kaiser Health News with support from .

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The effort is pegged to the success of a little-known entity called a “” (HEN). In December, the government selected 26 HENs and charged them with preventing more than 60,000 deaths and 1.8 million injuries from so-called “hospital-acquired conditions” over the next three years. That would be the equivalent of eliminating all deaths from HIV/AIDS or homicide over the same period.

Despite those big numbers, and an initial price tag of $218 million, it’s unclear whether the HENs are adequately ambitious or still only pecking away at the patient safety problem. While this is by far the most comprehensive public or private patient safety effort ever attempted in this country, it still aims to eliminate less than half the documented, preventable patient harm.

The inspiration for these networks comes from similar collaborative projects run by the Institute for Healthcare Improvement and other groups. Dr. Donald Berwick, IHI’s founder and president, headed up the Centers for Medicare & Medicaid Services for two years and launched a larger  that includes the HENs.

In December, the government chose a mix of national and local groups — primarily health systems and hospital organizations — to run individual HENs. Each HEN is charged with spreading safety-improvement innovations that have been proven to work in leading hospitals to others through intensive training programs and technical assistance. Although the program lasts three years, initial HEN contracts are for two years, with an “option year” dependent upon performance.

This bottom-line accountability is what sets the HENs apart from past voluntary efforts.ÌýProgram co-directors Dr. Paul McGann and Dennis Wagner give weekly briefings to Health and Human Services Secretary Kathleen Sebelius. “This is a full-court press unlike anything I’ve seen in my 10 years in government,” McGann says.

Although the HENs’ total cost is slated to rise to $500 million by its third year, that’s still chicken feed compared to what the government says will be savings of up to $35 billion from safer care, including up to $10 billion in savings for Medicare. In addition to preventing injuries and deaths, the program plans to eliminate 1.6 million preventable hospital readmissions.

Still, there remains the question of whether the program’s goals should be even more sweeping. And one might wonder why the chance to not harm patients is not reason enough for hospitals to change without being paid by the government.

For context, it helps to understand that the most widely quoted estimate of preventable patient harm – 44,000 to 98,000 deaths and one million injuries annually – was probably low. That estimate caused an uproar in a . Today, it seems conservative. The IOM total was based on studies conducted in hospitals in the mid-1980s. Recent research by the HHS Office of the Inspector General (OIG) and others has found a much higher rate of harm. A Medicare patient today has a , a risk about four-to-seven times greater than in the IOM report.

Moreover, , the OIG concluded, even including incidents that led to patient deaths. “If you measure all-cause harm, you find it in about one-third of patients,” says the University of Utah’s Dr. David Classen, lead author of a that appeared in Health Affairs. That lack of progress testifies to very modest pressure to show results.

Enter the HENs, prodded by a stick.

In 2008, Medicare began denying payments to hospitals for eight complications of treatment, the program’s first major use of negative incentives.Ìý, along with efforts to pressure hospitals through public . Meanwhile, the 2010 health reform law includes financial penalties that go into effect later this year to discourage preventable readmissions.

Put differently, hospitals now have a significant financial as well as ethical incentive to participate in a hospital engagement network. Even so, just 3,800 of the nation’s 5,000 acute-care hospitals have done so.

Federal officials stress they are paying the HENs, which both guide and oversee hospitals, not individual institutions. For instance, a HEN run by a national consortium of academic medical centers is building a data analytics infrastructure which it will share with another HEN run by a national public hospitals group. State and local HENs have said they will form “learning communities,” providing technical expertise and one-on-one coaching reporting and tracking databases. Each HEN will monitor member hospitals’ progress and, in turn, be monitored by HHS.

Meanwhile, two groups that are operating HENs and are national leaders in patient safety say that the program will be helpful even in light of the care improvements they have already made. Executives at the Ascension Health system and the Premier hospital alliance say that the resources, cooperation and infrastructure assistance from the federal program will enable even their groups to reach a level of performance improvement unattainable on their own. One reason is that participants in the HEN must reduce hospital-acquired conditions by 40 percent from their starting point, not from a potentially laxer national average.

That still leaves the question of how much harm could truly be eliminated. HHS hopes to save 20,000 lives and roughly $12 billion each year. (The harm avoided will be to all patients, but only the financial savings from avoiding harm to Medicare patients will accrue to the program.) By way of context Premier says that if all U.S. hospitals achieved similar results to its , whose results were announced in January, it would save more than 87,250 lives and $34 billion in health care costs in just one year.Ìý has had similar success, although the two organizations are measuring a somewhat different set of indicators from each other and from the HEN program.

Consumer advocates such as Martin Hatlie, a co-founder of , and Helen Haskell, head of Mothers Against Medical Error, believe the program’s target is too low. Still, both Hatlie and Haskell support the program’s approach — and the Medicare decision not to pay for some medical problems caused by hospital mistakes.

Says Haskell, “I do think federal dollars – whether offered or withheld – are the key to getting hospitals to pay attention to safety.”

Michael L. Millenson is a Highland Park, Illinois-based consultant, a visiting scholar at the Kellogg School of Management and the author of .

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The anxiety when a loved one is injured is compounded when you know just how risky making things better can get. As a long-time advocate for patient safety, my interest in the topic has always been passionate, but never personal. Now, as Susan was being rushed into the emergency room, I wanted to keep it that way. “Wife of patient safety expert is victim” was a headline I deeply hoped to avoid.

Michael Millenson and his wife, Susan (Photo provided by Millenson)

In the weeks after the accident, we spent time at a 50-bed hospital in Maine; a Boston teaching hospital where Susan was transferred with a small vertebra fracture at the base of her neck and broken bones in her left elbow and hand; and a large community hospital near our suburban Chicago home. There were plenty of opportunities for bad things to happen — but nothing did. As far as I could tell, we didn’t even experience any near misses.

What went right? After all, though our health care system knows how to prevent errors that kill 44,000 to 98,000 people in hospitals each year, that death toll . Based on personal and professional observations, I’d simplify the formula that kept Susan safe into three variables: consciousness, culture and cash.

Consciousness of patient safety sounds easy, but it isn’t. The harm caused patients is inadvertent and often occurs as part of complex interventions. As a result, pointedly noted, “clinicians have labeled virtually all harm as inevitable for decades.”

But today, the cloak of invisibility is being lifted. Twenty-six states require hospitals to report certain medical errors; Medicare and some private insurers won’t pay for problems caused by a growing list of quality and safety lapses, and the government has launched the $1 billion Partnership for Patients to dramatically reduce avoidable harm.

Just as importantly, patients are worried. In a poll by Consumers Union, 77 percent of respondents expressed high or moderate concern that they might be harmed by a hospital infection and 71 percent had the same concern about medication errors. Inevitably, more patients and their families are speaking up — as I most certainly did, albeit as politely as possible.

When the ER nurse at Maine’s York Hospital gave Susan morphine, I asked about the dosage and timing. When she was transferred to Massachusetts General Hospital in Boston, I asked each medical professional to identify themselves and what they were doing. Although it’s impossible to know if my questions had any positive impact, at a minimum they reinforced an existing safety consciousness.

Although consciousness of a problem can spur change, sustaining it requires a supportive culture. Can there be any more graphic expression of a safety culture commitment than Baylor Health Care System’s mission to eliminate preventable deaths, preventable injuries and preventable risk?  Or Ascension Health’s “healing without harm” initiative and its goal of reducing preventable deaths by 900 each year? (They’ve reached a minimum of 1,500 so far.) Both organizations have published results in the peer-reviewed literature.

Glenbrook Hospital in suburban Chicago — it’s part of the NorthShore University HealthSystem — isn’t quite as ambitious in its objectives. Still, its culture was obvious even before I peeked at the monthly infection report left sitting on a reception desk. When the orthopedic surgeon was explaining the procedure he would be doing, he talked about safety. The consulting neurosurgeon (due to Susan’s neck injury) talked about safety. The anesthesiologist talked about safety. Right before surgery, nurses fitted Susan with surgical stockings to prevent deep vein thrombosis — an evidence-based guideline followed by fewer than half of hospitals. When I challenged the surgical team on appropriate prophylactic antibiotic use, a nurse indignantly cited a study showing I was mistaken.

I backed off, happy they’d thought about the issue seriously. But I did feel emboldened to ask whether the team in the operating room took time-outs before surgery (the evidence shows it helps make sure everyone’s on the same page before you start cutting) and whether the team introduced themselves before proceeding (believe it or not, even the doctors may not be entirely certain who is behind those masks). Yes and yes, the answers came back.

Culture change at hospitals is easier these days with like Ascension and Baylor, and with safety checklists like the one developed by Johns Hopkins’ critical care specialist . But if consciousness is one barrier to culture change, another one of at least equal importance is cash.

There’s a link between financial stress and patient distress. A recent study in  found the 178 “worst” hospitals in the United States care for more than twice the proportion of elderly minority and poor patients as the nation’s 122 “best” hospitals, where costs are lowest and quality highest. As one headline put it, “Bad Hospitals, Poor Patients.”

Money talks in other ways. I’ve written about how some hospitals implicitly see adverse events (although, of course, actual patient deaths thwart that goal). The hospitals where my wife was treated were all prosperous. Even without worrying about a reluctance to confront complications, would a cash-strapped York have transferred Susan to a tertiary care facility, or would they have assured a well-insured patient they could take care of her broken neck? Would a bottom line-driven Mass General or Glenbrook have angled for a longer hospital stay?

It’s tough enough to change culture. It’s even tougher if it you think you’ll lose money doing so. That’s why Medicare is increasingly linking payment to explicit quality and safety indicators.

We ask a great deal of physicians, nurses and other professionals. Those whom we encountered juggled multiple roles — healers attending to the ill and scared, prudent managers of health-care resources and team players in system improvement. For the skill and grace with which they performed all those roles we were deeply grateful. Thanks to them, Susan has now recovered to the point that to the casual observer there’s no obvious evidence of her multiple injuries.

Our experience showed that “doing the right thing” — appropriate care — and “doing the right thing right” — safe and effective care — can become the norm at rural, suburban and big urban teaching hospitals alike. On a personal level for the two of us, and on a system level for all of us, that’s very good news.

Michael L. Millenson is a Highland Park, Illinois-based consultant, a visiting scholar at the Kellogg School of Management and the author of .

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What the two men are advocating is simple: hospitals should offer the same level of professional staffing and patient care on weekends as during the rest of the week. They should do this, the two men , because trying to cram seven days of care into five leads to a cascade of problems that harm and even kill patients. It also costs a lot of money.

That’s the commonsense part. The hopeless part is that Long and Vaswami, both affiliated with the , seem to believe that doctors, nurses and hospital execs will read their article and then spontaneously volunteer to work the weekend shift.

American hospitals are complex entities, but at heart they remain the doctor’s workshop, dependent upon the goodwill of physicians who admit and care for patients. Maintaining that goodwill requires treading carefully. For instance, telling a neurosurgeon, “You’re working Wednesday through Sunday this week” would rank high on the list of what a friend of mine calls a “career-limiting event.”

Long and Vaswami are aware they’re tampering with long-standing tradition, but as justification they offer a disturbing catalog of the effect of care controlled by the calendar.

To begin with, bunching scheduled admissions in midweek often overwhelms the staff, leading to “significant” increased risk of patient death or admission to the Intensive Care Unit. Filled beds force emergency rooms to discharge patients to “inappropriate care locations,” with the hospital relying on specialized teams to ride to the rescue “when patients deteriorate because of inadequate care.” At the same time, “medically appropriate transfers may also be delayed or rejected.”

And that’s when hospitals are operating normally. Patients admitted over the weekend face an increased risk “because critical diagnostic or therapeutic modalities are not available,” while patients staying over the weekend experience “delays at best and deterioration in clinical condition at worst.”

Finally, peak-and-valley scheduling is inefficient, causing hospitals to build expensive new facilities instead of efficiently using existing capacity. With an aging population and new access to health insurance, that approach will cost “billions of dollars.”

For all their indignation, however, Long and Vaswami pull their punches on both causation and remediation. So, for instance, in a 1,000-word essay backed by citations from The New England Journal of Medicine and similar sources, they never once use the words “doctor” or “physician” when referring to those whose behavior needs to change. Indeed, Long, an anesthesiologist, and Vaswami, an MBA, seem to run away from the implications of their own words. Avoiding either practical recommendations or moral outrage, they conclude: “Health care professionals have no choice but to carefully consider [emphasis added] whether weekends off are more important to us than the quality and cost of care we provide to our patients.”

I’m surprised they didn’t just write, “Take a few days off to think about it.”

Of course, the two men understand they are opening a Pandora’s box. The kind of compromises hospitals make to keep the medical staff happy is not a topic anyone wants to openly discuss. Let’s look at a few examples.

In a by the American Association of Critical Care Nurses nearly nine of 10 nurses said they’ve seen doctors make mistakes or take dangerous shortcuts. Yet only four in 10 nurses felt empowered to speak up. In a similar vein, 3 to 5 percent of hospital physicians are estimated to be outright disruptive, with a between their misbehavior and problems ranging from nurse turnover to outright errors. Researchers bemoan the unwillingness of doctors to discipline colleagues or hospitals to risk alienating big admitters.

In that kind of environment, it takes a special person to question who the hospital is really set up to serve. Myra Rosenbloom, the elderly lady I mentioned earlier, is that kind of person.

Myra first called me back in 1993. Jack Rosenbloom, her husband of 45 years and her partner in a kosher catering business, had been admitted to a local hospital the previous September after suffering a heart attack. Jack was in stable condition when Myra visited him on Saturday evening but then started suffering chest pains. The hospital declared a code-blue emergency, but on a weekend night no doctor was available. Jack died that night in the ICU.

That’s when Myra discovered that in Indiana, as elsewhere, no law required a doctor to be on duty, only that one be available within a certain time. (Typically, that’s 15 to 30 minutes.)

Myra initiated a one-woman crusade to require hospitals over 100 beds to have a doctor other than the one in the emergency room on duty at all times. During Indiana’s 1994 legislative session, she slept for five cold nights on a hard wooden bench inside the Capitol before the legislature passed a watered-down bill requiring a doctor, but letting an ER doc count towards the requirement. An ER physician was on duty at the hospital where Jack died, but he’d been too busy with other patients to answer the code-blue call.

Facing tenacious opposition from hospital groups that said her idea would cause them economic hardship, Myra has since then failed to win approval of a tougher law in Indiana, failed to pass a law in Illinois and failed to called the Physician Availability Act. It was first introduced in Congress in 1976, was reintroduced for a few years, vanished and then resurfaced in 2009 with the backing of Rep. Jan Schakowsky, a Democrat from suburban Chicago. At the time, Myra was 85 years old.

I called Myra the other day, and she said Schakowsky wants her to find some Republican co-sponsors so Schakowsky can reintroduce the bill. “I won’t give up till the day I die,” Myra told me with the same spirit as when we first spoke 18 years ago.

Perhaps if the nascent specialty called “nocturnists” had existed back in the early 1990s, there would have been someone to save Jack Rosenbloom that Saturday night. But the larger point made by Long and Vaswami remains. The distortions caused by giving provider convenience a greater priority than clinical necessity is exacting a fearful and avoidable toll of deaths, injuries and expense that far outweighs the cost of addressing the problem.

If Long, Vaswami and colleagues are serious about how hospitals operate, they would do well to act seriously. They could start by showing even a smattering of Myra Rosenbloom’s persistence and courage.

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No, this isn’t one more commentary on the Georgia Republican’s checkered marital past. I’m referring to a different relationship, the one between Gingrich and the health policy community. A critical component of the climb back to prominence for a man who inspired nearly as much distrust in his own party as in the opposition was proving he could work harmoniously with those holding differing views on an important policy issue — how to reform U.S. health care.

Gingrich succeeded so well that some of the policy recommendations he was touting just a few years ago bear a close resemblance to Obama administration actions that Gingrich now denounces as leading us to “a centralized health care dictatorship.”

The romance between Gingrich and the health wonks, and Gingrich’s makeover as a leader with ideas as much substantive as political, began after the appearance of his 2003 book, Saving Lives & Saving Money. The book gave credibility and visibility to a set of ideas being talked about in the health policy world about using information technology to improve medical care.

In those early days of the Bush administration, IT types were still health policy wallflowers, sitting by a silent phone waiting for someone who wanted to talk about “computerized physician order entry.” But the wallflowers blossomed into belles of the ball after Gingrich coined the phrase, “Paper kills.” He also used his status and connections to advance the concept and capture the attention of the federal government, the news media and leaders of health care organizations.

In return, the health care world heaped rewards on its newfound friend. There were speech invitations at a reported $50,000 a pop and six-figure membership fees paid to his for-profit . Gingrich also received honors attesting to his non-partisan good works. For instance, he and then-Sen. Hillary Clinton, D-N.Y., shared an award from the National Committee for Quality Assurance. The Healthcare Information and Management Systems Society recognized Gingrich’s “commitment and leadership in working with both Republicans and Democrats.”

New Newt neutralized the negative images of the polarizing politician. The change could be seen in a 2004 headline that proclaimed: “As Speaker, Gingrich knew how to divide. Now he aims to unite — to transform health care as we know it.”

Old Newt stormed off President Clinton’s Air Force One miffed over a perceived lack of respect. New Newt quietly got himself appointed to a three-year term on the obscure National Advisory Council to the Agency for Healthcare Research and Quality.ÌýOld Newt was “the most divisive figure in the recent history of the House,” as the put it in 2000. New Newt had “reinvented himself as a respected entrepreneur of ideas,” concluded a 2005 profile. The stature Gingrich had gained from his work with the health policy community, along with his efforts related to national security, was a central part of that reinvention.

It was about this time that I began to feel for myself the powerful pull of the New Newt charm offensive. I had been appointed to the National Commission on Quality Long-Term Care, co-chaired by Gingrich and former Sen. Bob Kerrey, D-Neb. Up close and personal, the famed Scourge of All Things Liberal could seem positively benign: “Newt” to one and all Beatific smile… Ideas being spouted with a professorial air.

Nonetheless, unmistakable signs began to emerge that New Newt was more rebranding than reinvention. There was, for instance, the senior adviser at his Center for Health Transformation who spoke privately of proposing a real conservative plan to cover all the uninsured, a goal to which the Bush administration had only paid lip service. However, the true purpose was political — capturing enough independent voters to regain Republican control of the House in 2008.

Meanwhile, at the long-term care commission, Gingrich began inviting new members to join who fit his ideological mold. And, come to think of it, Saving Lives & Saving Money started off and ended with pages of political photos, including Gingrich and Dick Cheney, not noted for an interest in health IT interoperability.

The shiny skein of New Newt inevitably began to wear away. Our commission closed its doors at the end of the 2007, but one could see Old Newt re-emerging as the 2008 campaign beckoned. Since then, the process has only quickened.

To give just one example, Gingrich-as-health-wonk for years advocated reforms such as “data-driven reimbursement” informed by best practices, a national electronic health network and a focus on prevention and wellness. All those items — and others Gingrich supported — are contained in the HITECH Act, part of the budget stimulus package and the Affordable Care Act.

That shouldn’t be a surprise. A menu of measures to improve the efficiency of U.S. health care has long enjoyed bipartisan support. That only changed when Republican leaders decided to demonize “Obamacare” as a means of discrediting the Democratic president.

As Gingrich seeks the chance to try to defeat President Obama next year, he won’t accomplish that goal by being a consensus-seeking wonk. Nor, frankly, should he be one. Whether or not you like his views, Gingrich is a brilliant communicator and politician. Ideas he may have; an intellectual, he is not.

In the speeches Gingrich gives about leadership, he tells listeners that success depends upon a clear strategy and “entrepreneurial rather than bureaucratic behavior.” As it happens, a former colleague of Newt’s on that long-ago advisory council is now one of the Obama administration’s most prominent health care bureaucrats, Dr. Donald Berwick. Back then, New Newt must have listened and learned, since in his book he praises Berwick’s quality improvement work. But today’s Old Newt told Fox News’ Bill O’Reilly that Berwick’s appointment as head of the Medicare program was just another example of Obama’s “secular Socialist machine.”

I guess an entrepreneur running for president has to go after votes wherever he can get them.Ìý

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The government’s long-awaited on Accountable Care Organizations have brought a dose of ugly reality to a concept that’s always seemed coated with a patina of pixie dust. Unless those regs are substantially changed before the clock strikes Jan. 1, 2012 — the statutory date for ACO implementation — going to turn back into a scullery maid and the horse-drawn carriage transporting her to the Health System Transformation Ball will be revealed as nothing more than four mice and a pumpkin.

The essence of the ACO concept is using financial incentives to reward doctors and hospitals for redesigning care processes to provide “high quality and efficient service delivery,” in the words of the Patient Protection and Affordable Care Act. As I wrote last fall, ACOs have been the one reform beloved by Republicans and Democrats; doctor groups and insurance companies; policy wonks and profit-seeking capitalists. This unusual unanimity was due in part to a lack of specifics that enabled every stakeholder to gaze upon the ACO and see reflected their very own version of Prince Charming.

Conservatives hail the ACO as marketplace medicine, while liberals focus on organized systems of care replacing fee-for-service chaos. Providers applaud a reform that places them at its center, while health plans know that providers asked to bear financial risk — if an ACO doesn’t measure up, the government won’t pay up — will seek out actuarial experts like them as partners. ACOs also are expected to require the products and services sold by a host of consultants and entrepreneurs.

For medical groups and hospitals considering becoming an ACO, Medicare offers a straightforward risk-reward proposition. Providers must invest considerable resources in building an infrastructure and institutional culture capable of managing and measurably improving the health of a defined group of Medicare beneficiaries. In return, however, ACOs that meet the government’s standards will make much more money than if they clung to the old ways of care delivery.

The central problem with the draft regs, however, is that the risk-reward ratio is highly skewed. The Centers for Medicare & Medicaid Services painstakingly delineates a dizzying litany of hurdles to surmount, from documenting progress on 65 different quality measures to Medicare editing your marketing materials and to government monitors descending upon your offices. Meanwhile, the promised rewards are wrapped in a fuzzy package of impenetrable risk-adjustment algorithms and wait-till-next year financial commitments that sound like a cross between a cell-phone contract and a time-share vacation offer.

In the classic fairy tale formula, a king offers his beautiful daughter’s hand in marriage and half his kingdom to the young man brave and resourceful enough to ford a dangerous stream, climb a treacherous mountain and then slay a ferocious dragon. But if Medicare were making the rules, the successful suitor would be lucky to get a goodnight kiss — if not have the door slammed in his face. Not surprisingly, the list of volunteers to become an ACO under these conditions appears to be extremely short.

Consultant Steven Lieberman, a 30-year veteran of the Congressional Budget Office, warns that the new regs could kill ACOs outright. “The proposed regulation imposes unfavorable economics, unrealistic requirements, high uncertainty and significant risks for ACOs,” he writes . In the same vein – and — Ron Klar, a physician who has consulted extensively to health plans and to CMS, says the agency has created a program “likely to have few participants.”

Lieberman and Klar are both ACO supporters, but their concerns are widely, perhaps universally, shared. Those wary of offending CMS have mostly praised the agency for simply issuing the regs, while emphasizing how intently regulators will listen to complaints during the comment period. Support for specific provisions is scarce.

Still, it’s hard not to feel some sympathy for the bureaucrats. Yes, as Klar points out, they have written rules “overloaded with provisions to mitigate the likelihood that any conceivable negative possibility will occur.” Yet in today’s polarized political climate, any sort of backlash could prove fatal. One can envision a piqued ACO participant in (an Ohio town represented by House Speaker John Boehner) prompting a full-scale congressional investigation.

At the same time, opening the spigot of government funding to private-sector innovators, as the Bush administration did with MedicareAdvantage plans (or was that Medicare-Take-Advantage?) risks a backlash from liberal Democrats and Tea Party Republicans alike.

CMS is being asked to implement a risk-sharing program where everyone wins and a that disrupts nobody. It’s a handicap heavier than that borne by the private sector, where ACOs continue to proliferate, and more burdensome even than the shackles on the CMS Innovation Center, whose mandate to finance “demonstration projects” provides more political flexibility.

None of this, however, should cause us to lose sight of what’s at stake. The ACO concept continues to represent an extraordinary, perhaps even unique, opportunity to begin to remake American medicine in ways that are critical to our nation’s economic health and to health itself. Squandering that opportunity would be indefensible.

The potential reward is worth taking some real risks to achieve. When writing the final ACO rules, CMS has the chance to spin the dross of the current regulations into something of genuine value to providers, even if it’s not quite -quality gold. If the feds fail, it is all of us, not just those on Medicare program, who could live unhappily ever after.

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Conservatives, like liberals, have a more-or-less coherent set of ideas. They use political power to push preferred policies, whether related to health care, housing or a hundred other possible issues. William F. Buckley Jr., one of the fathers of modern American conservatism, “had a way of making conservatism a holistic view of life not narrowed to the playing fields of ideology alone,” as .

Although cynics may claim conservative credentials, their view of government is really nothing more than a quarrel about its cost. It brings to mind Oscar Wilde’s immortal phrase, “The cynic knows the price of everything and the value of nothing.”

The contrast between the two viewpoints was on stark display at two recent marquée meetings, AcademyHealth’s yearly and the sprawling Health Information and Management Systems Society — HIMSS — Health IT .

AcademyHealth’s “Running of the Wonks” (my term, not theirs) is a magnet for researchers and policy mavens who are inured by long experience to most political rhetoric. Yet at the general session featuring a bipartisan dialogue among congressional staffers, the harsh rhetoric from the GOP participants stunned the crowd. The new federal health law, it seemed, was evil incarnate, and the rhetoric of “repeal and replace” was wielded with a fundamentalist zeal.

“The bureaucracies that administer ObamaCare” must be cut, declared one aide to a powerful congressional leader, setting the tone. And in case anyone didn’t get the point, the word “ObamaCare” was deliberately repeated every few syllables in a tone of disdain combined with wonder at how such a monstrosity had ever come to be. (AcademyHealth meeting rules said the staffers could not be quoted by name.)

The audience of wonks quailed, then quietly queued up for the question-and-answer period. They knew, after all, that the health law’s fine print incorporates a generous helping of initiatives championed by both conservatives, and those on the left. Besides, these were staffers speaking, not politicians playing to the press. Surely, gentle reason would triumph. Alas, it was not to be.

The ? “You mean, the prevention health slush fund, as we like to refer to it?” replied a GOP staffer.

The at the Centers for Medicare & Medicaid Services? “An innovation center at CMS is an oxymoron,” responded a  Republican aide, before adding a personal barb aimed at the attendees: “Though it’s great for PhDs who come to Washington on the government tab.”

There was also no reason the government should pay for “so-called comparative effectiveness research,” another said.

“Everything’s on the chopping block,” said yet another.

Everything? At HIMSS, where GOP staffers also spoke, attendees were chagrined to learn that “everything” applied to them, too. The that were part of the American Recovery and Reinvestment Act were targeted in legislation introduced in late January by Rep. Jim Jordan, R-Ohio, chairman of the Republican Study Group. His bill would repeal this funding and eliminate all remaining stimulus spending, including about $45 billion in unspent health IT funds.

Those focused on the substance of health policy might be forgiven for feeling blindsided. After all, the in the 2008 presidential election called for coordinated care, greater use of health information technology and a focus on Medicare payment for value, not volume. Once-and-future Republican presidential candidates such as former governors Mike Huckabee (Ark.), Mitt Romney (Mass.) and Tim Pawlenty (Minn.), as well as ex-Speaker of the House Newt Gingrich, have long promoted disease prevention, a more innovative federal government and increased use of information technology. Indeed, federal health IT “meaningful use” requirements can even be seen as a direct consequence of Gingrich’s popularization of the phrase, “Paper kills.”

Ah, but that was back before the Republican cynics swept into power. It was back before traditional GOP conservatives — worried that any suggestions outside a single-minded focus on slashing spending would be seen as disloyal — eschewed ideas in favor of ideological declarations.

This column was filed just days after a two-week compromise was signed into law to avoid a federal government shutdown. It allowed funding for health reform to continue, but instituted other budget cuts. Obviously, the cynics yielded a bit, at least for the moment, to the conservatives, and the liberals and centrists have given ground to both.

Still, one wonders what the urbane Buckley would think of a movement that seems intent on ignoring the real-world context of its actions. Buckley launched his lifetime crusade against liberalism with God and Man at Yale, a book that took aim at the academics who’d taught him as an Ivy League undergraduate. Alas, the GOP cynics are cocooned instead in an underground bunker of their own design, as impervious to realities they’d prefer to ignore as the ivory tower academics they’ve come to scorn.

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In an inconspicuous control room at the Sioux Falls, S.D., headquarters of the , nurses keep round-the-clock watch on motion and humidity sensors in the living rooms, bedrooms and bathrooms of elderly men and women in five states.

The seniors — a handful in their own homes and the rest in assisted living facilities owned by Good Samaritan — are part of one of the most comprehensive remote health monitoring efforts anywhere. Using sophisticated sensors, computerized pattern recognition and human responders, Good Samaritan hopes to show it can detect and head off health threats to the elderly and thereby accomplish two important goals. The first is saving money on medical costs. The second is helping seniors feel secure enough to “age in place” at home or avoid moving from assisted living to a skilled nursing facility.

Whether this costly technology will ultimately prove clinically or economically effective remains uncertain. So, too, is whether a benign health care purpose can help overcome the unsettling “Big Brother” overtones for some potential users. What is clear, however, is that health care is joining a national trend toward greater surveillance of everyday life.

For example, more than 70 U.S. cities now use sensors to pick up the sound of gunfire and alert authorities even before 9-1-1 is dialed. Auto insurers are to a car’s computer system to monitor driving habits and, with the driver’s permission, calculate premiums accordingly. Even some farmers are with monitors allowing automated milking systems to track the cow’s milk production, amount of feed eaten and even how long it chews its cud. If the system detects a problem, it can call the farmer on his phone.

What benefits bovines might also help humans, albeit with appropriate modifications. Good Samaritan is the nation’s largest nonprofit provider of senior services, operating more than 240 facilities in 24 states. Working with the University of Minnesota, the system recruited 1,600 seniors in North Dakota, South Dakota, Minnesota, Nebraska and Iowa to test the impact on cost, quality of care and senior independence of a comprehensive set of monitoring tools. With an $8.1 million grant from the Leona M. and Harry B. Helmsley Charitable Trust, the LivingWell@Home study began collecting data at 40 of its assisted living facilities in January 2011, and will stop at the end of June 2013.

LivingWell@Home comprises three technologies. First, sensors from are distributed throughout the living space. (The company stresses that no cameras or microphones are involved.) When a senior is sleeping a motion sensor records how often he or she moves in bed. Showering, toileting and other activities of daily living are also analyzed by WellAware algorithms and scrutinized by nurses for changes that might signal health problems.

The second piece is a medical alert button from that includes an auto-alert function designed to detect a fall and call for help even if the user is incapacitated. Lastly, remote monitoring is provided by the through a clock radio-sized console in each apartment. It turns on each morning and prompts seniors to strap on a special blood pressure cuff, step on a special scale and transmit that and other information back to the monitors in Sioux Falls.

Jacci Nickell, who is Good Samaritan’s vice president of development and operation delivery systems, emphasizes that the technology is just a tool. “Unless you gather, integrate and interpret that data in a meaningful way to the client and to their formal and informal caregivers, a sensor hanging on a wall isn’t going to help anyone,” she says. “It’s what you do with that data, and how you optimize wellbeing.”

Good Samaritan isn’t waiting for the study results to be finalized to roll out the LivingWell@Home service, in which the system has a financial stake, as an option in all its assisted living facilities. It’s also putting parts of the technology into some skilled nursing facilities and even into seniors’ own homes.

The organization’s website tells the story of an elderly woman who agreed to have the sensors installed in the South Dakota farmhouse where she lived alone. Not long afterwards, the sensors detected a change in her toileting that prompted a call from a nurse.ÌýIn response, the woman sought out her doctor, who discovered a bladder infection. “Maybe it was God talking to me,” says 83-year-old Carol Tipton in a , seemingly near tears.

“We think the use of the technology can reduce the need for physical visits and will save expense and time,” Nickell says. Still, the high-tech security blanket doesn’t come cheap. The technology costs $500 to $750 per month per person at home and about $175 a month for residents in Good Samaritan assisted living facilities that already have a personal emergency response button service. By comparison, notes Mary Cain, managing director of consulting firm HC3, conventional disease management costs well under $100 per month per patient.

“It’s a very small percent of the population that’s going to benefit from [the Good Samaritan] level of monitoring,” Cain says. “How many will you monitor, and who is paying?”

A similar cautionary note comes from a spokeswoman for United Healthcare, the nation’s largest health plan. United already covers devices such as those used to detect abnormal heart rhythms or measure blood sugar.Ìý But “health insurers typically rely on guidance from the clinical community in making coverage decisions,” says the spokeswoman, and with sensors and similar technology “it’s too early to do so at this time.”

Privacy also remains a concern. Some critics may detect overtones of a 1983 song by The Police that warns, “Every breath you take, every move you make, we’ll be watching you.” As Christine Sublett, a health privacy and security consultant, put it: “Individuals should have the right to know exactly what information is being transmitted and that appropriate controls are in place.” Good Samaritan says it takes appropriate precautions, but the research study may not provide a rigorous test of protection against hackers. Nor has Good Samaritan or its vendors yet encountered feed, as has happened to makers of defibrillator monitors and similar technologies.

Still, other companies are jumping into this market. For instance, offers a radar beam to provide in-home monitoring of vital signs, activities of daily living and falls. The company suggests its equipment be placed inconspicuously behind a picture frame. And offers to collect data from motion, temperature, door, chair and bed sensors, in addition to pill box sensors for monitoring medication use and caller ID information to keep an eye out for telephone scams.

Choices are also proliferating for consumers willing to pay out of pocket for detailed quantification of their diet, exercise and sleep patterns. In just one example, sells wearable sensors said to gather 5,000 data points a minute on skin temperature, heat flux and galvanic skin response. The company says its aim is to provide users with a personalized assessment of health issues such as stress, fatigue and depression.

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The old axis of access ­in U.S. health care – insured or uninsured – is being replaced by the kind of gradations and complexity in determining who-gets-what-when-for-what-price for which the airline industry has become famous.

Some recent data and reactions to the provisions of the Affordable Care Act reinforce the trend. Here’s an overview:

Millenson

Being able to afford any kind of seat. While the number of Americans left standing at the gate because they can’t afford a health insurance “ticket” is declining, the scheduled takeoff in insurance coverage has run into mechanical difficulties. The Census Bureau announced this month that the number of uninsured dropped slightly in 2011 to 48.6 million, or 15.7 percent of the population. That slide is partly due to a health law provision allowing parents to keep children on their insurance plans until age 26.

But prospects of adding another 30 million Americans starting in 2014 and going forward under the health law’s various mandates and subsidies are now up in the air. The Supreme Court did not ground the entire law, but it did invalidate the penalty designed to compel states to expand Medicaid to many above the federal poverty line. That decision could void tickets to health insurance for an estimated three million people, says the , and possibly a lot more, according to a by two liberal legal experts.

A ticket isn’t the same as a seat. As airline passengers have learned, having a ticket isn’t the same as having a confirmed seat. In 2011, they wouldn’t accept new Medicaid patients because of payment issues; a smaller number of doctors have said the same thing about Medicare patients. Even with some private plans, you may be on permanent standby because the doctor of your choice does not accept your health plan.

Your private jet is ready. Of course, when money is no object, there are those who rate the equivalent of a private jet. That group would include individuals paying for “boutique” services like Guardian 24/7 (whose one-page public simply says, “By Invitation Only”), and . The latter promises “medical research…at your fingertips,” your complete health records instantly available online and “access to outstanding medical and emergency support anytime, anywhere.”

First class, commercial flight. What’s more interesting is what happens behind the curtain separating first class from other travelers on a commercial flight. Seated up front are the senior corporate managers who get “executive” physicals at places like the Mayo Clinic plus reimbursement checks for their out-of-pocket costs. One CEO with a total compensation package of about $9 million received another $23,000 to pay his medical bills, . These executive perks will be stopped by the health law in 2014 if loopholes can’t be found.Ìý

Business class. Unlike Medicaid “recipients,” Medicare ‘beneficiaries’ start off with a generous benefit at a modest price and can easily upgrade. They can choose a Medicare Advantage plan in which the average enrollee received more than $70 in additional benefits and reduced cost-sharing, . In addition, plans provide wrap-around coverage to pay costs traditional Medicare doesn’t. And even middle-class retirees may be able to upgrade to low-end concierge medicine, like .

Also traveling business class are those participants in the fast-dwindling number of health plans provided by unions, or private companies where the worker contribution is minimal and benefits are generous.

Coach, but some people get better seats and prices. Patients with traditional Medicare coverage, , are more likely than those with private health insurance to get needed care, to avoid access problems due to cost, to avoid medical bill problems and to be satisfied with their coverage. Medicare even in access and drug expenditures.

But being a high-wage worker with a good employer-sponsored plan also is a great way to get a good ticket. A new found that workers at businesses with more low-wage employees paid an average of nearly $1,000 more for their share of premiums than workers in a high-wage environment. That may not quite equal a free “executive” physical at the Mayo Clinic, but it’s not bad. (KHN is an editorially independent program of the foundation.)

Overall, workers at small firms face higher cost sharing, including higher copayments and higher deductibles, and may face a greater premium contribution, the KFF survey found. Think of it as a high-cost ticket and maybe a middle seat, to boot. In that same vein, the health overhaul’s ban on insurers using pre-existing condition information to refuse coverage or raise prices doesn’t take effect until 2014, which affects today’s self-employed workers who are older and have families. Those workers can find themselves paying much more than the  under an employer plan.ÌýState plans for high-risk individuals who are otherwise uninsurable typically are high priced and full of restrictions.

Sorry, your flight has been delayed. Of course, even sitting in first class doesn’t mean your flight won’t have mechanical problems or weather delays or a rough landing. Similarly, the most comprehensive insurance is no guarantee of high-quality, safe and appropriate care.

A new ticketing system? For all the inconveniences of the current health insurance system, it is at least familiar. However, both the public and private sectors have plans to shake up the shopping process as has happened in the era of deregulated airlines. It may come through easy-to-compare online shopping for basic health plans when the health law’s coverage mandate takes effect in 2014. It may be the use of vouchers and comparative shopping among insurers for Medicare beneficiaries, as in the Republican Medicare plan proposed by Rep. Paul Ryan, R-Wis., the GOP vice presidential nominee. Or it may be in the increased use of high-deductible health plans by the private sector that put the onus on employees to choose the best care value.

Unlike with airline tickets, however, consumer choices in health care can lead to consequences that truly are non-changeable and non-refundable. Whether the industry turmoil leads to more Americans getting a better “seat” at a better price remains to be seen.

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There is a corner of the health care industry where rancor is rare, the chance to banish illness beckons just a few mouse clicks away and talk revolves around venture deals, not voluminous budget deficits.

Welcome to the realm of Internet-enabled health apps. Politicians and profit-seeking entrepreneurs alike enthuse about the benefits of “liberating data” – the catch-phrase of U.S.ÌýChief Technology Officer Todd Park – to enable it to move from government databases to consumer-friendly uses. The potential for better information to promote better care is clear. The question that remains unanswered, however, is what role these consumer applications can play in prompting fundamental health system change.

, a physician, attorney and senior program officer at the Robert Wood Johnson Foundation, is optimistic. “We think that by harnessing this data and getting it into the hands of developers, entrepreneurs, established businesses, consumers and academia, we will unleash tremendous creativity,” Painter said. “The result will be improved and more cost efficient care, more engaged patients and discoveries that can help drive the next generation of care.”

The foundation is backing up that belief with an open checkbook. RWJF recently to , a multi-functional symptom checker for web and mobile platforms. Developed by two Johns Hopkins University medical students, the app determines a possible diagnosis far more precisely than is possible by just typing in symptoms as a list of words to be searched by “.” Symcat also links to quality information on different providers and can even direct users to nearby emergency care and provide an estimate of the cost.

Symcat received its check in early June at the , an event where the  upbeat tone was reflected in its official nickname, Datapalooza. Sponsored by the Department of Health and Human Services and the Institute of Medicine, the first such meeting in 2010 fit into a cozy auditorium. This year’s gathering drew nearly 1,500 attendees to the Washington Convention Center to discuss how consumer-friendly data could disrupt old ways of delivering health care information.

The federal government plays multiple roles in that effort as convener, innovator, cheerleader and facilitator, the latter through an aggressive program to open up data to the private sector. Symcat, for instance, draws on disease prevalence data from the Centers for Disease Control and Prevention. Other presenters and exhibitors showed off new efforts to apply these federal resources to help anticipate asthma attacks, make diabetes care more effective and improve survival estimates in cancer patents.

The intense interest in consumer health IT comes in response to “an increasingly health care ‘do-it-yourself’ world,” notes economist Jane Sarasohn-Kahn. now use health-related blogs, social networks, ratings websites or apps. Health and medical apps for the iPhone now target fitness, stress, chronic disease, mental health, smoking cessation and medication adherence, to name just some categories tracked by MobiHealthNews.

Funding has followed the crowd, with in just two years to $766 million, and the average start-up pulling in nearly $12 million. The medical app market, already growing faster than the general apps, will grow 25 percent annually over the next five years, according to .

Despite the buoyant marketplace, it remains to be seen whether the effectiveness of individual apps will . While MobiHealthNews health- and medical-related iPhone apps as of April, the reliability of any particular app or even category of apps is hard to determine. One research group that both content and user interface be tailored as necessary to respond to cultural differences among different racial and ethnic groups. Separately, another group of researchers examining web-based tools to help consumers control their diabetes that “few tools … met our criteria for effectiveness, usefulness, sustainability and usability.”

That uncertainty shadowing this fast-evolving field is one reason the Food and Drug Administration wants to regulate medical apps it believes could present a risk to patients if they don’t work as intended. That sentiment prompted a backlash among those fearful that bureaucratic caution would block innovation. In mid-July, that, among other provisions, calls on HHS to report to Congress on an “appropriate, risk-based regulatory framework pertaining to health information technology, including mobile medical applications.” FDA is expected to release guidelines reflecting its thinking by year-end.

Opening up new information sources to patients will also affect the traditional doctor-patient relationship. There is growing activism by some patients who don’t want to wait to become full, in their care. For instance, Hugh Campos, who has long-standing heart problems, for demanding access to the data feed from his pacemaker. At the same time, some physicians wonder whether this level of involvement truly represents a trend. In a , Dr. Arnold Relman, former editor of the New England Journal of Medicine, said he had “some reservations about the depiction of a future patient who is consumed by constantly watching [remote] sensors talk to his smartphone. I don’t think that patients are going to be motivated to do that all the time.”

A found that about one in 5 mobile phone users search for health information. And experts caution that lasting behavior change is often blocked by barriers as much psychological as informational. An app whose interface is appealing isn’t the same as one that’s effective.

Jessie Gruman, a four-time cancer survivor who heads the Center for Advancing Health, points out that “keeping ourselves alive and out of pain is a serious business.” Those who are sick don’t need apps that are fun, says Gruman. Rather, “we want a technology that is efficient and useful –one that will help us take care of ourselves so that we can live lives that are fun.”

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A radical change just getting underway in the U.S. health system could transform how medical treatment has been paid for since Hippocrates made his first house call. But the new payment method faces conflicting dangers: either it won’t be strong enough to upend entrenched incentives or it will be so successful it will prove too politically disruptive to survive.

The “accountable care organization” replaces the idea of reimbursing individual doctors and hospitals by procedure with a lump-sum payment to clinicians working as a formal ACO team. Under the terms of the Affordable Care Act, a Medicare ACO agrees to be responsible for all the care needs of a group of patients and to be paid based on those patients’ health outcomes, satisfaction and costs.

The federal government recently announced that Medicare ACOs are now serving more than a million elderly Americans in locales as diverse as Los Angeles County, the Mississippi Gulf Coast and New York City’s Chinatown. That number is expected to at least triple by year’s end. At the same time, most  are also experimenting with ACOs, leading to a potentially powerful convergence.

“This is a vast change,” said Dr. George Lundberg, editor-at-large of MedPage Today and former editor in chief of the Journal of the American Medical Association. “It is a credible way to move the health-care system.”

Millenson

But as Lundberg and others caution, that credibility will be tested as ACOs move from concept to reality.Ìý 

The drawbacks of fee-for-service reimbursement are hardly secret. In 1909, the playwright George Bernard Shaw wondered why “any sane nation, having observed that you could provide for the supply of bread by giving bakers a pecuniary interest in baking for you, should go on to give a surgeon a pecuniary interest in cutting off your leg.” A century later, McKinsey Global Institute identified “” as one reason U.S. medical spending is more than 25 percent higher per person than even in other industrialized nations.

ACOs explicitly target the “value versus volume” problem. In an ACO, a group of physicians and a hospital share clinical and financial responsibility for providing all care needed by a group of patients whether in the hospital or outside it. Rather than each procedure propping up the bottom line, the partnership prospers by keeping patients healthy and meeting clinical and cost-effectiveness goals. The intent is to reward quality, not quantity, of care.

ACOs differ in important ways from the last two major attempts to infuse cost-consciousness into American medicine. In the mid-1980s, with Medicare in crisis, Congress changed how hospitals were paid. The old “cost-plus” system, giving every hospital a guaranteed profit margin, was replaced by a “prospective payment system,” in which Medicare would pay a flat fee set in advance and based on each patient’s diagnosis, not each hospital’s costs. Following that change, the average length of a Medicare hospital stay plunged, and many private insurers adopted the same payment model.

In the mid-1990s, health maintenance organizations and other private insurers moved to more restrictive managed care contracts using a variety of fixed payment schemes meant to push providers to reduce unnecessary care, or lose money. At the height of managed care’s influence, the average rate of dropped to less than a third that of both general inflation and workers’ raises.

Both victories proved short-lived.

With Medicare, there was a backlash against patients being discharged “quicker and sicker” that subsided when initial anecdotes proved overblown. Still, hospitals soon found ways to move care to the outpatient setting or other places where prospective payment didn’t apply.

With managed care, the was more sustained. A spate of attributed to sharp cutbacks in genuinely needed care – such as new moms being discharged within 24 hours, ready or not – sparked a political uproar that ultimately persuaded insurers to loosen the rules.

ACO advocates have tried to learn the lessons of both too tight and too loose controls. For example, the “” designed by Blue Cross and Blue Shield of Massachusetts, considered a model for ACOs, addresses the cost-shifting that allowed facilities to work around prospective payment by including inpatient and outpatient treatment, pharmacy and behavioral health.Ìý At the same time, to protect providers from feeling unfair financial responsibility, the contract includes adjustments for factors such as general inflation and how healthy a particular group of patients has been.

Unlike prospective payment or managed care, ACOs also include a long list of rules meant to balance cost-containment incentives. Medicare requires ACOs to be run by hospitals or doctor groups – not insurers – and beneficiaries can seek care outside the ACO without financial penalty. Moreover, the government has mandated 33 publicly disclosed quality measures related to care coordination and patient safety, preventive health services, at-risk populations and the patient experience of care.

“You don’t get paid a dime if you don’t hit the quality metrics,” said Donald Fisher, president of the American Medical Group Association, a strong proponent of the concept.

Hopes run high. In a recent , Lundberg wrote that ACOs could help “build a new medical world based less upon … lucre, and more on … outcomes” such as keeping patients healthy and treating illness effectively. Providers would no longer profit from catering to the “worried well.”

But the potency of that profit potential is exactly what concerns ACO skeptics.ÌýEstablishing a Medicare ACO is voluntary and current financial rewards are modest, mostly due to fears that larger financial incentives might trigger accusations of “rationing” at a time when the political consensus for innovation is fragile. That raises the question of why providers should forego fee-for-service until forced to do so.

Lawrence Casalino and Stephen Shortell, two well-regarded academics, under the largest Medicare ACO program, “even an efficient, high-quality ACO will gain less money from sharing in savings than it would have earned if it had simply continued with business as usual.”

Going forward, the balance of ACO risk and reward will be crucial. Even if the health reform law is overturned, the concept has had . Moreover, the Medicare fee schedule for physicians and prospective payments to hospitals is failing to keep pace with medical inflation, even though Congress staved off a 27 percent reduction in physician fees that had been scheduled for March 1. In this continued era of fiscal austerity, Medicare can either pay all providers less and less money for all the care they give or slow costs by paying an adequate reimbursement to doctors and hospitals providing high-value care. .

“The system cannot and will not pay what it has in the past,” said economist Michael Chernew, a professor of health care policy at Harvard Medical School. “The boat is sinking, and they’ve built a reasonable life raft.”

Chernew says an ACO-type contract allows providers to reap the benefits from providing more efficient and effective care. That’s one reason he believes ACOs are now being offered by even high-profile and prosperous organizations, such as Harvard-affiliated Partners HealthCare System.

Medicare has authority to create incentives for all providers to join ACOs without having to go back to Congress for permission. That’s unusual. “If it works, it’s easy to expand,” said Andrew Croshaw, a partner in the health care practice of Leavitt Partners.

And if that indeed happens, says AMGA’s Fisher, “this is the beginning of the end” of fee-for-service medicine.

This article was produced by Kaiser Health News with support from .

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The effort is pegged to the success of a little-known entity called a “” (HEN). In December, the government selected 26 HENs and charged them with preventing more than 60,000 deaths and 1.8 million injuries from so-called “hospital-acquired conditions” over the next three years. That would be the equivalent of eliminating all deaths from HIV/AIDS or homicide over the same period.

Despite those big numbers, and an initial price tag of $218 million, it’s unclear whether the HENs are adequately ambitious or still only pecking away at the patient safety problem. While this is by far the most comprehensive public or private patient safety effort ever attempted in this country, it still aims to eliminate less than half the documented, preventable patient harm.

The inspiration for these networks comes from similar collaborative projects run by the Institute for Healthcare Improvement and other groups. Dr. Donald Berwick, IHI’s founder and president, headed up the Centers for Medicare & Medicaid Services for two years and launched a larger  that includes the HENs.

In December, the government chose a mix of national and local groups — primarily health systems and hospital organizations — to run individual HENs. Each HEN is charged with spreading safety-improvement innovations that have been proven to work in leading hospitals to others through intensive training programs and technical assistance. Although the program lasts three years, initial HEN contracts are for two years, with an “option year” dependent upon performance.

This bottom-line accountability is what sets the HENs apart from past voluntary efforts.ÌýProgram co-directors Dr. Paul McGann and Dennis Wagner give weekly briefings to Health and Human Services Secretary Kathleen Sebelius. “This is a full-court press unlike anything I’ve seen in my 10 years in government,” McGann says.

Although the HENs’ total cost is slated to rise to $500 million by its third year, that’s still chicken feed compared to what the government says will be savings of up to $35 billion from safer care, including up to $10 billion in savings for Medicare. In addition to preventing injuries and deaths, the program plans to eliminate 1.6 million preventable hospital readmissions.

Still, there remains the question of whether the program’s goals should be even more sweeping. And one might wonder why the chance to not harm patients is not reason enough for hospitals to change without being paid by the government.

For context, it helps to understand that the most widely quoted estimate of preventable patient harm – 44,000 to 98,000 deaths and one million injuries annually – was probably low. That estimate caused an uproar in a . Today, it seems conservative. The IOM total was based on studies conducted in hospitals in the mid-1980s. Recent research by the HHS Office of the Inspector General (OIG) and others has found a much higher rate of harm. A Medicare patient today has a , a risk about four-to-seven times greater than in the IOM report.

Moreover, , the OIG concluded, even including incidents that led to patient deaths. “If you measure all-cause harm, you find it in about one-third of patients,” says the University of Utah’s Dr. David Classen, lead author of a that appeared in Health Affairs. That lack of progress testifies to very modest pressure to show results.

Enter the HENs, prodded by a stick.

In 2008, Medicare began denying payments to hospitals for eight complications of treatment, the program’s first major use of negative incentives.Ìý, along with efforts to pressure hospitals through public . Meanwhile, the 2010 health reform law includes financial penalties that go into effect later this year to discourage preventable readmissions.

Put differently, hospitals now have a significant financial as well as ethical incentive to participate in a hospital engagement network. Even so, just 3,800 of the nation’s 5,000 acute-care hospitals have done so.

Federal officials stress they are paying the HENs, which both guide and oversee hospitals, not individual institutions. For instance, a HEN run by a national consortium of academic medical centers is building a data analytics infrastructure which it will share with another HEN run by a national public hospitals group. State and local HENs have said they will form “learning communities,” providing technical expertise and one-on-one coaching reporting and tracking databases. Each HEN will monitor member hospitals’ progress and, in turn, be monitored by HHS.

Meanwhile, two groups that are operating HENs and are national leaders in patient safety say that the program will be helpful even in light of the care improvements they have already made. Executives at the Ascension Health system and the Premier hospital alliance say that the resources, cooperation and infrastructure assistance from the federal program will enable even their groups to reach a level of performance improvement unattainable on their own. One reason is that participants in the HEN must reduce hospital-acquired conditions by 40 percent from their starting point, not from a potentially laxer national average.

That still leaves the question of how much harm could truly be eliminated. HHS hopes to save 20,000 lives and roughly $12 billion each year. (The harm avoided will be to all patients, but only the financial savings from avoiding harm to Medicare patients will accrue to the program.) By way of context Premier says that if all U.S. hospitals achieved similar results to its , whose results were announced in January, it would save more than 87,250 lives and $34 billion in health care costs in just one year.Ìý has had similar success, although the two organizations are measuring a somewhat different set of indicators from each other and from the HEN program.

Consumer advocates such as Martin Hatlie, a co-founder of , and Helen Haskell, head of Mothers Against Medical Error, believe the program’s target is too low. Still, both Hatlie and Haskell support the program’s approach — and the Medicare decision not to pay for some medical problems caused by hospital mistakes.

Says Haskell, “I do think federal dollars – whether offered or withheld – are the key to getting hospitals to pay attention to safety.”

Michael L. Millenson is a Highland Park, Illinois-based consultant, a visiting scholar at the Kellogg School of Management and the author of .

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The anxiety when a loved one is injured is compounded when you know just how risky making things better can get. As a long-time advocate for patient safety, my interest in the topic has always been passionate, but never personal. Now, as Susan was being rushed into the emergency room, I wanted to keep it that way. “Wife of patient safety expert is victim” was a headline I deeply hoped to avoid.

Michael Millenson and his wife, Susan (Photo provided by Millenson)

In the weeks after the accident, we spent time at a 50-bed hospital in Maine; a Boston teaching hospital where Susan was transferred with a small vertebra fracture at the base of her neck and broken bones in her left elbow and hand; and a large community hospital near our suburban Chicago home. There were plenty of opportunities for bad things to happen — but nothing did. As far as I could tell, we didn’t even experience any near misses.

What went right? After all, though our health care system knows how to prevent errors that kill 44,000 to 98,000 people in hospitals each year, that death toll . Based on personal and professional observations, I’d simplify the formula that kept Susan safe into three variables: consciousness, culture and cash.

Consciousness of patient safety sounds easy, but it isn’t. The harm caused patients is inadvertent and often occurs as part of complex interventions. As a result, pointedly noted, “clinicians have labeled virtually all harm as inevitable for decades.”

But today, the cloak of invisibility is being lifted. Twenty-six states require hospitals to report certain medical errors; Medicare and some private insurers won’t pay for problems caused by a growing list of quality and safety lapses, and the government has launched the $1 billion Partnership for Patients to dramatically reduce avoidable harm.

Just as importantly, patients are worried. In a poll by Consumers Union, 77 percent of respondents expressed high or moderate concern that they might be harmed by a hospital infection and 71 percent had the same concern about medication errors. Inevitably, more patients and their families are speaking up — as I most certainly did, albeit as politely as possible.

When the ER nurse at Maine’s York Hospital gave Susan morphine, I asked about the dosage and timing. When she was transferred to Massachusetts General Hospital in Boston, I asked each medical professional to identify themselves and what they were doing. Although it’s impossible to know if my questions had any positive impact, at a minimum they reinforced an existing safety consciousness.

Although consciousness of a problem can spur change, sustaining it requires a supportive culture. Can there be any more graphic expression of a safety culture commitment than Baylor Health Care System’s mission to eliminate preventable deaths, preventable injuries and preventable risk?  Or Ascension Health’s “healing without harm” initiative and its goal of reducing preventable deaths by 900 each year? (They’ve reached a minimum of 1,500 so far.) Both organizations have published results in the peer-reviewed literature.

Glenbrook Hospital in suburban Chicago — it’s part of the NorthShore University HealthSystem — isn’t quite as ambitious in its objectives. Still, its culture was obvious even before I peeked at the monthly infection report left sitting on a reception desk. When the orthopedic surgeon was explaining the procedure he would be doing, he talked about safety. The consulting neurosurgeon (due to Susan’s neck injury) talked about safety. The anesthesiologist talked about safety. Right before surgery, nurses fitted Susan with surgical stockings to prevent deep vein thrombosis — an evidence-based guideline followed by fewer than half of hospitals. When I challenged the surgical team on appropriate prophylactic antibiotic use, a nurse indignantly cited a study showing I was mistaken.

I backed off, happy they’d thought about the issue seriously. But I did feel emboldened to ask whether the team in the operating room took time-outs before surgery (the evidence shows it helps make sure everyone’s on the same page before you start cutting) and whether the team introduced themselves before proceeding (believe it or not, even the doctors may not be entirely certain who is behind those masks). Yes and yes, the answers came back.

Culture change at hospitals is easier these days with like Ascension and Baylor, and with safety checklists like the one developed by Johns Hopkins’ critical care specialist . But if consciousness is one barrier to culture change, another one of at least equal importance is cash.

There’s a link between financial stress and patient distress. A recent study in  found the 178 “worst” hospitals in the United States care for more than twice the proportion of elderly minority and poor patients as the nation’s 122 “best” hospitals, where costs are lowest and quality highest. As one headline put it, “Bad Hospitals, Poor Patients.”

Money talks in other ways. I’ve written about how some hospitals implicitly see adverse events (although, of course, actual patient deaths thwart that goal). The hospitals where my wife was treated were all prosperous. Even without worrying about a reluctance to confront complications, would a cash-strapped York have transferred Susan to a tertiary care facility, or would they have assured a well-insured patient they could take care of her broken neck? Would a bottom line-driven Mass General or Glenbrook have angled for a longer hospital stay?

It’s tough enough to change culture. It’s even tougher if it you think you’ll lose money doing so. That’s why Medicare is increasingly linking payment to explicit quality and safety indicators.

We ask a great deal of physicians, nurses and other professionals. Those whom we encountered juggled multiple roles — healers attending to the ill and scared, prudent managers of health-care resources and team players in system improvement. For the skill and grace with which they performed all those roles we were deeply grateful. Thanks to them, Susan has now recovered to the point that to the casual observer there’s no obvious evidence of her multiple injuries.

Our experience showed that “doing the right thing” — appropriate care — and “doing the right thing right” — safe and effective care — can become the norm at rural, suburban and big urban teaching hospitals alike. On a personal level for the two of us, and on a system level for all of us, that’s very good news.

Michael L. Millenson is a Highland Park, Illinois-based consultant, a visiting scholar at the Kellogg School of Management and the author of .

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What the two men are advocating is simple: hospitals should offer the same level of professional staffing and patient care on weekends as during the rest of the week. They should do this, the two men , because trying to cram seven days of care into five leads to a cascade of problems that harm and even kill patients. It also costs a lot of money.

That’s the commonsense part. The hopeless part is that Long and Vaswami, both affiliated with the , seem to believe that doctors, nurses and hospital execs will read their article and then spontaneously volunteer to work the weekend shift.

American hospitals are complex entities, but at heart they remain the doctor’s workshop, dependent upon the goodwill of physicians who admit and care for patients. Maintaining that goodwill requires treading carefully. For instance, telling a neurosurgeon, “You’re working Wednesday through Sunday this week” would rank high on the list of what a friend of mine calls a “career-limiting event.”

Long and Vaswami are aware they’re tampering with long-standing tradition, but as justification they offer a disturbing catalog of the effect of care controlled by the calendar.

To begin with, bunching scheduled admissions in midweek often overwhelms the staff, leading to “significant” increased risk of patient death or admission to the Intensive Care Unit. Filled beds force emergency rooms to discharge patients to “inappropriate care locations,” with the hospital relying on specialized teams to ride to the rescue “when patients deteriorate because of inadequate care.” At the same time, “medically appropriate transfers may also be delayed or rejected.”

And that’s when hospitals are operating normally. Patients admitted over the weekend face an increased risk “because critical diagnostic or therapeutic modalities are not available,” while patients staying over the weekend experience “delays at best and deterioration in clinical condition at worst.”

Finally, peak-and-valley scheduling is inefficient, causing hospitals to build expensive new facilities instead of efficiently using existing capacity. With an aging population and new access to health insurance, that approach will cost “billions of dollars.”

For all their indignation, however, Long and Vaswami pull their punches on both causation and remediation. So, for instance, in a 1,000-word essay backed by citations from The New England Journal of Medicine and similar sources, they never once use the words “doctor” or “physician” when referring to those whose behavior needs to change. Indeed, Long, an anesthesiologist, and Vaswami, an MBA, seem to run away from the implications of their own words. Avoiding either practical recommendations or moral outrage, they conclude: “Health care professionals have no choice but to carefully consider [emphasis added] whether weekends off are more important to us than the quality and cost of care we provide to our patients.”

I’m surprised they didn’t just write, “Take a few days off to think about it.”

Of course, the two men understand they are opening a Pandora’s box. The kind of compromises hospitals make to keep the medical staff happy is not a topic anyone wants to openly discuss. Let’s look at a few examples.

In a by the American Association of Critical Care Nurses nearly nine of 10 nurses said they’ve seen doctors make mistakes or take dangerous shortcuts. Yet only four in 10 nurses felt empowered to speak up. In a similar vein, 3 to 5 percent of hospital physicians are estimated to be outright disruptive, with a between their misbehavior and problems ranging from nurse turnover to outright errors. Researchers bemoan the unwillingness of doctors to discipline colleagues or hospitals to risk alienating big admitters.

In that kind of environment, it takes a special person to question who the hospital is really set up to serve. Myra Rosenbloom, the elderly lady I mentioned earlier, is that kind of person.

Myra first called me back in 1993. Jack Rosenbloom, her husband of 45 years and her partner in a kosher catering business, had been admitted to a local hospital the previous September after suffering a heart attack. Jack was in stable condition when Myra visited him on Saturday evening but then started suffering chest pains. The hospital declared a code-blue emergency, but on a weekend night no doctor was available. Jack died that night in the ICU.

That’s when Myra discovered that in Indiana, as elsewhere, no law required a doctor to be on duty, only that one be available within a certain time. (Typically, that’s 15 to 30 minutes.)

Myra initiated a one-woman crusade to require hospitals over 100 beds to have a doctor other than the one in the emergency room on duty at all times. During Indiana’s 1994 legislative session, she slept for five cold nights on a hard wooden bench inside the Capitol before the legislature passed a watered-down bill requiring a doctor, but letting an ER doc count towards the requirement. An ER physician was on duty at the hospital where Jack died, but he’d been too busy with other patients to answer the code-blue call.

Facing tenacious opposition from hospital groups that said her idea would cause them economic hardship, Myra has since then failed to win approval of a tougher law in Indiana, failed to pass a law in Illinois and failed to called the Physician Availability Act. It was first introduced in Congress in 1976, was reintroduced for a few years, vanished and then resurfaced in 2009 with the backing of Rep. Jan Schakowsky, a Democrat from suburban Chicago. At the time, Myra was 85 years old.

I called Myra the other day, and she said Schakowsky wants her to find some Republican co-sponsors so Schakowsky can reintroduce the bill. “I won’t give up till the day I die,” Myra told me with the same spirit as when we first spoke 18 years ago.

Perhaps if the nascent specialty called “nocturnists” had existed back in the early 1990s, there would have been someone to save Jack Rosenbloom that Saturday night. But the larger point made by Long and Vaswami remains. The distortions caused by giving provider convenience a greater priority than clinical necessity is exacting a fearful and avoidable toll of deaths, injuries and expense that far outweighs the cost of addressing the problem.

If Long, Vaswami and colleagues are serious about how hospitals operate, they would do well to act seriously. They could start by showing even a smattering of Myra Rosenbloom’s persistence and courage.

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No, this isn’t one more commentary on the Georgia Republican’s checkered marital past. I’m referring to a different relationship, the one between Gingrich and the health policy community. A critical component of the climb back to prominence for a man who inspired nearly as much distrust in his own party as in the opposition was proving he could work harmoniously with those holding differing views on an important policy issue — how to reform U.S. health care.

Gingrich succeeded so well that some of the policy recommendations he was touting just a few years ago bear a close resemblance to Obama administration actions that Gingrich now denounces as leading us to “a centralized health care dictatorship.”

The romance between Gingrich and the health wonks, and Gingrich’s makeover as a leader with ideas as much substantive as political, began after the appearance of his 2003 book, Saving Lives & Saving Money. The book gave credibility and visibility to a set of ideas being talked about in the health policy world about using information technology to improve medical care.

In those early days of the Bush administration, IT types were still health policy wallflowers, sitting by a silent phone waiting for someone who wanted to talk about “computerized physician order entry.” But the wallflowers blossomed into belles of the ball after Gingrich coined the phrase, “Paper kills.” He also used his status and connections to advance the concept and capture the attention of the federal government, the news media and leaders of health care organizations.

In return, the health care world heaped rewards on its newfound friend. There were speech invitations at a reported $50,000 a pop and six-figure membership fees paid to his for-profit . Gingrich also received honors attesting to his non-partisan good works. For instance, he and then-Sen. Hillary Clinton, D-N.Y., shared an award from the National Committee for Quality Assurance. The Healthcare Information and Management Systems Society recognized Gingrich’s “commitment and leadership in working with both Republicans and Democrats.”

New Newt neutralized the negative images of the polarizing politician. The change could be seen in a 2004 headline that proclaimed: “As Speaker, Gingrich knew how to divide. Now he aims to unite — to transform health care as we know it.”

Old Newt stormed off President Clinton’s Air Force One miffed over a perceived lack of respect. New Newt quietly got himself appointed to a three-year term on the obscure National Advisory Council to the Agency for Healthcare Research and Quality.ÌýOld Newt was “the most divisive figure in the recent history of the House,” as the put it in 2000. New Newt had “reinvented himself as a respected entrepreneur of ideas,” concluded a 2005 profile. The stature Gingrich had gained from his work with the health policy community, along with his efforts related to national security, was a central part of that reinvention.

It was about this time that I began to feel for myself the powerful pull of the New Newt charm offensive. I had been appointed to the National Commission on Quality Long-Term Care, co-chaired by Gingrich and former Sen. Bob Kerrey, D-Neb. Up close and personal, the famed Scourge of All Things Liberal could seem positively benign: “Newt” to one and all Beatific smile… Ideas being spouted with a professorial air.

Nonetheless, unmistakable signs began to emerge that New Newt was more rebranding than reinvention. There was, for instance, the senior adviser at his Center for Health Transformation who spoke privately of proposing a real conservative plan to cover all the uninsured, a goal to which the Bush administration had only paid lip service. However, the true purpose was political — capturing enough independent voters to regain Republican control of the House in 2008.

Meanwhile, at the long-term care commission, Gingrich began inviting new members to join who fit his ideological mold. And, come to think of it, Saving Lives & Saving Money started off and ended with pages of political photos, including Gingrich and Dick Cheney, not noted for an interest in health IT interoperability.

The shiny skein of New Newt inevitably began to wear away. Our commission closed its doors at the end of the 2007, but one could see Old Newt re-emerging as the 2008 campaign beckoned. Since then, the process has only quickened.

To give just one example, Gingrich-as-health-wonk for years advocated reforms such as “data-driven reimbursement” informed by best practices, a national electronic health network and a focus on prevention and wellness. All those items — and others Gingrich supported — are contained in the HITECH Act, part of the budget stimulus package and the Affordable Care Act.

That shouldn’t be a surprise. A menu of measures to improve the efficiency of U.S. health care has long enjoyed bipartisan support. That only changed when Republican leaders decided to demonize “Obamacare” as a means of discrediting the Democratic president.

As Gingrich seeks the chance to try to defeat President Obama next year, he won’t accomplish that goal by being a consensus-seeking wonk. Nor, frankly, should he be one. Whether or not you like his views, Gingrich is a brilliant communicator and politician. Ideas he may have; an intellectual, he is not.

In the speeches Gingrich gives about leadership, he tells listeners that success depends upon a clear strategy and “entrepreneurial rather than bureaucratic behavior.” As it happens, a former colleague of Newt’s on that long-ago advisory council is now one of the Obama administration’s most prominent health care bureaucrats, Dr. Donald Berwick. Back then, New Newt must have listened and learned, since in his book he praises Berwick’s quality improvement work. But today’s Old Newt told Fox News’ Bill O’Reilly that Berwick’s appointment as head of the Medicare program was just another example of Obama’s “secular Socialist machine.”

I guess an entrepreneur running for president has to go after votes wherever he can get them.Ìý

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The government’s long-awaited on Accountable Care Organizations have brought a dose of ugly reality to a concept that’s always seemed coated with a patina of pixie dust. Unless those regs are substantially changed before the clock strikes Jan. 1, 2012 — the statutory date for ACO implementation — going to turn back into a scullery maid and the horse-drawn carriage transporting her to the Health System Transformation Ball will be revealed as nothing more than four mice and a pumpkin.

The essence of the ACO concept is using financial incentives to reward doctors and hospitals for redesigning care processes to provide “high quality and efficient service delivery,” in the words of the Patient Protection and Affordable Care Act. As I wrote last fall, ACOs have been the one reform beloved by Republicans and Democrats; doctor groups and insurance companies; policy wonks and profit-seeking capitalists. This unusual unanimity was due in part to a lack of specifics that enabled every stakeholder to gaze upon the ACO and see reflected their very own version of Prince Charming.

Conservatives hail the ACO as marketplace medicine, while liberals focus on organized systems of care replacing fee-for-service chaos. Providers applaud a reform that places them at its center, while health plans know that providers asked to bear financial risk — if an ACO doesn’t measure up, the government won’t pay up — will seek out actuarial experts like them as partners. ACOs also are expected to require the products and services sold by a host of consultants and entrepreneurs.

For medical groups and hospitals considering becoming an ACO, Medicare offers a straightforward risk-reward proposition. Providers must invest considerable resources in building an infrastructure and institutional culture capable of managing and measurably improving the health of a defined group of Medicare beneficiaries. In return, however, ACOs that meet the government’s standards will make much more money than if they clung to the old ways of care delivery.

The central problem with the draft regs, however, is that the risk-reward ratio is highly skewed. The Centers for Medicare & Medicaid Services painstakingly delineates a dizzying litany of hurdles to surmount, from documenting progress on 65 different quality measures to Medicare editing your marketing materials and to government monitors descending upon your offices. Meanwhile, the promised rewards are wrapped in a fuzzy package of impenetrable risk-adjustment algorithms and wait-till-next year financial commitments that sound like a cross between a cell-phone contract and a time-share vacation offer.

In the classic fairy tale formula, a king offers his beautiful daughter’s hand in marriage and half his kingdom to the young man brave and resourceful enough to ford a dangerous stream, climb a treacherous mountain and then slay a ferocious dragon. But if Medicare were making the rules, the successful suitor would be lucky to get a goodnight kiss — if not have the door slammed in his face. Not surprisingly, the list of volunteers to become an ACO under these conditions appears to be extremely short.

Consultant Steven Lieberman, a 30-year veteran of the Congressional Budget Office, warns that the new regs could kill ACOs outright. “The proposed regulation imposes unfavorable economics, unrealistic requirements, high uncertainty and significant risks for ACOs,” he writes . In the same vein – and — Ron Klar, a physician who has consulted extensively to health plans and to CMS, says the agency has created a program “likely to have few participants.”

Lieberman and Klar are both ACO supporters, but their concerns are widely, perhaps universally, shared. Those wary of offending CMS have mostly praised the agency for simply issuing the regs, while emphasizing how intently regulators will listen to complaints during the comment period. Support for specific provisions is scarce.

Still, it’s hard not to feel some sympathy for the bureaucrats. Yes, as Klar points out, they have written rules “overloaded with provisions to mitigate the likelihood that any conceivable negative possibility will occur.” Yet in today’s polarized political climate, any sort of backlash could prove fatal. One can envision a piqued ACO participant in (an Ohio town represented by House Speaker John Boehner) prompting a full-scale congressional investigation.

At the same time, opening the spigot of government funding to private-sector innovators, as the Bush administration did with MedicareAdvantage plans (or was that Medicare-Take-Advantage?) risks a backlash from liberal Democrats and Tea Party Republicans alike.

CMS is being asked to implement a risk-sharing program where everyone wins and a that disrupts nobody. It’s a handicap heavier than that borne by the private sector, where ACOs continue to proliferate, and more burdensome even than the shackles on the CMS Innovation Center, whose mandate to finance “demonstration projects” provides more political flexibility.

None of this, however, should cause us to lose sight of what’s at stake. The ACO concept continues to represent an extraordinary, perhaps even unique, opportunity to begin to remake American medicine in ways that are critical to our nation’s economic health and to health itself. Squandering that opportunity would be indefensible.

The potential reward is worth taking some real risks to achieve. When writing the final ACO rules, CMS has the chance to spin the dross of the current regulations into something of genuine value to providers, even if it’s not quite -quality gold. If the feds fail, it is all of us, not just those on Medicare program, who could live unhappily ever after.

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Conservatives, like liberals, have a more-or-less coherent set of ideas. They use political power to push preferred policies, whether related to health care, housing or a hundred other possible issues. William F. Buckley Jr., one of the fathers of modern American conservatism, “had a way of making conservatism a holistic view of life not narrowed to the playing fields of ideology alone,” as .

Although cynics may claim conservative credentials, their view of government is really nothing more than a quarrel about its cost. It brings to mind Oscar Wilde’s immortal phrase, “The cynic knows the price of everything and the value of nothing.”

The contrast between the two viewpoints was on stark display at two recent marquée meetings, AcademyHealth’s yearly and the sprawling Health Information and Management Systems Society — HIMSS — Health IT .

AcademyHealth’s “Running of the Wonks” (my term, not theirs) is a magnet for researchers and policy mavens who are inured by long experience to most political rhetoric. Yet at the general session featuring a bipartisan dialogue among congressional staffers, the harsh rhetoric from the GOP participants stunned the crowd. The new federal health law, it seemed, was evil incarnate, and the rhetoric of “repeal and replace” was wielded with a fundamentalist zeal.

“The bureaucracies that administer ObamaCare” must be cut, declared one aide to a powerful congressional leader, setting the tone. And in case anyone didn’t get the point, the word “ObamaCare” was deliberately repeated every few syllables in a tone of disdain combined with wonder at how such a monstrosity had ever come to be. (AcademyHealth meeting rules said the staffers could not be quoted by name.)

The audience of wonks quailed, then quietly queued up for the question-and-answer period. They knew, after all, that the health law’s fine print incorporates a generous helping of initiatives championed by both conservatives, and those on the left. Besides, these were staffers speaking, not politicians playing to the press. Surely, gentle reason would triumph. Alas, it was not to be.

The ? “You mean, the prevention health slush fund, as we like to refer to it?” replied a GOP staffer.

The at the Centers for Medicare & Medicaid Services? “An innovation center at CMS is an oxymoron,” responded a  Republican aide, before adding a personal barb aimed at the attendees: “Though it’s great for PhDs who come to Washington on the government tab.”

There was also no reason the government should pay for “so-called comparative effectiveness research,” another said.

“Everything’s on the chopping block,” said yet another.

Everything? At HIMSS, where GOP staffers also spoke, attendees were chagrined to learn that “everything” applied to them, too. The that were part of the American Recovery and Reinvestment Act were targeted in legislation introduced in late January by Rep. Jim Jordan, R-Ohio, chairman of the Republican Study Group. His bill would repeal this funding and eliminate all remaining stimulus spending, including about $45 billion in unspent health IT funds.

Those focused on the substance of health policy might be forgiven for feeling blindsided. After all, the in the 2008 presidential election called for coordinated care, greater use of health information technology and a focus on Medicare payment for value, not volume. Once-and-future Republican presidential candidates such as former governors Mike Huckabee (Ark.), Mitt Romney (Mass.) and Tim Pawlenty (Minn.), as well as ex-Speaker of the House Newt Gingrich, have long promoted disease prevention, a more innovative federal government and increased use of information technology. Indeed, federal health IT “meaningful use” requirements can even be seen as a direct consequence of Gingrich’s popularization of the phrase, “Paper kills.”

Ah, but that was back before the Republican cynics swept into power. It was back before traditional GOP conservatives — worried that any suggestions outside a single-minded focus on slashing spending would be seen as disloyal — eschewed ideas in favor of ideological declarations.

This column was filed just days after a two-week compromise was signed into law to avoid a federal government shutdown. It allowed funding for health reform to continue, but instituted other budget cuts. Obviously, the cynics yielded a bit, at least for the moment, to the conservatives, and the liberals and centrists have given ground to both.

Still, one wonders what the urbane Buckley would think of a movement that seems intent on ignoring the real-world context of its actions. Buckley launched his lifetime crusade against liberalism with God and Man at Yale, a book that took aim at the academics who’d taught him as an Ivy League undergraduate. Alas, the GOP cynics are cocooned instead in an underground bunker of their own design, as impervious to realities they’d prefer to ignore as the ivory tower academics they’ve come to scorn.

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