Standing At The Gates of Hell

Je Suis Charlie? That all depends. Am I Charlie, a faceless Parisian joining with thousands of others along the Avenue des Champs-Élysées in candlelit vigil mourning a national tragedy? Or am I Charlie, a major newspaper like the New York Times having to carefully weigh my support of free speech – however rancor and callous that may be – against my potential complicity in unwittingly embracing and spurring additional tragedy? Either way, it’s no fun being Charlie.

Unless you have been hibernating through the cold of January or living under a rock you have some knowledge of the tragic events that unfolded in Paris on January 7th. At approximately 11:30 that morning two men armed with Kalashnikov rifles and other assault weapons entered the offices of Charlie Hebdo – a French satirical weekly newspaper – and slaughtered 12 individuals, including its popular yet controversial editor, Stéphane Charbonnier. The perpetrators were subsequently killed following a massive manhunt, as was their wont, being self-proclaimed Jihadists whose attack they claimed was vengeance for Hebdo’s cartoonish portrayal of the Prophet Muhammad.

Charlie Hebdo’s historical agenda of satire reflects an equal opportunity offensive. Charbonnier said two years earlier that, “we have to carry on until Islam has been rendered as banal as Catholicism." Anyone with a working familiarity of history will recall the Catholic church’s legacy is anything but banal. But whereas Christianity has by and large been secularly assimilated into a separation of church and state, radical elements of Islam seem increasingly intent on remaining more than a few centuries behind. Thus be to tyrants and zealots and their expedient interchangeability in the name of power and control.

In the aftermath of the events in Paris columnists, pundits and editorialists have taken to whatever venue will have them to let us all know who’s at fault, what could have been done to prevent it and what we absolutely, positively must do next to prevent further aggression. They write and speak with such authority that it truly is amazing they have either been silent up to now or just recently had the epiphany that will save us from the gates of hell.

The reality is there are so many different ways to theoretically and intellectually slice the myriad social and political challenges of extremism in the name of religion that even the Whitehouse is afraid to use the term, Radical Islam.  Obama ne résiste avec Charlie? If there is a war against that extremism who or what exactly are we fighting against? A religion? An idea? Criminals? A nation-state? The aforementioned experts believe it’s somewhere between one of those and all of the above. Brilliant, right?

All I know, or what I think I know in any event – if you’ve followed my blog, you know this is a substantial subject-matter departure – is that terrorism will never go away as long as it can have the effect desired by its perpetrators.  And I know that in the long run it will never achieve its desired purpose. Never has. What I believe is that terrorism or violence of any type in the name of a religion wanes in proportion to the ability of that religion’s followers to achieve prosperity and happiness.

And so eventually, the power and control held by the few under the guise of religious fundamentalism will crumble under the weight of the many who become educated and enlightened to how they have been manipulated for centuries into oppression and  subservience. We have seen this taking shape already, and electronic communications are helping to accelerate the process. In the meantime, I am afraid, there is going to be a lot more hell to pay no matter what course of action is chosen.

  ~ Sparky

CCRCs As Healthcare Providers

HCG1Earlier this month Steve Maag, LeadingAge’s Director of Residential Communities, shared an insightful video presentation (a Quickcast) on environmental and industry trends that are anticipated to impact the future of continuing care retirement communities (CCRCs). If you are in any type of leadership position in an organization that owns and/or operates a CCRC with some level of responsibility for that organization’s future direction, then I strongly encourage you to find 15 minutes to watch this presentation.

There are three broad areas Steve addresses, including consumerism, healthcare reform and technology. This being a blog on healthcare public policy, a couple of years back I shared some of my own thoughts on the risks and perils that CCRCs face in assessing their role as a healthcare provider in the post, CCRCs: Healthcare Providers—Or Not.

Now having some additional data points I thought it might be interesting to revisit what I wrote back in August 2012. I then identified five major areas that CCRC organizations needed to be cognizant of as they assess strategic positioning as a healthcare provider in their market:

Healthcare delivery related cost pressures
New care delivery and payment models
Increasing demand for home and community-based services
The need for infrastructure investments
Potential future tax consequences for nonprofit organization

In considering the impact these areas could have on organizations unwilling or unable to effectively address that impact it was my opinion then that those organizations would be further ahead to get out of the healthcare business altogether than to wait on the sidelines. Fast forward 29 months and I will double down on that assessment.

Successful CCRC organizations of the future are making the requisite investments today to assess their healthcare market environment and determine how they can effectively and profitably integrate into that environment. To assist organizations with that process I recently updated my whitepaper: A Framework for Strategic Planning & Positioning in an Era of Healthcare Reform. Please feel free to download and use to help your organization with this critically important assessment.

  ~ Sparky

Should The Employer Mandate Survive?

Over the period January 8th through the 11th of last week the Morning Consult conducted a poll of 1,707 registered voters to understand their views regarding the Employer Mandate. The reported responses have a margin of error of +/- 2.4% (I assume that’s at 95% CI). What they found seems a bit counterintuitive at first. But it may reflect an indication of where we sit along the curve to better understanding the economics of healthcare in the United States.

Of those polled, 74% believe that a 40-hour workweek should constitute full-time employment – not 30, the definition used as part of the Affordable Care Act’s employer mandate provision. But only 58% support Congress’s effort to legislatively change that definition. Why? Dunno. And yet, 57% of respondents overall support the employer mandate provision of the Act, and 55% believe companies should provide healthcare for part-time employees.

Whether employers are required to provide health insurance for their workers at 20, 30 or 50 hours misses the broader discussion of whether the employer mandate still makes sense in light of other provisions of the Act having been enacted. And it misses the political discussion of whether it’s a reasonable and plausible giveback to a Republican Congress that’s carried around the repeal and replace bone long enough.

Even the most ardent opponents of the ACA have to admit, if they are being honest, the past few years have increased the individual and social consciousness of healthcare as a very real – and very expensive – commodity that has been more misunderstood than any other product or service in history. And despite the major early challenges of the insurance exchanges most indications now support the dawning of a new dynamic in financing healthcare delivery: the expansion of individual insurance and responsibility.

Ever since wage freezing during WW II led employers to use healthcare benefits in seeking competitive advantage recruiting workers the disconnect between what individuals pay out of pocket for healthcare – and what healthcare actually costs to produce – has been an underlying source of tremendous waste and inefficiency. Have the exchanges, coupled with the incremental increase in Medicaid expansion, made the employer mandate concept moot – or worse, an economic albatross that could stifle growth at a time when the country just might be turning a corner?

What do you think?

  ~ Sparky


Sorry Charlie: Too Many Sharks at the Trough

There is an old analogy in healthcare that refers to the largesse of national healthcare spending as the Big Tuna. Many sharks feed off that tuna – the extension of the analogy being that many individuals and organizations financially benefit from being in the healthcare industry without adding any real value to the consumers served by the industry – patients.

This is my interpretation of an article posted by Dr. Fred Pelzman on New Year’s Day, Return the clinician to the center of the health care experience, on the KevinMD healthcare system blog. Dr. Pelzman asks what I believe should be the quintessential question of the 2015 healthcare policy debate: “Are we allowing the health care system to be transformed by people who should not be transforming health care?”

Now, it should be remembered that it was a clinician – Dr. Donald Berwick – who popularized the Triple Aim concept that came out of the Institute for Healthcare Improvement prior to the Affordable Care Act being passed. Clinicians are not exempt from thinking big thoughts and hoping to altruistically apply that thinking to achieve goals and objectives that are widely held desirable by society. So I don’t know if getting them unselectively more involved is going to lessen the incredible waste that rightly drives physicians like Dr. Pelzman crazy.

But I do know – or rather I believe, anyway – there is a finite limit of tuna available to satiate the sharks before they start feeding on the patients. It’s indignantly ironic that clinicians are being pressured to improve performance in the name of value when a great deal of the non-clinical world is only being held accountable to producing value in the abstract – and most often ex post facto.

Unquestionably, there needs to be greater connectivity between the work performed by non-clinicians and the ultimate value produced for patients. This is not going to be any easier to measure than patient outcomes’ metrics currently being explored and tested on/by clinicians. So what? Get used to it.

As I have written before, I wholeheartedly agree with those who, like Dr. Pelzman, promote the central role clinicians must play in assessing, planning and implementing healthcare public policy. But if you look at the landscape you will see there are already quite a few retired clinicians in that space, and the system is still largely a mess. So there must be more to the story.

What do you think is missing?


Is Being Ignorant Better Than Being Stupid?

In the poem, Ode on a Distant Prospect of Eton College, Thomas Gray wrote that, "where ignorance is bliss, ’tis folly to be wise." He was referring to the unfettered ability of time to ultimately win any race against human pain and sorrow – and since that race is determined before it is run, why not walk and enjoy what you may. Or something like that.

Earlier this week renowned healthcare economist, Uwe Reinhardt, wrote an editorial for the Healthcare Blog: Rethinking the Gruber Controversy: Americans Aren’t Stupid, But They’re Often Ignorant – And Why. Reinhardt reminds us that stupid implies the inability to learn, whereas ignorance is lacking information and knowledge. And when it comes to most public policy, including healthcare policy, Reinhardt points out there is no lack of ignorance caused by four contributing considerations.

First, the social and economic analysis associated with most controversial policy involves complex and (too) often complicated approaches. Then secondly, special interests representing differing positions with respect to such policy usually seek to further complicate that analysis in order to gain popular support for their individual position. And then too, considerable cause for ignorance can be attributed to the general lack of individual interest in public policy. Reinhardt writes the third and fourth contributors represent some combination of individuals lacking time and/or interest (what does not impact us directly tends not to interest us).

Whatever and however the relative causes contribute to ignorance of public policy the political maelstrom surrounding the Affordable Care Act has certainly helped highlight that disconnect. And when it became publicized this fall that Jonathan Gruber had made the now infamous remark about the “stupidity of the American voter” the nature of that disconnect became politically contentious.

Even a fundamental understanding of the majority of that Act remains elusive to most. And nearly every stakeholder with a horse in the race if you will has relied upon that reality to exploit ignorance for the purpose of individual and/or public gain. This is the crux of Reinhardt’s article: that the inherent nature of our political system necessarily involves positioning policy in ways that belie known (or unknown and unintended) consequences negatively impacting various constituencies of those stakeholders.

For example, he believes that consumer driven healthcare is a veiled means of facilitating care rationing in a market economy; individual savings that receive preferential tax treatment in lieu of a defined purpose (e.g., FSAs and HSAs) are a means of regressive taxation; and tax preferences should really be considered tax expenditures that require direct or indirect subsidization through higher tax burdens on those not receiving those preferences (burden shifting).

Reinhardt ends the post with a passage from Alexis de Tocqueville’s Democracy in America. People all too often hear what they want to hear. When the choices of those individuals represent personal benefit to others – e.g., whether through a consumer choice to purchase or a vote to elect a candidate – there is the inherent incentive to tell them what they want to hear.

Reinhardt’s post reinforces what I wrote back in November about how I would like to see this modest little blog advance in 2015, and so I thought it was a fitting end to the year. Next year ought to be fascinating with a newly Republican-controlled Congress, a refusal-to-be lame duck President and a Supreme Court that again will have its objective temerity put on trial via a challenge to the Affordable Care Act.

Through it all, I hope to continue sharing with you that which reflects honesty, integrity and a steadfast commitment to always seek the truth – even when the truth is hard to hear.

Happy New Year!
  ~ Sparky

Top Healthcare Policy Themes of 2014

Yesterday on the Policy Prescriptions website curator Cedrick Dark, MD, MPH, FACEP, shared his list of top tweets in 2014, each referring to a story or graphic. I have with gratitude to Dr. Dark recast that list below for Pub patrons, highlighting the key policy area focused upon.

  ~ Sparky

Medicaid Expansion: Will it really reduce ER utilization?
A story by @sarahkliff  on January 2nd in the Washington Post

Population Health: How much of the US’s poor performance on value can really be explained away?
graphic shared by @davidmwessel on March 3rd

Industry Consolidation: Will it be a case of Be careful what you wish for . . . ?
A story by @philgalewitz in the Washington Post on April 21st

Big Data & Health Policy: What can two Medicaid studies – Massachusetts and Oregon – teach us about public health statistics and policy?
A post in The Incidental Economist by @afrakt on May 7th

Mental/Behavioral Health: Is Medicaid expansion an effective way to address the epidemic rise in MH/BHS and substance abuse?
A graphic from the American Health Counselors Association on May 27th

Physician Shortage: What’s the truth – can we know – about Healthcare Reform’s impact on physician supply relative to demand?
A story by @amitabhchandra2 in Vox on July 31st

Cuts in Provider Reimbursement: Is cost cutting via physician compensation having unintended – dire – consequences?
An Op-Ed piece in the New York Times by @sjauhar on July 21st

Value in Healthcare: “People bankrupt themselves to get healthcare and that means it’s incredibly valuable, unless one thinks people are incredibly stupid.”
A tweet shared by @amitabhchandra2 on May 6th

The Non-Healthcare Side of Healthcare: Only 20% of health outcomes is determined by clinical care
A graphic provided by @CHRankings on October 25th

Politics of the Affordable Care Act: Will Jonathan Gruber become the sacrificial lamb for an administration and congress that duped the stupid American voter?
A CNN news piece by @jaketapper on November 19th

National Healthcare Spending: Where does $2.9 trillion get spent?
A graphic in the Washington Post on December 3rd

The Uninsured: The Administration claims 10 million have gained health coverage. Not everyone agrees on the methodology used.
Official release from @WhiteHouse shares this and other portended accomplishments in 2014 on December 19th

Hpapyy Hlodiyas

ErodedMentalHealth_THUMBIf you have followed my blog over the past few years, you know by now that I am passionate, and write rather frequently, about mental and behavioral healthcare policy. So I first wanted to share with you an informative and powerful infographic (below) from the Best Social Work Programs website.

And secondly, I wanted to take just a moment to remind you this is an especially hard time of the year for someone you very likely know – and may even know very well. The absence of friends and family lost is felt more acutely. Pressure is greater to suppress feelings of anxiety and sadness. Failures of achievement must be reconciled with another year’s passing.

Try to remember that with few exceptions the person you know who may be struggling with mental and/or behavioral health issues finds very little joy in having a negative influence on your holidays. They did not choose to be saddled with their disease any more than those with Diabetes, Heart Disease or COPD chose their lots in life.

Here’s hoping that messages like the one below will continue to build public awareness and find their way into more proactive mental/behavioral health policy in 2015.



The Cleveland Clinic’s Big Gamble

When I first started speaking on the Affordable Care Act back in the fall of 2010 one of the observations I liked to make was about needing to change the cost trajectory resulting from chronic disease. I would say something to the effect that, “if we are somehow successful at becoming more efficient, expanding access and affordability – none of it is going to matter if we cannot become a healthier country.” I didn’t have any research or statistics to support my thinking – it just seemed axiomatic given a fundamental understanding of disease incidence, costs and demographics.

My good friend and colleague Dr. Toby Cosgrove, President and CEO of the Cleveland Clinic (okay, so we’ve said hello to one another on a few flights back and forth from Ft. Lauderdale) posted an article on his LinkedIn blog this morning: New Way to Fight Chronic Disease that puts some meat on the bone of my rudimentary understanding of public health. Dr. Cosgrove notes some very basic facts about chronic disease management in the United States.

  • The CDC estimates that 75% of all healthcare expenditures in the US are attributable to chronic disease ($2.85 trillion in 2013)
  • Almost one out of every two adults (117 million) is afflicted by chronic illness
  • More information on the impact chronic disease has on our healthcare system can be found on the CDC website.

Dr. Cosgrove’s article introduces the Cleveland Clinic’s recently opened Center for Functional Medicine, which is a collaboration with the Institute for Functional Medicine led by Dr. Mark Hyman. The thematic focus of the Center is to take a more holistic approach to individual health and wellness and driving at the underlying causes of chronic disease – whether related to genetics, environment or lifestyle.

Functional Medicine is not intended to be a replacement of traditional medicine. We aren’t talking about spiritual healing, wild berries and unproven treatment regimens. It is intended to recognize and address the underlying causes of chronic disease that, if effectively addressed, will reduce the need for traditional medicine. But it also should be able to compliment and enhance the effectiveness of traditional medicine.

Given the magnitude of the problem and the impending consequences on our country it is exciting news that a medical institution no less than the Cleveland Clinic has chosen to proactively attack this problem with pragmatism and innovation. That’s the good news. Now here’s the bad: human nature is an incredibly obstinate challenge that isn’t likely to bow in the face of the best efforts of worthy institutions such as the Cleveland Clinic.

Understanding the underlying causes that lead to chronic disease is one thing. Being able to change human behavior in a manner that addresses those causes is quite another altogether. And this tees up a host of moral policy conundrums where we start to look at responsibility of the individual versus society. Demographics will intensify these to a level that I suspect will lead to significant social unrest.

So while I applaud the Cleveland Clinic for taking the bull by the horns in seeking to address this immeasurable challenge facing us, I do hope they understand what happens if they let go.


Do Hospital Amenities = Value?

33ec2fbThere was an article in yesterday’s Dallas Morning News, Hospitals compete for patients with creature comforts, by Jim Landers that shares how hospitals are making huge capital expenditures in the name of patient satisfaction. The purported impetus behind this is in recognition of Medicare payments tied to patient-satisfaction scores under the Hospital Value-Based Purchasing Program. But there also has to be an element of competitive market positioning that is more to do with attracting a patient than satisfying a patient.

In either case, an obvious concern has to be to what extent, if any, more attractive aesthetics, better tasting food and higher speed Wi Fi access impact patient outcomes. Recall, Value = Outcomes / Cost. So what must be considered is how patient perceptions and experience factor into outcomes. Whereas one might  subscribe to a stricter definition of did the patient get well? others might want to consider is the patient happy?

From a policy perspective, to what extent should we be using tax dollars to make people happy versus making them well? From a holistic vantage point we want to consider those two objectives part and parcel of a singular goal. But again that old bugaboo raises its head: to the extent we measure achievement of a holistic goal by using objective criteria to assess subjective reality we risk wasting resources chasing an elusive butterfly.

Of course, the real irony here is that public policy designed to incent market-oriented provider behavior that improves value maybe doing more to increase the denominator than the numerator of the value equation. Makes you wonder whether we would be better off to just let the market develop solutions without artificial incentives – or whether it would make sense to stop pretending that healthcare is an industry that could ever provide value for a broad population left to its own devices.



How Images (And Hugs) Can Change the World

12-year-old Devonte Hart, Sgt. Bret Barnum share hug at Ferguson rallyIn 1604 Christopher Marlowe wrote these lines about Helen of Troy: “was this the face that launch’d a thousand ships and burnt the topless towers of Ilium?” The power of an image and its ability to evoke passion and emotion is ingrained in our history and social consciousness. This picture – and the story behind it – evoked so many personal feelings and emotions that I have had to sit quietly and alone for quite a while this Thanksgiving weekend determining what it was I wanted to share.

The photo above was caught by Johnny Nguyen at the start of a Ferguson rally being held in Portland, Oregon last Tuesday. Twelve-year-old Devonte Hart was holding a “Free Hugs” sign (more on that below) as he stood in front of a police barricade obviously upset.  Devonte’s mother, Jen Hart, is white, and she shared with reporters how her son has been struggling terribly to understand and reconcile his perceptions and understanding of what happened in Ferguson – and how race relations in his country will affect him as he grows into a man.

The officer pictured above, Sgt. Bret Barnum, works in the traffic division of the Portland police department and was at the site of the rally for crowd control. Standing about 10 feet from Devonte, officer Barnum noticed he was upset and called him over. They shook hands, chatted politely, Barnum expressing an interest in where Devonte went to school and what he had done this past summer. When asked why he was crying Devonte shared his concerns with the officer who empathized with those concerns. After they were done Barnum asked whether he might get one of the free hugs being offered. And thus be to infamy – maybe.

There was another time in our history when the camera captured an image that made a tremendous impact on the perception of race relations, but according to most accounts that image was not what it appeared to be. In his latest book, David & Goliath, Malcolm Gladwell relates the story behind this famous photograph of the civil rights movement in Birmingham, Alabama. The picture was taken by Bill Hudson of the Associated Press and shows 15-year-old Walter Gasden apparently being attacked by two police dogs during a May 3, 1963 protest in Birmingham.

But Walter Gasden was not a protester – he was a bystander who had been arrested by the officer in the photograph (Dick Middleton) for refusing an order to leave the street. It is believed that the police in the photograph are actually trying to hold the dogs back as Gasden strikes the dog with his left knee, causing it injury that required treatment by a veterinarian.

Diane McWhorter related this story in her book, Carry Me Home. Gladwell relied in part upon McWhoter’s account to relate how Wyatt Walker – an African American pastor and civil rights leader – had worked to confuse local authorities from being unable to distinguish protestors from bystanders in order to create chaos and a picture-perfect moment that had the purpose and effect Walker had hoped: it was printed in newspapers across the country with the understandable byline imagery of police using German Shepherds to attack a peaceful civil rights protestor.

Images can be incredibly powerful even when perception may not match reality (as in, perception is reality). A solitary image can profoundly impact a national cause just as a face can launch a thousand ships. Just as the image of a police officer accepting a free hug from a confused, scared and innocent youth can hopefully reset the dialogue we still desperately need to continue in this country on race relations, away from the hateful and destructive images of Ferguson that have perceptually hijacked that dialogue.

And what about those free hugs? The Free Hugs Campaign was started in 2004 by an Australian known under the pseudonym of Juan Mann (i.e., one man) in the Pitt Street Mall of Sydney.

imageI was first introduced to Free Hugs in 2010 when Sister Jill Bond of Catholic Health Service of Miami shared this 2006 video of the campaign shot in Hollywood, California (click on picture for link to the video). Set to the music of the late Israel Kamakawiwo’ole’s version of Over the Rainbow, it is one of the most captivating, inspiring and thought-provoking videos I have ever seen, and I have used it multiple times since in client workshops.

That it serves as an underpinning of the story behind the image of Devonte and Officer Barnum is emotionally compelling to me on multiple levels. In a time when technology has done so much to keep us connected it truly amazes – and depresses – me to realize just how disconnected we have become. And how way too often it seems our preference is to remain that way unless someone – like an innocent 12-year-old boy whose heart is full of love and wonder – has the courage to help us understand how simply powerful one hug can be – especially when it’s captured as an image that can be shared with others.


Policy Prescriptions ®

The Evidence-Based Health Policy™ Experts

By Dr. Bill Thomas


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