Medicine’s Tragedy of OR

Thanks to Dr. Paul Wiseman for sharing the NY Times op-ed article,  How Medical Care Is Being Corrupted, via LinkedIn this afternoon. Article authors Pamela Hartzband and Jerome Groopmannov are on the faculty of Harvard Medical School and co-authors of Your Medical Mind: How to Decide What is Right for You.

    The article deals with an old nemesis in healthcare policy: individual incentives. More particularly, how the misalignment of individual incentives can often be the Trojan horse befalling well-intended policy initiatives.

    Idealistically, as patients we we want our doctors to have our best interests in mind at every touch point of our experience with them. And fortunately, I believe that continues to by and large hold true. But the forces pushing against physicians to maintain that altruistic objectivity and autonomy on our behalves is being vehemently tested by what the authors describe as, “financial forces largely hidden from the public [that] are beginning to corrupt care and undermine the bond of trust between doctors and patients.”

    Though coming from different sources the common thread is the push toward value-based payments. I have written here in the past on value and value-based healthcare. The theory is market-based sound logic: value = outcomes/cost. The challenge, as I have written before, starts within a few nanoseconds after you start to contemplate how to objectively assess outcomes and whose value are we talking about?

    As Hartzband and Groopmannov importantly note, there is a challenging conflict between what is perceived as valuable for population health (i.e., in the aggregate) versus what is valuable for individual health. Physician payment incentives are increasingly being created based upon broad public health metrics (e.g., incidence of hypertension and hyperlipidemia, which are both often treated with medications that can be very effective – but also have significant side effects that can vary significantly from one individual to the next).

    So it doesn’t take too many connected dots to imagine the potential conflict of interest between wanting to hit the metrics versus doing what’s in the best interest of the patient. And the challenges are compounded when it’s not just the rewards that are in play – but the potential punishment for not following prescribed protocols from third parties – e.g., poor ratings publications and/or loss of base payments. That’s what is known in the non-scientific world as getting it coming and going.

    So what the authors propose is the establishment of legislation that would make public information available on, “the hidden coercive forces” that could be at the root of physician-patient incentive misalignment due to the aforementioned consequences of well-intended policies. That may not be enough, but it’s an important recognition that the policies may not work as intended. I note, however, that they do not recommend going backwards to the past era of, “paternalism, where doctors imposed their views on the patient.”

    Progress often means a couple of steps forward and a few back. Trying, learning and adjusting. This is a fundamental difference in  thinking among healthcare policy types that believe we just have to give Adam Smith’s invisible hand wider breadth. Way back in 1995, Jim Collins (Good to Great) wrote an article, (Building Companies to Last), in which among other areas of recognition – that even back then noting that relying on lessons of the past would not suit us well in a world of transformational change – he discusses embracing the genius of the “and.” This is a theme that has pervaded much of his work since.

    Too often those critical of policy initiatives jump for self-satisfactory joy whenever they come across fair and objective criticism of those initiatives. But such criticism, if you can get by the politics (yeah, I know), doesn’t have to be viewed through the prism of the Tranny of Or. It can be viewed as an opportunity to learn and work toward the Genius of And.

      ~ Sparky

Photo Credit: Alex Merto

Stupid Is As Stupid Does

If you haven’t heard or read about the recent uncovering of remarks made by Jonathan Gruber in relation to the crafting and passage of the Affordable Care Act (i.e., ObamaCare: pub patrons will note I rarely use that term even though I have largely supported it), then it is most likely because you are stupid. Yes, sorry, but that’s the sad reality of affairs according to intelligentsia types like Professor Gruber.

Aaron Blake writing in the Washington Post yesterday argued effectively that Gruber’s remarks will likely have little effect on any legislative initiatives to fully repeal the ACA. And as Kevin Drum pointed out in MotherJones, while Gruber’s choice of wording may have been very poor, he is right in noting that most of the electorate knows very little about public healthcare policy – if that’s what Gruber indeed meant. To me, stupid implies the inability to learn. I think Gruber may have accurately depicted an electorate that is disinterested in and/or unwilling to learn. Even still, I question how someone supposedly so smart could be so stupid.

Whatever term might best describe the initial benchmark of the electorate’s understanding of healthcare delivery, policy and regulations back in 2010, it has certainly advanced substantially from then. I’d like to think I’ve contributed a smidgeon since I started this blog in May of 2012. Whether the ACA is repealed, amended or dismantled one line at a time (parish the thought – I read the whole damn thing) healthcare public policy debate between January 2015 and the November elections of 2016 promises to be as energized, contentious and fraught with misinformation and misunderstanding as ever.

And knowing that, I am hoping to take the PolicyPub to a higher level next year. I am hoping to invite guest bloggers representing differing perspectives and backgrounds. Through my firm’s recent strategic alliance with Healthcare Lighthouse we are exploring ways to collaborate on sharing of healthcare public policy knowledge and information in ways that bring real value to organizations involved in healthcare. I am hoping to reenergize our free private discussion group where healthcare public policy is debated based on the merits of ideas and beliefs, and not sound bytes and news clippings.

To accomplish this I am going to need help. I am going to need to find others who share my passion for wanting to learn, understand and share their knowledge on the inner workings of healthcare public policy – and more importantly, the impact of that policy on patients and provider organizations. If you know of anyone who would be interested in adding to the discussion, please have them contact me.

I would like to commit myself in 2015 to proving how wrong Mr. Gruber is: not only is our electorate not stupid – but neither by implication are they willing to allow college professors to determine the future of our healthcare delivery system while they sit back and accept what’s given to them.

  ~ Sparky

Effective Communication: A Shared Illusion

Shaw_George-001I wrote last week in my post, Mental Illness Is A Community Disease that I was planning to participate in today’s public listening session held in connection with the development of new criteria that will impact Certified Community Behavioral Health Clinics (CCBHC). Mandated under Section 223 of the Protecting Access to Medicare Act of 2014, the intent is to strengthen community mental health systems by establishing higher standards of care and better coordination and communication across individuals, organizations and agencies that provide assistance and care to individuals in their communities.

Among the five topic areas discussed today (see previous post), not surprisingly I found Care Coordination to be the most interesting because of the parallels I recognized between mental/behavioral health and post-acute/long-term care. These include:

both groups of individuals typically require help from both community-based services and supports, as well as healthcare providers, and the lack of sharing of timely information across those entities in both instances is a challenging obstacle to managing care;

both groups rely heavily on Medicaid to fund needed services and care – and so both are likely to increasingly have to navigate the world of managed care – which doesn’t bode well in light of the point above;

both groups have evidentially achieved significant benefit from taking a holistic approach to care;

there is a need with both groups to understand and address the impact that varying levels of cognitive awareness can have on patient activation; and

the ability to achieve sustainable wellness in both groups is often primarily dependent upon the ability to maintain meaningful, long-term connectivity with care providers (in particular where medication management is concerned).

Most importantly however, germane to – yet beyond just – the importance of care coordination, a key take away from today’s sharing of thoughts, insights and the occasional organizational promotion and positioning was the shared impact that ineffective communication has in mental/behavioral health as it does in post-acute/long-term care. And really, across all of healthcare as has been discussed here before.

Effective communication is an art form, but it’s an art that can be taught and learned among willing participants. All too often, however, that willingness comes from a desire to be heard rather than to be understood – and to understand. George Bernard Shaw (pictured above) once wrote that, “the single biggest problem in communication is the illusion that it has taken place.”

Despite, or perhaps in good measure because of, all the technological advancements that have achieved miraculous achievements in healthcare we still fall well short of our potential to reduce human suffering because of a basic inability to communicate effectively.

I would like to see more sharing of experiences and best practices in care integration between mental and behavioral health and post-acute/long-term care: each probably could learn a lot from the other. But that would involve effective communication . . .


Does Legislative Negligence Trump Legislative Intent?

The Supreme Court today agreed to hear the King v. Burwell case, which – similar to Halbig v. Burwell, wherein the DC Circuit Court ruled against Burwell (i.e., the Affordable Care Act) in July – challenges the legality of tax subsidies used to offset the cost to individuals buying health insurance through federally administered exchanges. As the ACA was written subsidies were to be available through state run exchanges, but since most states opted out of creating and running their own exchanges more than two-thirds of everyone who signed up for health insurance did so through federal exchanges. Of those, approximately 85% – or 5 million people – received subsidies at an average value of approximately $3,200 per year.

Those folks stand to lose that benefit – and in many cases likely health insurance –if SCOTUS determines that the letter of the law should supersede legislative intent. Beyond that, given the actuarial models supporting expansion of individual health insurance under the ACA the prospective financial viability of that expansion would likely becomes untenable.

Congressional staffers had already been discussing ideas of how to work around the loss of tax subsidies – but that was before this Tuesday. The new sheriff in town won’t be very anxious to support legislative efforts that seek to save Obamacare in any fashion. What can be done through regulations? My guess is not much, so a ruling in favor of King would likely be the devastating blow detractors have been chasing since March of 2010.

From a retrospective standpoint this is just another serious distraction in a long line of legal and administrative obstacles that have become part and parcel of legislative implementation. It reflects the urgent and manipulative manner in which the Affordable Care Act was rammed through passage in March 2010 following a string of made-for-TV political events that played out beginning with the death of Senator Ted Kennedy in August 2009.

Ever since then Republicans have argued that a policy initiative of the breadth and scope of the Affordable Care Act necessarily should have been subject to broader bipartisan support, such as what would have been required through a normal reconciliation process of the two House and Senate bills. While at the same time Democrats have argued Republicans’ expressed concern has largely been a case of “protesting too much” and only really being concerned with stopping any legislative initiative of the President, regardless of its policy merits.

In any event, what SCOTUS will have to wrestle with is attempting to understand the contextual purpose of the health insurance subsidies and whether legislative intent is a sufficient enough consideration to disregard the stated restriction of those subsidies to only state run exchanges. As someone who has supported the ACA I don’t share this from the perspective of looking for any opportunity to blow it up. But I think it has to be taken into consideration by the Court that the law’s contorted framework and structure is a theoretical obstacle for accepting the legislative intent argument.

How can you accept legislative intent as a theoretically understood precept for a provision of an act that in several significant instances (i.e., CLASS, the employer mandate, renewal of noncompliant plans, special enrollment and hardship exemptions), has not been implemented as intended? Are the justices required to not consider legislative enactment and just look at the Act independently of the apparent disconnect? I’m not a lawyer, so maybe I am just thinking of this like a four year old – but then someone is going to have to explain to me what’s wrong with my logic.

Cheers and enjoy the weekend,
  ~ Sparky

Mental Illness Is A Community Disease

For those Pub patrons interested in being kept informed on happenings affecting the futureneeding-mental-health-care of mental health policy in the US. the Substance Abuse and Mental Health Services Administration (SAMHSA) will be holding a public listening session next Wednesday, November 12th, to solicit input and feedback on the establishment of criteria for  the Certified Community Behavioral Health Clinics (CCBHC) Demonstration Program, as outlined in Protecting Access to Medicare Act (P.L. 113-93, Section 223).

    The demonstration program was originally introduced as the Excellence in Mental Health Act by Senators Stabenow (D-MI) and Blunt (R-MO) and U.S. Representatives Matsui (D-CA) and Lance (R-NJ) and is an effort to strengthen community mental health systems by establishing higher standards of care and better coordination and communication across individuals, organizations and agencies that provide assistance and care to individuals in their communities. 

Under provisions of the Act, which was an extender bill used to delay until March of next year pending cuts to Medicare, a maximum of eight states will be selected to participate in a two-year demonstration program whereby the federal government will pay a matching percentage to those states for providing medical assistance for mental health services equal to what Federally Qualified Health Centers (FQHCs) currently receive for primary care services. This is strictly an outpatient clinic initiative (i.e., no funding for inpatient care, boarding, residential treatment).

Example services to be provided by CCBHC’s under the demonstration program include 24-hour crisis management, screening assessments and diagnostic services, outpatient mental health and substance-abuse services, primary care screening and peer support and counseling. The HHS secretary is to determine criteria for a clinic to be certified by a state as a CCBHC no later than September of next year. Next week’s session will solicit input on criteria such as,

  • staffing requirements: e.g., qualifications, areas of experience & expertise, licensing and credentialing, recruiting;
  • availability, scope and accessibility of services: e.g., looking beyond crisis management, determining basis of financial responsibility, evidencing service and referral relationships;
  • care coordination: e.g., relationships with other providers, integration into and with community services and agencies, enabling technical requirements;
  • governance, accountability & reporting: e.g., organizational authority, measuring outcomes, evidential reporting.
  • The secretary is also directed to provide guidance for the establishment of a prospective payment system for this demonstration program, no later than Sept. 1, 2015.

    As I have shared in this space numerous times before, mental and behavioral health services are underfunded and inadequately available to meet the growing needs across the country. We are learning more every day of the evidentiary benefits – to the individual and society – of taking a holistic approach to individual health and welfare. I am hoping to learn more next week whether and how this demonstration program might lead to addressing this critical concern – and I will report back what I learn.


Alba gu bràth!

Ian Morrison wrote an interesting piece today in H&HN Daily: Will Your Hospital Maintain Its Independence? Most anything that starts with, “My native c32f740dadef6f60188f14b376a76efcScotland,” attracts my attention, but Dr. Morrison makes some very interesting comparisons between nationalism and traditionalism that are especially insightful in understanding the current healthcare landscape in the US. More particularly, he offers some useful observations on the national referendum for independence in Scotland at a social level and resistance to change in the US healthcare industry at an individual level.

Scotland recently rejected a call for independence from the United Kingdom by a margin of 55% to 45%. From what I followed in The Times as a run up to the vote it was anticipated to be a lot closer. An emotionally charged issue as one might expect when contemplating the future fate of a nation, the debate over independence goes way (way) back. When I was in Edinburgh in mid 90s I met family there fervid about having such a referendum on the ballot. And, of course, if you’re familiar with Braveheart, you know the thirst for independence goes back to when battles were fought with spears and arrows and naked bums.

The point is, human commitment and passion run deep whenever and wherever the past is concerned. As a nation, it’s the cultural mores and traditions that bind together its citizenry into a common purpose that forms a society beneficial to the individuals participating in – and often fighting for – that society. At an individual level it’s the ability to associate with that purpose through reflection and introspection – memories as it were, whether real or perceived.

Though often positioned as an assertive claim to acquire, it is really most often a defensive maneuver to retain. And thus the desire for independence – at both a national and individual level – therefore also reflects an inherent resistance to change. And that is the parallel Morrison draws to the American healthcare system. An historical cast of passionate, empathetic caregivers – both individuals as well as the institutions to which those individuals have belonged – is being threatened by, “the relentless growth of large regional systems of care coming to dominate the landscape.”

The concern is genuine and real, and how it will ultimately play out is still far from being determined. Morrison shares a few thoughts on how individuals and organizations might best prepare for decisions affecting their own independence. He rightly points out that maintaining independence at all costs may not be prudent, but I direct you to his article (link at the beginning of this post) because it really is worth the read.

I would add to his thoughts the need for a true sense of urgency to create a market strategy that addresses the prospect of remaining independent – or not. Reactive thinking is never strategic. Very often necessary, unavoidable and critical to survival – but not strategic. Take the time now to ensure your organization’s leadership team is in alignment on how it will approach threats to independence – before that threat is manifested as a fete accompli.

  ~ Sparky

What’s Next for Healthcare?

On the eve of this national midterm election polls are continuing to suggest a decided shift in congressional2014_elections_senate_map power. According to Real Clear Politics, current polling indicates 45 Democratic candidates are probable Senate winners, while 47 Republican candidates are positioned to be elected – leaving 8 races considered tossups. If voting plays out as polling suggests – and really, that’s a subject ripe and deep enough for a few hundred theses over the next decade I would think – Republicans only need to win half of those races to secure a 51-seat majority in the Senate.

The Affordable Care Act continues to be unpopular at around 38% of the country having a favorable opinion and 52% having an unfavorable opinion. With Republicans controlling both houses of Congress and their long-standing opposition one would think repealing the ACA would be priority one. But with President Obama’s unequivocal certainty to veto any attempt to repeal the ACA and 60 votes needed for cloture an outright repeal is unlikely. And candidly, a lot of Republicans are not anxious to take away parts of the Act that have proven popular.

So what is likely then. The Senate has never held a symbolical repeal vote, so it will be politically important to Republican Senators they have an opportunity to be on the record as voting for repeal. So we’ll have to endure that circus. Once past the political symbolism I think it is anyone’s guess what’s next. And that’s because it’s anyone’s guess who will ultimately control the soul of the Republican party.

There is the school of thought that a Republican majority in Congress would reflect a referendum on incumbency over frustration with that body’s inability to accomplish anything meaningful. To be sure, it would also be viewed as a referendum on the Administration. But another two years of meaningless symbolic gestures at the President’s expense might not play well for Republicans in 2016, which will be for even bigger stakes. While a more moderate tone from Republicans willing to find common ground with Democrats could lead to modifying and/or repealing the most unpopular aspects of the ACA.

On the other hand, strong-willed elements of the party’s conservative wing could once again seek to hold the Republican Party hostage in the name of being committed to their ideological base. Realizing their only chance of gaining popular support on a national level is to galvanize that ideology beyond current levels of support they don’t have much to lose by risking the ire of those who might view them as obstructionists.

If there were to be some revisions that somehow could be agreed upon by both parties, they would likely need to already have popular appeal – e.g., repeal of the employer mandate provision, repeal of the annual health insurance fee, repeal of the medical device tax – and possibly even repeal, or at least modification of, the individual mandate.

Why are these appealing? Because they lower costs to voters – whether directly or intuitively through the cost of doing business. What is far less attractive are things like repealing individual tax credits and cost-sharing subsidies for health insurance and funding of Medicaid expansion. That leaves a bit of problem for Republicans then, doesn’t it: cutting revenue without cutting expenses while seeking to be fiscally prudent as a primary positioning strategy ahead of the 2016 presidential election.

So how would this be political conundrum be reconciled? Hands, please.

My educated (as in reading the writing on the wall) guess is we will see even more pressure on providers to control costs and system utilization. More emphasis on provider risk sharing. Continued focus on value and tying outcomes to investment. Further support for capitation-based payment models via managed care. Oh, and increased pressure to embrace performance improvement and quality-based systemic approaches that have proven successful in achieving production efficiencies in other industries.

Whatever the outcomes of tomorrow – and however those outcomes manifest in the legislative and regulatory impact on the healthcare industry – all healthcare providers would do well to understand and accept that staying on top of state and federal activities is going to be crucially important to organizational survival.

  ~ Sparky

This Is Not Your Grandma’s Taxi

Having worked with numerous organizations over the years that provide services and care to seniorsDelorean_DMC-12_Time_Machine_in_San_Francisco living in their communities I know that transportation is very often a primary obstacle to expanding and improving those services and care. Whether needed for a doctor’s visit, a rehabilitation appointment, a flu shot, a socialization event, a trip to visit family – it is typically not the distance as much as the inability to coordinate the timing of demand with availability in an efficient manner that creates challenging cost obstacles.

There are organizations across the country that have been effective at tackling this obstacle by leveraging information and communication technology. For example, Senior Transportation Connection serves individuals in Cuyahoga County, Ohio by utilizing mapping and scheduling algorithms (EasyRides©). I had the opportunity to visit their “command center” a few years back and was impressed with how much they are able to do with so little financial support. Truly amazing.

Even so, seniors using STC have to schedule their travel appointments by noon two days prior to the appointed time. It doesn’t take a great deal of imagination to realize there will be many circumstances when the best efforts to plan ahead will fall well short of providing the level of access needed for many seniors still wanting to live independently.

Enter Uber. Jason Oliva writes in yesterday’s Senior Housing News that the San Francisco-based ride service company has just announced it will be expanding its transportation services into San Diego. UberWAV and uberASSIST are ride offerings specifically designed to accommodate elderly individuals living with disabilities.

For those – who until recently included myself – unfamiliar with the Uber concept, the simple genius (yeah, one of those V8 moments I’m afraid) is the development of a smartphone application that connects passengers with vehicles for hire. Not a cab for hire, mind you, but an individual who has signed up and been vetted to provide safe, reliable transportation (yes, I would like to understand that whole process better myself – but that’ not the point of this post).

From a business perspective, the value proposition appears to be the ability to concurrently offer convenience and affordability on the demand side while providing income-earning flexibility and lower barriers to entry on the supply side. As you might imagine, the lower barriers to entry proposition has not played well with taxi and limousine companies – there have actually been protests staged in several countries, including Germany, France and England. I’m sure we’ll get round to it once we get by Halloween.

Now you can just see where this idea is going to eventually cause all sorts of policy issues: free market solutions to public challenges usually do, for better or worse. What are the safety risks? Who is insuring those risks? What happens after the first case of elder abuse is reported?

Having the requisite vehicle apparatus to accommodate disability is one thing – having a driver that can thoughtfully and emotionally navigate through an individual’s confusion and dementia is another. Will seniors be able to use the application in a crisis? Can it/should it be available in cases of emergency? There’s a lot to think about to protect seniors from abuse – intended or not.

On the other hand, if we follow the tried and true path of policymaking we will almost certainly regulate Uber services to the point where a creative solution becomes cost prohibitive. Without market-driven innovation we will never be able to tackle all of the challenges associated with a dramatically aging society.

What do Pub patrons think? Share your thoughts by leaving a comment.

  ~ Sparky

Photo credits:
Delorean DMC-12 Time Machine in San Francisco
CC BY-SA 3.0
Ed g2s – Own work

I Will Never Forget

I_Will_Never_Forget_CoverLast week I shared with Pub patrons the amazing night at the 2014 LeadingAge annual meeting featuring the premier of Glen Campbell: I’ll Be Me. As a follow up to that and to contribute further toward the education and awareness of the challenges associated with caring for individuals afflicted with Alzheimer’s disease and other forms of dementia I wanted to share with you Elaine Pereir’a book, I Will Never Forget.

Elaine tells the story of her mother’s battle with dementia and how it turned a brilliant woman into someone confused, compromised and agitated in its wake. It is a tribute to her mother’s journey – and it was written for everyone facing a similar journey.

Elaine is a retired school occupational therapist who has worked with special needs children. She earned her bachelor’s degree in occupational therapy from Wayne State University and later completed her master’s degree. She can be reached at


When Being Right Mattered

An American journalistic icon passed away yesterday. Ben Bradlee was the editor of the Washington Post during Bob Woodward and Carl Bernstein’s investigative reporting that was to become Watergate. Bradlee was the quintessential well-heeled news junkie with one foot on a banana peel and the other cemented firmly on the first step of the Lincoln Memorial: “with firmness in the right as God gives us to see the right.”

Bradlee was infamous for making it known that being, “right” is what mattered more than the means to knowing you were right. Getting it right wasn’t easy, and it wasn’t without mistakes. But getting it right mattered more than anything else.

Who can watch any news network today and feel even the slightest bit of confidence that getting it right is what really matters? Getting it first matters. Getting it with images matters. Getting it in a surreptitious fashion matters. Getting it right? Sure, why not if that doesn’t cost any more.

In the 1976 movie, All the President’s Men (based upon Woodward and Bernstein’s book of the same name) Jason Robards won an Academy Award for his performance portraying Mr. Bradlee. Last year Bradlee was awarded the Presidential Medal of Freedom.

I know I am being scornfully satirical and disingenuous in discounting the many journalists who still emulate Bradlee’s commitment to getting it right. Their inability to attract a larger audience that shares such an interest is a cultural reality beyond their control.

And yet how ironic is it that as we sit here in 2014 some of us are nostalgic for one of the darkest periods in American political history because we long for the truth – even when the truth might not be something we want to hear, or accept.

  ~ Sparky

Policy Prescriptions ®

The Evidence-Based Health Policy™ Experts

By Dr. Bill Thomas


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