May 19, 2013

At What Price Transparency

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On May 8th the New York Times headlined the article, Hospital Billing Varies Widely, Government Data Shows.  For Democrats, further evidence that hospitals continue to use their market prowess to gouge the poor and uninsured. For Republicans, further evidence that the Affordable Care Act is failing miserably in controlling costs and empowering consumers. For news reporters, fodder for controversial content. For anyone who has worked in healthcare for any meaningful time – a BIG YAWN (see also, Pick a Price, Any Price, addressing this phenomenon from a Consumer-Driven Healthcare perspective).

It’s not just a non-story but a very old and very tired non-story as well. The cause and effect relationship between the cost of resources that go into delivering care at hospitals and the established charges for that care (i.e, the hospital charge master) bears a weakly causal relationship at best. That reality is a result of the Medicare reimbursement methodology (and, in turn, other governmental programs – e.g., Medicaid – as well as commercial insurers largely adopting very similar approaches).

Healthcare reimbursement in the US is a long and complicated story and one that, from a financial perspective, has seen many winners and many losers – neither of which group represents the individuals that are supposed to benefit from healthcare: the patients. If I can try to sum up the experience of the past half century it would be that effort upon effort has been made to develop systems that fairly reimburse healthcare providers for their costs plus a profit (or income, as it were for the individual).

There are two major problems with cost-based reimbursement: the first is the ability to prospectively allocate overhead costs in a logically consistent manner for a production model that is extremely complicated and constantly changing; the second (and a by-product of the first) is the faulty logic that holds historical production/cost relationships are reasonable predictors of future costs, which belies the effects of innovation, efficiency and productivity improvements.

So why am I jumping on the bandwagon to beat a dead horse. Because I believe the media attention focused on the wide variability in hospital pricing is symptomatic of a much bigger challenge we have in healthcare delivery – and in turn, healthcare public policy: that is, transparency. And in an age of electronic information enlightenment, the public policy issues surrounding transparency both transcend and go well beyond healthcare.

Take for example the two current scandals adding more paralysis to an already ineffective government in DC (as if that were possible).  In the first, the IRS appears to have selectively targeted 501(c)(4) applications based, at least in part, upon political motivations.  In the second, the Justice Department secretly obtained phone records of AP reporters last year stemming from concerns over national security leaks. Information is power – and power easily abused, particularly when the stakes are high as in politics.

The term, transparency, calls up thoughts of truth, honesty, candid, forthright – all terms that are generally consistent with values espoused by the better parts of our nature. So it is a difficult reconciliation that the promotion (or abuse) of transparency can lead to information ending up in the hands of those for whom it was never intended. In other words, as the recording, storage and sharing of electronic information proliferates transparency and privacy are going to increasingly become public policy enemies.

And other than issues of national security nowhere is this confrontation already more acute than in healthcare. Concern over patient privacy has long been one of the primary obstacles to IT adoption in healthcare, and right that it should be. What is more private than our individual health records? But the knife cuts both ways as we know. Under our legal system, quite often the right of privacy is abused as a faux obstacle impeding transparency. This is often manifested in healthcare as over charging third-party payers for services and care not actually provided.

A common theme of the Affordable Care Act is the promotion of transparency with particular emphasis in two areas: patient outcomes and cost data. While the latter faces allocation methodologies and consistency challenges, the former faces the additional challenge of subjectivity in establishing measurements. These are challenges that absolutely must be overcome.

Transparency in healthcare is a necessary prerequisite to patient empowerment, which has the potential to drive organic performance improvement that doesn’t come at the cost of additional regulatory oversight. Transparency is also a prerequisite to determining value (i.e., outcomes divided by costs), which is the basis upon which many employers, commercial insurers and governmental programs are developing new healthcare payment models (i.e., payment for value – not volume).

Throughout history strategies of both business and war have often depended upon the advantage gained from having access to information where others do not. Whenever there are two competitors – or world enemies – transparency holds the potential to give an advantage to one over the other. And so as long as the US healthcare delivery system remains positioned someplace between a market-based system and universal system the push for transparency is likely to continue facilitating unintended and undesired consequences.

Cheers,
  Sparky

 

Filed Under: Editorials & Opinions, Transparency · Tagged: , , , ,
Apr 25, 2013

Accepting the Realities of Aging

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head-in-sand . . . or not.  The Associated Press-NORC Center for Public Affairs Research last week released the report, Perceptions, Experiences and Attitudes among Americans 40 or older. Sponsored by the SCAN Foundation, the report presents research based upon interviews of just over 1,000 individuals aged 40 and older regarding their views on aging.

From a public policy perspective, the key takeaway underscores a phenomenon common to discussion and debate over how to finance the future long-term care needs of an aging population. At a time in our lives when we are at our peak earning potential we typically also have the highest propensity to spend – quite often as a necessity of family survival. The past half-decade has heightened further that reality for many of us.

Of those interviewed, fully 30% would rather just not think about aging – while an additional 32% were only somewhat comfortable thinking about getting older. Not surprisingly, there was an apparent correlation between being more comfortable (I would posit, willing) to think about and discuss aging and the respondent’s age. Ailments and infirmities tend to be quite effective at breaking down one’s belief in mind over matter as a plausible substitute for the elusive fountain of youth.

In what I interpret as a perceptual vote of no confidence in government’s ability to effectively address the looming cost crisis attendant to long-term care, 51% of interviewees between the ages of 40 and 54 – and 48% between the ages of 55 and 64 – are a great deal or quite a bit concerned about affording the long-term care they may require as they age. This is compared to only 30% of those over the age of 65 (i.e., Medicare eligible) who share the same concern.

Whether that represents a false sense of security or not, it is worth noting the research also highlighted the continuing misperceptions that many individuals have regarding their probability of needing future long-term care, its costs, programs available to provide assistance and how to plan for future needs. For those directly involved in providing long-term care services and support those perceptions are accepted realities.  But for those in positions of public policy influence and responsibility the consequential understanding of those realities is a lot less clear.

Of course, I am thinking of the Commission on Long-Term Care, which pursuant to Section 643 of the Taxpayer Relief Act, is charged with developing, “a plan for the establishment, implementation, and financing of a comprehensive, coordinated, and high-quality system that ensures the availability of long-term services and supports for individuals in need of such services and supports, including elderly individuals, individuals with substantial cognitive or functional limitations, other individuals who require assistance to perform activities of daily living, and individuals desiring to plan for future long-term care needs.”"

There is widespread belief that a key element of any successful plan should include efforts to create greater awareness and education surrounding the individual realities of long-term care. The research shared above serves to underscore that belief. What is largely unknown, however, is whether such investments are worthwhile. We have so far seen the relatively disappointing results of investments in health and wellness (as an aside, I wonder whether Senator Harkin has seen that research).

Sometimes things that seem to be intuitively correct are disproved by empirical evidence. The failure of long-term care insurance to gain greater traction may be an indicator that education and awareness regarding the need to plan for long-term care will have a limited ability to overcome the strong human inclination to stay in the moment.

Since it is also true, however, that intuition often bears fruit only through successive efforts to overcome obstacles, I do believe education and awareness, along with wellness and prevention, should continue to be encouraged from a healthcare and long-term care public policy perspective.  In making those investments, however, programs with tighter feedback loops that help measure relative effectiveness are not only prudent but will help accelerate the desired outcomes of those investments.

Cheers,
  Sparky

Filed Under: Aging, Editorials & Opinions · Tagged: , , ,
Apr 18, 2013

Senate Leadership Reprised

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It is admittedly difficult to rail against the travesties of political injustice in modern American democracy without quickly feeling your feet go out from under you in a wave of self-conscious hypocrisy. But after the blatant expression of individual cowardice that took place in the US Senate yesterday I am left wondering whether that inane and inept institution has outlived its useful purpose of balancing the interests of national majorities against those of individual states.

According to an ABC Washington Post-ABC News Poll, over 90% of Americans are in favor of universal background checks as a prerequisite to gun ownership (as are 85% of NRA households by the way). That was still not quite enough to convince more than 46% of the US Senate to accept the will of the American majority over the metaphorical bags of gold being dangled in front of them by the NRA (or rather, being taken away).

I’m not going to beleaguer Pub visitors with a diatribe on the pure idiocy of turning a blind eye to even legitimately considering what was a common sense and widely accepted gun control policy measure. I rather refer you to former Representative Gabrielle Giffords’ editorial in the New York Times, A Senate in the Gun Lobby’s Grips.

I have long held that the political realities are such that we can expect no change until being elected becomes more like being chosen to serve jury duty than winning the lottery. The addiction to political power in this country is now so strong that with few exceptions elected officials have become whores to the status, fame and fortune attendant to public office. They achieve through Congress that which they would never be able to achieve through any other legal means of personal industry.

And the greatest irony I find in this is mockery of democracy is that those who most ardently oppose any encumbrance upon gun acquisition and ownership do so under the auspices of individual rights and liberties. I wonder whether they really trust a sitting body of government to protect those rights and liberties when that body has clearly and blatantly demonstrated its ability to ignore the will of a strong majority in favor of the political influence bought and paid for by business interests. Be careful what what you wish for Daniel Boone . . .

Cheers,
  Sparky

Filed Under: Editorials & Opinions, Gun Control · Tagged: ,
Mar 31, 2013

Readmission Realities

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The topic of Hospital Readmissions has evolved into a primary point of discussion and debate within the nation’s lexicon of Healthcare Reform, most notably through broadly accessed media outlets not typically associated with in-depth reporting on medicine and healthcare. As often happens, by the time such a topic traverses the tipping point of being newsworthy it will have actually been around for quite a while in  smaller though certainly no less important academic circles.

As an example, Dr. Elliott Fisher and colleagues were sharing their research findings on hospital readmissions back in 1994 in the New England Journal of Medicine. Using Medicare claims data they studied discharge patterns in Boston and New Haven between October 1987 and September 1989. What they found was that, “hospital-specific readmission rates varied substantially …” and that “no relation was found between mortality (during the first 30 days after discharge or over the entire study period) and <sic> either community or hospital-specific readmission rates.”

In their conclusions they noted that, “regardless of the initial cause of admission, Medicare beneficiaries who were initially hospitalized in Boston had consistently higher rates of readmission than did Medicare beneficiaries hospitalized in New Haven. Differences in the severity of illness are unlikely to explain these findings. One possible explanation is a threshold effect of hospital-bed availability on decisions to admit patients.”

In other words, despite what is  understandably a popular media association, identification, concern and debate over whether and how reducing hospital readmissions represents a prudent means of lowering healthcare expenditures without impacting quality or outcomes is not a phenomenon borne of the Affordable Care Act. More importantly for my purpose here, understanding the history of hospital readmissions as a policy topic is to understand and accept the challenges associated with developing public policy intended to incent reductions.  And of course, the primary case in point here is Section 3025 of the Affordable Care Act, the Hospital Readmissions Reduction Program (HRRP).

I believe there is justifiable concern with the HRRP, particularly in the realm of unintended consequences. But I also believe those concerns have thus far tended to be self-serving and inflated when compared to the potential benefits. I addressed these points just about a year ago in the post, Is Focus on Hospital Readmissions Misguided? That was in reaction to another article published in NEJM, Thirty-Day Readmissions – Truth and Consequence. Now fast forward to an article published this past week in the NEJM, A Path Forward on Medicare Readmissions. Are you getting the sense that the hospital readmissions topic is nothing if not complex and contentious?

In this latest contribution to the subject, authors Drs. Karen Joynt and Ashish Jha identify two recent developments that provide insights into how HRRP implementation appears to be playing out.  The first was a MedPAC report evidencing a decrease in national rates of readmission for all causes, from 15.6% in 2009 to 15.3% in 2011. The second is an emerging recognition, based on CMS reports, that hospitals most susceptible to financial penalties under the HRRP are also those most likely to provide care for individuals with complex and/or expensive healthcare needs. In other words, this suggests that HRRP implementation has the potential to provide a financial disincentive leading to disparities in care availability.

Rather than chucking the HRRP as a policy failure, however, the authors suggest an approach that is quite admittedly conceptually foreign to a government characterized by intransigence and stubbornness: they suggest modifying the program in reaction to what is learned during implementation. Specifically, they first suggest adjusting readmission rates for socioeconomic status. Second, they suggest weighting the HRRP penalties according to the timing of the readmission to better recognize the potential causes of that readmission. And finally, they suggest an offsetting credit be given for comparatively lower mortality rates in recognition of hospitals – e.g., large teaching hospitals – where readmission rates are more likely to be an expected consequence of keeping their sickest patients alive.

The authors correctly point out that, “no policy is ever perfectly designed at inception, and policies should be changed as new evidence emerges.” At the same time, we should be cognizant where policies reach too far or are impractical in their design. For example, the UK’s National Health System (NHS) Medical Director, Bruce Keogh, announced this past Friday that hospitals there will face future reduction in fees for failing to follow the latest clinical guidance (i.e., quality standards).

In my thinking, there is both a philosophical as well as practical difference between policies that provide financial incentive through measuring health outcomes versus measuring the means and methods of achieving those outcomes. But if our aim is to develop a healthcare system that leverages the productivity and efficiency advantages of market-based solutions, while guarding against the market failures inherent to healthcare, we will need to be vigilant in avoiding the slippery slope of policy dysfunction.

Cheers,
  Sparky

Filed Under: Editorials & Opinions, Hospital Readmissions · Tagged: , ,
Mar 8, 2013

A Failure to Communicate

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ht_lorraine_bayless_nt_130304_wg2The topic of End-of-Life Care took another turn on February 26th with the passing of Mrs. Lorraine Bayless (pictured left) at Glenwood Gardens in Bakersfield, California.  As I write this, there is still a lot of conflicting information circulating on the Internet about what happened that day and why.  And there is certainly no shortage of opinions about what went wrong – or not. There also appears to be a great deal of misunderstanding on what a CCRC is, what services and care are provided – and what care responsibilities a CCRC has to its independent living residents.

There are elements of this story that, if for no other reason than respect for Mrs. Bayless’ family, should remain with this story – i.e., primarily an assessment of Glenwood Gardens’ policies and procedures. But there are also elements of this story that transcend our need to better understand and assess models of care relative to individual rights and end-of-life care. It is in the latter interest I offer this post.

Last August, I wrote a post, CCRCs: Healthcare Providers – Or Not? I wrote then,
“for a segment of the senior population, typically over the age of 75, CCRCs are a very attractive retirement housing option. They offer the comfort and security of a community tailored to meet the physical and emotional needs of seniors, the social energy of a community setting and the critically important peace of mind that personal services, assistance and care are available, when and if needed, removing that potential caregiving burden from their adult children raising families of their own.”

Ah, but there’s the rub that I think this story will eventually wind its way towards: what constitutes, “when and if needed?” And who gets to decide when and if its needed? On the afternoon of February 26th at Glenwood Gardens, the 87-year old Mrs. Bayless clearly needed assistance if she were to have a chance to live (it was subsequently determined by her physician that she passed away from a massive stroke, most likely owing to what had been previously diagnosed as disease of the blood vessels supplying the brain).

Many of the news stories I have read characterize Mrs. Bayless’ residence as being independent living – as if it were conceptually unique and separate from the other offerings at Glenwood Gardens; i.e., assisted living, nursing care, Alzheimer’s/dementia care and hospice. While there is physical separation between the facilities providing these services and care, the underlying market positioning of a CCRC is their availability on a single campus.

The overt selling point being that someone does not have to move from the campus when and if they need services and care that extend beyond what is available through independent living. In fact, Glenwood Gardens’ website promotes having 24-hour access to staff. Whether this can be interpreted as having access to emergency medical care provided by nursing staff in other areas of the CCRC I think is going to get a lot of discussion and debate.

I think the more immediate questions here, however, are first, whether Mrs. Bayless would have wanted life-saving efforts performed.  In statements afterwards her family seemed to indicate she would not, though Mrs. Bayless did not have any advance directives in place, and the paramedics that arrived on the scene ultimately provided CPR in any event.  And second, would CPR, if started earlier, have been helpful. Very often, CPR is ineffective in such situations – and when it is effective in reviving a frail elderly person it can often result in terrible injury, leaving the individual incapacitated and facing a prolonged and painful death.

As challenging and difficult as they are, it would be nice to think these were the questions guiding management’s and staff’s decision making of that afternoon. But that doesn’t appear to be the case.  In a statement, Brookdale Senior Living, owner of Glenwood Gardens, said, “this incident resulted from a complete misunderstanding of our practice with regards to emergency medical care for our residents. We are conducting a company-wide review of our policies involving emergency medical care across all of our communities.”

When the dust finally settles I think  what we will find is a failure to communicate on multiple levels and between multiple parties. If Mrs. Bayless’ wishes were clearly understood by her family, why was a DNR order not in place? If management at Glenwood Gardens understood corporate policy and procedure, why is Brookdale Senior Living now leaving them out to dry? If the staff at Glenwood Gardens clearly understood policy, why was the person on the 911 call seeking the input of others to affirm her position?

So the key takeaway I have from this story and all of the opinions surrounding it is that it reinforces the critical importance of effective communication – and how very often its lacking stands in the way of better healthcare. The same core ability that must be a critical element of any strategic planning effort we engage in with leadership teams at healthcare provider clients is just as applicable to any effort that involves human beings for which there are expectations those individuals will work together to achieve desirable results.

As I have written before, it is truly amazing that today we live in a world where communication has never been easier – yet never been more difficult.

Cheers,
  Sparky

Filed Under: Editorials & Opinions, End-of-Life Care · Tagged: , , , ,
Mar 6, 2013

Why Can’t We Be Friends?

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Partisanship is as ingrained into the political fabric of this country as are the imported core ideologies from whence it sprang. The history of our domestic partisanship can be traced to the days of George Washington’s presidency with the establishment of the Federalist Party (led by Alexander Hamilton – being in favor of a strong federal government) and the Jeffersonian Republicans, which under Thomas Jefferson’s leadership advocated for strong state governments.

And our history is replete with examples where the individual and collective passions of partisanship have led to bitter conflict, even being manifested in physical assaults on the floors of both houses of Congress.

Shown below is a cartoon depicting a fight in the House of Representatives between Republican Matthew Lyon and Federalist Roger Griswold as depicted in this 1798 engraving. Lyon was the first member of Congress to have an ethics violation charged filed against him when he was accused of “gross indecency” for spitting in Griswold’s face (Griswold had called Lyon a scoundrel, considered profanity at the time).qAnd in 1856, at the heyday of debate over slavery, South Carolina Senator Preston Brooks – deeply agitated at what he considered Massachusetts Senator Charles Sumner’s libelous characterization of Brooks three days earlier in his infamous, “Crime Against Kansas” speech (at which Brooks was not present to protest) – used a metal cane to pummel Sumner, who had to be carried off the Senate floor.
So perhaps, in retrospect, the challenges of partisan politics standing in the way of addressing the nation’s fiscal crisis need to be taken in context. Or do they?

This morning, the Bipartisan Policy Center hosted a town hall meeting facilitated by USA Today’s Washington Bureau Chief Susan Page at the Ronald Reagan Presidential Foundation and Library to launch the Commission on Political Reform. Beginning today, the 30-member commission will be holding forums across the country in the hope of engaging a body politic unwittingly caught up in the maelstrom of political polarization that has been exacerbated and capitalized upon by a Media that serves a profit motive first and civic responsibilities somewhere south of fifth.

Take this, for example. In advance of the new Commission’s launch USA Today recently conducted a clever – albeit devious – poll in which it surveyed 1,000 individuals who were asked to assess two education polices: the first plan would reduce class sizes and make sure schools teach the basics; the second plan would increase teacher pay while making it easier to remove underperforming teachers.

Half of the respondents were told the first plan was a Democratic plan and the second a Republican plan. For the other half of respondents, the labels were reversed. In both instances, respondents overwhelmingly (by a margin of 3 to 1) favored the plan that was associated with their party affiliation. In fact, both sets of respondents were inclined to describe their support as being “strongly” in favor, regardless of which policy was represented.

The BPC’s President, Jason Grumet, in introducing this morning’s town hall panel was deliberate in noting the Commission’s purpose is not to create Kumbaya symmetry wherein political discourse becomes an effort to go along in order to get along. To the contrary, robust debate is needed now more than ever – because the complexity and urgency of the challenges facing our nation demand it.

But today, intelligent, productive discourse and debate is buried in sound bite rhetoric designed to be easily digested by a society in transit, always seeking first to be entertained – and then thoughtful and concerned. Along with that the tribal instincts of our modern social conscience have made the concept of political compromise tantamount to failure.  Since today’s town hall meeting was held at the Reagan Library, I thought it would be fitting to end this post with a quote from President Reagan’s autobiography.

“When I began entering into the give and take of legislative bargaining in Sacramento a lot of the most radical conservatives who had supported me during the election didn’t like it.  ‘Compromise’ was a dirty word to them and they wouldn’t face the fact that we couldn’t get all of what we wanted today. They wanted all or nothing and they wanted it all at once. If you don’t get it all, some said, don’t take anything. I’d learned while negotiating union contracts that you seldom got everything you asked for. And I agreed with FDR, who said in 1933: ‘I have no expectations of making a hit every time I come to bat. What I seek is the highest possible batting average.’ If you got seventy-five or eighty percent of what you were asking for, I say, you take it and fight for the rest later, and that’s what I told these radical conservatives who never got used to it.”

Cheers,
  Sparky

Filed Under: Editorials & Opinions, Public Policy · Tagged: , , , ,
Mar 3, 2013

Shades of Grey

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Charlie Ornstein is a senior reporter at ProPublica and board president of the Association of Health Care Journalists. More importantly, he is the son of Harriet Ornstein, who passed away peacefully on January 18th of this year following a short stay in hospital. Last week, Charlie published an article relating his experience – How Mom’s Death Changed My Thinking About End-of-Life Care.

Reading Charlie’s article reminded me of the insights of Dr. John Henning Schumann, which I shared in my post, The Politics of Dying in America. Charlie’s experience is no different than that of hundreds of thousands of families every year. His perspective, however, is uniquely different because he is now in the unfortunate camp of having looked at end-of-life care from both an objective and deeply subjective vantage.

From a public policy perspective, the vulnerabilities of the American healthcare dragon are so easy to identify that you have to marvel at our inability to effectively exploit them. As Charlie points out in his article, about one-fourth of all Medicare expenditures are made during the last year of a beneficiary’s life. We are paying millions and millions of dollars to buy a few extra days. Doesn’t seem objectively reasonable does it?

What would you pay for one more day? Seeing as the day after one more day the collection agencies wouldn’t be able to reach me, I guess I’d pay whatever my credit would allow. That might get me through Good Morning America. On the other hand, my dad always told me that a noble goal was to leave the world indebted to no one while being the poorest soul in the cemetery. So I got that going for me . . .

Without any intention of being disrespectful to the cherished memory of Mrs. Ornstein, I make light of a scary and depressing topic simply because there isn’t much else to do with it that seems logical. And that’s where very often rational discussions of healthcare public policy breakdown: because one person’s calm, objective logic is another person’s emotional reality. I think this is at least partially what Charlie was getting at in his article.

The elasticity of demand for medical care is one of the most capricious concepts we face in analyzing and assessing healthcare public policy. What I would pay to stay alive another day is necessarily going to be different than what I would pay to keep someone I have never met alive. But the reality is that through public healthcare programs supported by taxation (e.g., Medicare and Medicaid) I do help pay to keep someone alive another hour, day – or hopefully, much longer. Fortunately, I’m not directly involved in that decision making because I cannot imagine what it would be like if I had to choose how my tax contributions should be used – or not – on a case-by-case basis.

The point of all this is while some folks involved in healthcare policy debate would have us believe the world is black and white – with clearly delineated focal points for determining what’s right and what’s wrong – it obviously is not. The real world is a thousand shades of grey between black and white and nowhere is that more evident than when the topic is end-of-life care.

Cheers,
  Sparky

 

Filed Under: Editorials & Opinions, End-of-Life Care · Tagged: , , , ,
Feb 28, 2013

The Political Realities of Sequestration

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imageNow be honest, before last summer had you ever heard the term, sequestration? Though I’m sure I did, I can’t recall when, and I am quite certain I wouldn’t have known the correct Jeopardy question, “What is the term used to describe the legal confiscation and possession of a defendant’s property in lieu of a judgment or court order?” And that’s not even the popular meaning now embedded into our political lexicon.

I have come to understand that Congress’ use of that term dates back to the 1985 Gramm-Rudman-Hollings Balanced Budget and Emergency Deficit Control Act in which it was used as a means of reforming Congressional voting procedures and intended to raise that body’s consciousness that budgeting should be a process of allocation from funds available – rather than an exercise in arithmetic reflecting the outcome of decentralized appropriations (insert favorite form of sardonic humor here).

The idea was that if the combined totals of appropriation bills passed separately by Congress resulted in spending in excess of the limits agreed to by Congress in the annual Budget Resolution, and then if Congress could not agree on ways to reduce that spending (or did not pass a higher Budget Resolution), then there would be an automatic reduction in spending: the aforementioned sequestration.  For me (and I’m sure many of you), this is a rather easy concept to understand because that’s how sequestration works in our house when our appropriations exceed our funding: we often call it, “cancelling our dinner reservation for Saturday evening.”

Back in fantasyland, however, the automatic reduction was to be sequestered by the Treasury and not disbursed as originally appropriated by Congress. In theory, the application of the sequestration is to be regarded pro rata across all agencies, though Congress has typically exempted certain programs such as Social Security and Defense.  The practical result has been that agencies not exempt would experience a disproportionate share of the spending reductions in order to achieve the total sequestration amount mandated.

As retired Senator, Phil Gramm, noted, “it was never the objective … to trigger the sequester; the objective was to have the threat of the sequester force compromise and action.”  Well, as we’ve seen, there is one thing that simply cannot be forced in Washington right now, and that is compromise. The reason for this is the stark contrast in political realities currently characterizing the two major parties.

The Obama Administration believes it won an electoral mandate to advance the country further in the direction of European style Social Democracy (different than Socialism, but closer than many in this country probably realize). And as Bob Woodward recently found out, they are taking a Machiavellian approach to whatever – and whoever – stands in their way. Woodward has lifted the curtain on the Administration, and he has garnered the attention and concern of a lot of folks, life myself, who have generally been supportive of it. And though I very much doubt it was his intention – or concern – he has created a strategic political opportunity for Republicans.

Unfortunately for their party, however, the Republicans are still wandering aimlessly in the sociopolitical dessert of the late-middle 20th Century, looking for the ghost of Ronald Reagan – or any ideological mantra that could garner greater than 50% support of their tattered leadership. In addition, because of the tremendous expense involved in campaigning in an era of modern media and super PAC’s (even in fending off same-party candidates in primaries), having party power of the House of Representatives is like having a gun with one bullet.  The party in power now gets one shot in a Congressional session to make a political impact.

So what we have is not a game of Chicken, where we wait to see which side blinks first.  We have a legitimate ideological stalemate that is being advanced and dominated by the promotion of minority interests holding sway over the respective parties. I say this because according to opinion polls I’ve seen, a significant majority of this country is in favor of raising taxes in order to pay down debt. What that majority is not in favor of is raising taxes to expand entitlements (there is also significant support for raising taxes and reducing entitlements).

The Administration wants to raise taxes to protect and expand the entitlements that are a critical component of their social agenda, while the Republicans want to reduce entitlements without raising revenue (taxes) so as not to alienate their primary campaign funding sources. The sad irony here is not that elected officials from both parties are acting selfishly in their political self-interests. That we’ve come to expect.  The sad irony is the perceived belief that placating minority interests is in their political self-interests more so than acting in harmony with the majority. Now, why is that?

Cheers,
  Sparky

Filed Under: Editorials & Opinions, Sequestration · Tagged: , , ,
Feb 27, 2013

It’s the Culture, Stupid

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This post’s title is what I reminded myself of when I read the recent interview Megan McArdle did with Delos (“Toby”) Cosgrove, CEO of the Cleveland Clinic.  In that article, Can the Cleveland Clinic Save American Health Care? Dr. Cosgrove shares and explains several of the core elements behind the Clinic’s success. I was able to identify two concepts discussed by Dr. Cosgrove that I believe are more important to redefining healthcare in the United States than anything else: alignment of incentives and change management.  Both of these concepts are, in turn, major pillars of organizational culture.

And both are concepts, which transcend the argument that comparisons to organizations like the Cleveland Clinic, the Mayo Clinic, MD Anderson Cancer Center, Memorial Sloan Kettering, Johns Hopkins, et al) are often misguided and counterproductive because of the unique positioning and market advantages those organizations hold.

As Ms. McArdle writes in her article,

”Great institutional cultures can accomplish great things.  But in some ways, that’s a problem for the rest of us. It’s natural to want to emulate the achievements of [the] Cleveland Clinic in our policies. But you can’t make a culture out of rules. Culture is an organic outgrowth of an organization’s history, it’s people, its successes and failures. It cannot be ordered from the top, or nurtured by simply altering the financial incentives. Cosgrove speaks of maintaining the institution’s culture in much the way that he talks of maintaining their electronic health records system: a constant process of checking in, re-evaluating, and upgrading.”

But Cosgrove also believes the Clinic’s success can be replicated.  In the article he states that, “yes, other people can do it. One of the things that is beginning to drive this is the patient satisfaction scores that is now becoming part of the pay for hospitals ….” but “both the incentives and the culture matter. They’re inexorably tied.”

Creating a culture that instills and motivates behavior, which reflects incentives tied to desired outcomes – whether those are measured in terms of access, cost or quality and safety – is a difficult challenge that really does not get substantially easier or harder in relation to the size of an organization.  This is because – as my friend and colleague, Craig Anderson (National Director of Healthcare at Dixon Hughes Goodman) is fond of saying – “organizations don’t, never have and never will change – people change, one person at a time.”

And individual change is very hard for all of us.  It means being even more uncomfortable in a world of constant uncertainty.  It means not having the level of control you mistakenly thought you had in the first place.  It means letting go of some very deep-seated beliefs on how your environment should be ordered, arranged and understood.

To create the kind of culture that has been successful at the Cleveland Clinic requires an artful infiltration of the organization’s psyche. Careful attention must be given to long-standing relationships and patterns of behavior.  It is quite easy to do more damage than good. But if done right, the payoff can be a remarkable transformation from a healthcare organization inexorably floundering in reaction to its environment – to an organization that is emulated for proactively achieving great success, like the Cleveland Clinic.

Cheers,
  Sparky

Filed Under: Cultural Change Management, Editorials & Opinions · Tagged: , , , ,
Feb 17, 2013

Gun Control and the ACA

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imageThis is the second occasion I have had in the past four months to correct a news piece that has appeared on the Breitbart web site regarding the Affordable Care Act.  Last November, I shared my disagreement with Dr. Susan Berry’s fallacious interpretation of a Journal of American Medical Association article on knee replacements under the Affordable Care Act.

Interestingly, that post – Death Panels Just Won’t Die – remains the most popular PolicyPub article landed upon.  Visitors come to it by using search engines and wanting to learn more about “Obamacare and knee replacements.” But today I am writing about Awr Hawkins’ piece from January 9, Obamacare Amendment Forbids Gun and Ammo Registration.

A good friend brought this to my attention via  forwarded e-mail. As with many topics of this type, the news gets passed around in emails, blogs and web sites and then reproduced, repurposed and morphed into all varieties of content (just as I am doing here).  As I did in my post on death panels referenced above, however, I will try again to be diligent here in providing to readers original source content, so that you can do your own research – and thinking.  I wish Mr. Hawkins had gone to such effort.  Here is what he wrote:

“Good news — it has become known that hidden deep within the massive 2800-page bill called Obamacare there is a Senate Amendment protecting the right to keep and bear arms.

It seems that in their haste to cram socialized medicine down the throats of the American people, then-Speaker Nancy Pelosi (D-CA) and Barack Obama overlooked Senate amendment 3276, Sec. 2716, part c.

According to reports, that amendment says the government cannot use doctors to collect ‘any information relating to the lawful ownership or possession of a firearm or ammunition.’

CNN is calling it ‘a gift to the nation’s powerful gun lobby.’

And according to Senate Majority Leader Harry Reid (D-NV), that’s exactly right. He says he added the provision in order to keep the NRA from getting involved in the legislative fight over Obamacare, which was so ubiquitous in 2010.”

In his piece, Hawkins references an article produced by HotAir.com, which, in turn, references a video report produced by CNN on the subject that Hawkins’ references in his article (following, so far?).  What the original reporting claims is that Title X, Sec. 2716, Subsection C was a, “little known” piece of the Affordable Care Act that was unwittingly passed in support of the gun ownership lobby by lawmakers whom many would assume are gun control advocates.  In particular, Harry Reid.

As the CNN piece points out, however, up until very recently, Harry Reid has been a rather reliable gun rights advocate.  More importantly, as Ed Morrissey writes on the HotAir site, “this isn’t that much of a bar on Congressional action. What can be done in this manner can be undone in the same manner.”

Even beyond Mr. Morrissey’s interpretation, however, what the above referenced section does is make it explicit the ACA does not empower the Federal government (primarily under the Secretary of the Department of Health and Human Services) with the right to collect, analyze and/or report data and information on gun ownership.  And it was rather widely understood at the time (sorry conspiracy theorists) that in order to achieve some measure of political support of the ACA by the Gun Lobby, this section was intended to provide assurance the ACA was not granting new Federal powers.

That is not the same thing as saying such powers have been henceforth forbidden or cannot be achieved through other means (i.e., through future legislation).  In other words, if Congress were to advance gun control legislation currently under consideration that requires stricter registration, tracking and reporting of gun ownership, there is nothing in the ACA that would conflict with that legislation.

President Obama recently issued 23 executive actions on gun control.  One of these is to, “clarify that the Affordable Care Act does not prohibit doctors asking their patients about guns in their homes." This has also been unfortunately interpreted by some media sources as a new Federal requirement that doctors are being required to act as deputies in ferreting out individuals at risk of committing gun violence.

In any event, while speaking on gun control during last week’s State of the Union, the President noted that, “each of these [gun control] proposals deserves a vote in Congress.  If you want to vote no, that’s your choice. But these proposals deserve a vote. Because in the two months since Newtown, more than a thousand birthdays, graduations and anniversaries have been stolen from our lives by a bullet from a gun."

What I believe this to mean is the President does not have the votes in Congress to pass any meaningful gun control legislation at this time.  But he is seeking to gain some measure of political capital by getting those opposed on record.

This is a very difficult ball of public policy yarn: wrapped in together you have healthcare delivery policy, mental health policy and gun ownership/gun control policy.  It requires serious efforts in research, understanding and debate.  It requires, wherever possible, a clear articulation of the known facts.  Although my readership is paltry compared to what Breitbart controls, I hope my efforts here will combat this latest demonstration of reporting laziness, manifested in unhelpful misinformation.

Cheers,
  Sparky

Blog post picture courtesy of www.sodahead.com

Filed Under: Editorials & Opinions, Gun Control · Tagged: , , ,
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