May 21, 2013

A Pub Celebration!

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FireworksI completely missed the One Year Anniversary of Sparky’s Policy Pub, which was last Tuesday (business is good, and nobody’s complaining). In the past year I contributed 70 posts that generated  roughly 3,600 views. Whether that’s above, below or right about average I have no idea. But I have had  a lot of fun writing each and every post, which was my goal to begin.

And it has been fascinating to follow the blog stat’s. My number one post continues to be Death Panels Just Won’t Die, which is hit upon most often by folks searching for information on whether knee replacements will be rationed under the Affordable Care Act. It’s for that very reason that post is also my favorite, as I tried very hard in it to combat the misinformation that exists about the Act and how that misinformation has been used to scare our most vulnerable members of society.

So to anyone and everyone who has taken the time to stop by the Pub and read my posts, I want to sincerely thank you for your time and interest. While I find great enjoyment in just having a reason to write, the recognition that comes from knowing someone else finds what I write worth their time to read is very special and very meaningful to me.

I have learned a lot on how to create content that is valuable, interesting and entertaining. I still have a lot to learn, and I am anxious to see where the year ahead will take me – and the Policy Pub.

See you in the Pub!!
  ~ Sparky

Filed Under: In the News, Public Policy · 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 24, 2013

Paging Dr. Watson . . .

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Watson, the IBM supercomputer, generated world interest in 2011 when it competed on Jeopardy against former champions of the famous TV game show and won the first prize reward of $1 million.  With access to 200 million pages of structured and unstructured content consuming four terabytes of disk storage, Watson performed without having access to the Internet.  Ever since IBM’s Big Blue beat Gary Kasparov in 1997 IBM has doubled down on its passion for developing technology that seeks to mirror the capabilities of the human mind.

Now that passion is taking Watson into the hospital and physician office. A February 11, 2013 article in Wired Magazine UK, IBM’s Watson is better at diagnosing cancer than human doctors, describes how IBM is partnering with Memorial Sloan Kettering Cancer Center in New York and Wellpoint to make Watson available (i.e., for a fee) to any hospital or clinic seeking its input on oncology cases, including proposed treatment protocols that seek to minimize cost.

The big advantage Watson has over human doctors is its ability to absorb and analyze enormous quantities of data – and then make that knowledgebase more accessible and more affordable.  As example, according to Sloan-Kettering, only 20% of the knowledge doctors use in diagnosing patients relies on trial-based evidence.  But it would take at least 160 hours of reading a week to keep pace with all of the medical knowledge being published – and that doesn’t include the time it takes to determine how to apply that knowledge in practice. Watson’s successful diagnosis rate for lung cancer is 90 percent, compared to 50 percent for human doctors.

This subject-matter reminds me of Malcolm Gladwell’s book, Blink, in which he tackles the subject of rapid cognition: how the human mind processes environmental stimuli and compares, contrasts and analyzes that stimuli against the billions of elements of data that comprise individual experiences comprising our conscious and unconscious memories.  Watson’s ability to replicate that capability is still a long way off.  But the progress already made is fascinating.

While fascinating, practical application of technological advancements in healthcare are often challenged by skepticism. How much of that challenge is created by the natural human resistance to change, how much results from not understanding the new technology – and how much is based upon previous experiences that demonstrate the risks of adopting technology before it is fully proven – is hard to know.

A lot of faith is being put into technology as the silver bullet to address the healthcare cost crisis. When you read something like what IBM is accomplishing with Watson you want to jump on that bandwagon.  When you spend an afternoon with clinicians that share real life stories of how their ability to deliver care is being impeded by technology that was supposed to make them more efficient and productive – well, not so much.

Cheers,
  Sparky

Filed Under: Clinical Technology, In the News · Tagged: , , ,
Dec 13, 2012

While Rome Burns

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Quick Take
As reported in The Hill yesterday, Federal Reserve Chairman, Ben Bernanke, shared a dire warning on the prospects for the US economy if our elected officials fail to resolve the critical impasse on how to avoid the Fiscal Cliff.  He also pointed out that the economy is already being negatively impacted because the uncertainty and prospect of going over the cliff is creating havoc in financial markets and impacting investment decisions.

With so much at stake it is beyond disheartening to watch the political posturing of the two extremes of political discourse.  On the Socialist left you have, thou shall not cut entitlements to anyone – while on the Tea Party right you have, thou shalt not raise one penny of taxation. 

Where do you go from there? That’s like being told to increase production while laying off workers.  Yeah, I know that can and has actually be done, which is another topic for another day – but you get the point.

Our country is being held captive by minority extremists at both ends of the ideological political spectrum – neither minority willing to compromise because being correct in their beliefs is more important to them than being part of a plausible – if not entirely agreeable – solution to the challenges that come with governing. 

I often wonder whether folks who relish in being identified as “part” of a political ideology discover through maturation which ideology aligns with their beliefs – or whether they form their beliefs to align with the ideology to which they seek to be identified as being part.  When someone claims they are a bleeding heart liberal, I’d like to see how much they donate to charity each year.  And when they claim to be a staunch conservative, I’d like to watch them discipline their kids.  Talk is cheap and even more so when emboldened by social media.

My point is that I have had it up to my eyeballs with having minority interests capturing and distorting majority attention – and being an obstacle that is much larger than defined by their electoral power.  Every person I have talked to over the past few weeks – Democrats and Republicans alike – is of a similar mind: both revenue increases (taxes) AND expense reductions (entitlements) are necessary.  I believe the majority of Americans know and understand that.  Do you?

Cheers,
  Sparky

Filed Under: Editorials & Opinions · Tagged: , ,
Dec 3, 2012

Big Data Assimilation

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In early October, I wrote a post entitled, Big Data and Brand Management.  In observing the Pub’s recent visit tracking activity that post has been getting some attention – particularly from the Netherlands.  I wish I had the time to investigate further to possibly understand why.

I do know that the subject of Big Data and Healthcare is quickly becoming one of the most intriguing – if not controversial, and to many, threatening – side shows of the big show that is Healthcare Reform and the impending implementation of the Affordable Care Act.

In the IT world this growing attention is seen as an anticipated awareness among the less informed masses to a level of consciousness they achieved over a decade ago.  But for all that foresight, there has been precious little headway made in addressing some very critical issues of access and security.  And that is because those issues are not clearly defined, have dramatic implications regarding personal privacy and must be framed within a context of assumptions about the future that are widely debatable and lacking entirely for empirical support.

There is a lot at stake here:  a huge potential for solving some very challenging social problems – yet just as great potential for infringing upon personal liberty.  While I share the justifiable concern over protecting the privacy of individual patient data and information, I believe that concern is clouding an even greater story here; and that is the alluring diagnostic trajectory that Big Data has launched us upon.

In combining Big Data (large static storage requirements) with highly complex  analytical algorithms (large dynamic memory capacity) requiring tremendous computing capacity (processing speed) what we are essentially doing is seeking to replicate and accelerate the thinking ability of the human brain.  The historically great equalizer of human intelligence has been a life’s experience.  To be sure, there are ways to broaden exposure to circumstances and events that contribute to such experience, but there is no way to accelerate the natural course of observable events, which ultimately comprise the sum total of that experience – nor the wisdom of maturity to make good use of it.

In the book, Blink, by Malcolm Gladwell, he explains the concept of rapid cognition: a fascinating treatise on how our minds instantaneously sort through and combine billions of observational data elements from our life’s experience, analyze the meaning of that data and then form a reasoned judgment about what we have just observed through our senses in a matter of a few seconds.  This is often also referred to as intuition, or a gut feel.  It’s something that has saved many lives owing to physicians’ diagnostic capabilities.

What many clinicians fear in a world of Big Data is an unproven overreliance on information technology to supplant or replace that diagnostic capability (or intuition, if you will).  While, in the aggregate, some of that concern may understandably be driven by a fear of professional obsolescence, I think the much more prevalent concern is challenging whether and when a machine will (ever) be able to truly replace the intuitive capability of the human mind.

And that really is at the heart of the longer-term Big Data dilemma, even if the focus right now is on privacy and protection.  I don’t mean to diminish such concerns, but I do believe we will ultimately be able to address those relevant concerns satisfactorily.

A much more difficult challenge, however, is assessing and understanding whether machines will eventually be able to capture the collective human knowledge and experience that clinicians currently rely upon and be able to analyze and apply that information in a way that achieves better overall patient outcomes than application of human assessment, analysis and reasoning.  And, if so, will patients be able to have access to that computing capability without needing human interface?

Then, what is the role of doctors in the future? Will there be a need for them? Will those who would have otherwise employed their talents in becoming physicians be the future engineers and programmers that work to develop, upgrade and enhance the computing capability of the new electronic caregivers?

A lot to think about.  Big Data offers a lot bigger challenges than just worrying about who owns the data.  The real concern is who is going to control the owner of the data – and how? Star Trek fans, think Borg.  Is that where we’re headed?

What do you think?

Cheers,
  Sparky

Filed Under: Editorials & Opinions, Information Technology · Tagged: , ,
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