Now What !?

At 7:30am on Wednesday, November 9th I received a Helen of Troy type text message: three simple words from a client that begged a thousand responses, simply asking, “now what?”

Unless you’ve been hiding under a rock for the past few Trump Winsweeks you are aware that healthcare in the United States is once again heading into turbulent policy waters with the election of a president whose political party has very different ideas about how to improve our healthcare delivery system. Or so we have been led to believe.

From what little is known to this point it is unlikely the Trump Administration will just blow up the Affordable Care Act in the first 100 days of its tenure. That is fortunate because, irrespective of your political beliefs, haphazardly dismantling the current system would undoubtedly result in unintended – and politically undesirable – consequences, potentially causing harm to millions of patients and healthcare providers.

That being said, there is no doubt substantial changes will be made and quickly by Washington, DC standards. If anything is predictable about Mr. Trump it is that he won’t be patient with bureaucratic efforts not quickly producing tangible results. Whether that impatience can be channeled into effective change management in a kingdom that literally thrives on maintaining the status quo only time will tell.

The next six months are going to be incredibly confusing and confrontational as we seek to consider and understand the potential ramifications of new health policy proposals. Speculation on the impact of such proposals will span from certain and imminent catastrophe to unbridled joy. Through it all be reminded that often in many ways the more things change the more they stay the same. To that point, in helping senior living organizations anticipate how to best position for changes in healthcare policy I think it is more prudent than ever to focus on what we know won’t change.

The accelerating demand for affordable housing, home and community-based services and healthcare resulting from the demographic realities of an aging population will not change. Underlying pressures such as technology and innovation driving up healthcare costs will not change. The growing impact of consumerism on healthcare will not change. Demand for qualified human caregiving resources outstripping supply will not change. The increasing burden chronic disease management puts on our delivery system will not change. I’m sure you can think of your own realities to add.

If you aggregate all of the environmental certainties shaping the healthcare industry today and in the future, logic dictates that value will continue to be at the center of new policy initiatives. And that means alternative payment models (APMs) will continue to garner support if not greater efforts to accelerate their adoption. Recall, the Medicare Access and CHIP Reauthorization Act (MACRA) provides substantial incentive for physicians to migrate into advanced APMs, and that legislation was passed by Congress with overwhelming bipartisanship. MedPAC, the nonpartisan legislative branch agency that provides Congress with analysis and policy advice on the Medicare program has also been very supportive of APMs.

So when answering the question, “now what?” my response is to continue developing organizational attributes that will build competitive advantage as a participant in APMs. Focus on the no regret investments that build enterprise value in the context of emerging care delivery models: e.g., demonstrating a commitment to continuous quality improvement; assess the value of specialization; improve productivity and reduce costs without impacting outcomes; develop an employee value proposition; build a robust cost accounting system; focus on beneficial referral relationships; measure and report on performance; invest in community-based downstream relationships.

A great way to learn more about what APMs entail – and to stay ahead of emerging research, ideas and discussion about their advancement – is to join the Healthcare Payment Learning & Action Network (HCPLan). This is a nonprofit organization that was launched by the Department of Health & Human Services in March of last year with a mission, “to accelerate the health care system’s transition to alternative payment models by combining the innovation, power, and reach of the private and public sectors.”

On October 25th of this year I had the opportunity of attending the fall LAN Fall Summit in Washington. The Summit brought together nearly 800 participants representing senior leaders from across the health care community, including providers, payers, employers, patients, consumer groups, health experts, and state and federal government agencies.

Here’s the singular most important message that I would like to share from my participation there: alternative payment models are not unicorns. They exist, they are being tested, learned from and gaining increased support daily. They are transcending the ideological spectrum of political discourse. The advance toward APMs is accelerating, and as shared above I do not see that being at all abated by the results of this presidential election. I can see the opposite effect taking shape.

Sadly, I believe there will come a time in the not too distant future when many nonprofit and smaller senior living organizations that depend upon post-acute/long-term care revenue for survival will find their organizations have waited until the decision of whether or not to participate in APMs has been taken out of their hands. For profit organizations are investing millions in learning how to compete and win under alternative payment models. If your organization is not taking steps to be equally competitive, then I would focus your energies instead on building acquisition value.

The first step in determining whether and how your organization can be competitive in a world of value-based care delivery models is to perform a gap assessment: what attributes must you have to compete under APMs compared to your organizational current state – and what investments are required to bridge that gap? Do you have the financial wherewithal to make those investments? How much time do you have to effectuate change?

That’s now what.

Cheers,
  ~ Sparky

Value Isn’t Working

HC FrustrationVALUE. I have written quite a bit in this space over the past three-and-a-half years on the role of value in healthcare and how it has been purported to be used as an effective public policy tool. Just type in, “value” on the search box to the right and 10 such posts will appear for your reading pleasure. But I haven’t written about value in the context I am about to now.

Earlier this week Paul H. Keckley, Managing Director of the Navigant Center for Healthcare Research and Policy Analysis, posted The Meaning of “Value” in Healthcare to the Health Care Blog.  In that post he argues rightly that the significant shortcoming of value as a driver of anything in healthcare is that it is not being defined by end users – i.e., patients, or consumers as it were. In stark contrast to what I have advocated in the past I would go beyond that.

Keckly muses of a system where consumer-driven healthcare is manifested in the dissemination of knowledge and information that empowers rational decision-making and the efficient allocation of resources. Where he stopped short – whether by omission or design – was to suggest the best means of achieving that nirvana. I will pick up the ball and take it a little further.

It is not enough to advocate for consumer-driven empowerment as the means of leveraging value in our healthcare system.  We must also recognize the stark reality that current healthcare policy – and in particular, the Affordable Care Act – is a tremendously effective impediment to achieving that empowerment.

I remain as convinced as ever that value – Porter’s axiomatic assertion that outcomes over cost will drive achievement of the IHI’s Triple Aim – is key to delivery system improvement. But I am terribly disillusioned that value can be effective in a system that is controlled in such a manner that it is determined artificially and arbitrarily by the likes of academics, bureaucrats, administrators and consultants.

Alternative payment models – and the care delivery models that are being developed in response to the artificial financial incentives they are offering – are doomed to ultimately fail because they lack the inert ability to leverage value as it is perceived by the individual consumer, one person at a time. By failure I do not mean they will be soon to go away – but they will not achieve the shared goals referenced above. Disagree?

Cheers,
  ~ Sparky

Of Flags & Windmills

I’m sure today’s contribution (one of two hopefully) will come as a great relief to those (both) of you who have been waiting patiently for a new post to the PolicyPub. I hadn’t planned on taking such a long hiatus, but the further it went along the easier I found it to escape the self-prescribed responsibility of producing blog content. I do truly enjoy writing, but I have to say I’ve also very much enjoyed some other distractions in the interim. Maybe I will write some about that down the road.

Anyway, I haven’t decided yet whether to still focus only on healthcare policy or expand the Pub’s spectrum to include general policy interests that appeal to a much broader audience. If anyone is still out there reading, perhaps you can give me some feedback.

I thought I might start back by dipping my toe in the water with a timely, non-healthcare policy issue.  And in keeping with the soggy great lakes summer this has been, as long as I am choosing to get my toe wet why not get entirely sucked into and soaked by the whirlpool of controversy surrounding the Confederate flag. Not only is the issue timely and more widely of interest than ICD-10 implementation, but so is my perspective having just returned this week from an annual trip to Gettysburg with my twelve year-old son.

Having been a student of the Civil War since his age I could easily turn the Pub into a daily diatribe on that subject alone. Whether it would be interesting or not – well, let’s just say there are fortunately many others who know quite a bit more about it and have both the time and artistic ability to cover it better than me.

But what I have learned over the years is the connection between slavery and the Civil War is as complex a study as you could hope to find in American history. Those having just a smidgeon of that understanding will admit candidly at least to themselves that the Confederate battle flag stands for a lot more than the institution of slavery to a great many people – then and now.

For starters, a fair reading of soldiers’ diaries on both sides of the conflict will quickly help one understand that slavery was not in the least a primary motivation that caused men on either side to risk and experience death in very often the most horrific fashion imaginable. The same could not be said for the powers that be responsible for starting the war – and hasn’t that always been the case throughout history. 

This is what to a historian is fascinating, complex and confusing. As the author Shelby Foote said, “people who say slavery had nothing to do with the war are just as wrong as those who say slavery had everything to do with the war.” But if you take slavery away as an issue then there most likely would have been no war. So it’s ultimate role cannot be diminished even if not fully understood.

That 19th century perspective of the flag notwithstanding, the 20th century was witness to countless occasions when the confederate battle flag was carried as part of protests and rallies that were blatantly racist, vitriolic and bigoted in both foundation and intent. And so to those generations alive today it is understandable their symbolic association of the flag is one of hatred, intolerance and fear. From this perspective I find it impossible to argue against removing it from government properties as was done yesterday in Columbia.

But to and for the memories of the thousands of men who died on the wrong side of history and morality I hope we will remember that symbols can mean many different things to many people. One cannot meaningfully judge history without being able to walk in the shoes of its actors.

Walking the battlefields and reading and hearing about the tremendous sacrifices that were made by all of the men who died in Gettysburg the Confederate battle flag has served as a symbol for a great deal more than the unfortunate place it occupies today in the hearts and minds of many.

I think there is more to this story, however. Beyond all of the symbolism and rhetoric that has provided salable content for media outlets in a manner and fashion normally ascribed only to sausage making is a very scary reality: we are becoming a country with a phenomenal ability to tilt at windmills. Not only have we become overly adept at tilting, we do so now at full gallop whilst trying to pass the horse ahead of us in order to be first off the cliff.

We have lost our common sense, balance and perspective – our ability to have intelligent, factual and candid debate. Social media has become a sadly expedient venue for pretending to express individual thoughts and ideas while the substance supporting those ideas is void.

So what does all this mean from my perspective on the Confederate flag issue? I think South Carolina made the right call to remove the confederate battle flag from statehouse grounds. No brainer. But the National Park Service removing items for sale containing the Confederate flag from its book store in Gettysburg? Just another example of more lemmings not wanting to be left at the station.

Cheers,
  ~ Sparky

DocFix is D O A

pic_related_022514_SM_A-Doc-Fix-Thats-Not-a-Fix_0Things have gotten so pitiful in Washington that political reporters – being anxious to share any news their audiences might find not depressing – are apparently falling over one another buying into the idea that a divided city can suddenly  come together and address the $174 billion political juggernaut of Medicare reimbursement for physician services. Using words like momentum, enthusiasm and optimism they report that Congress is advancing on a permanent Doc Fix.

Oh, please.

The rightwing of the Republican Party has already made clear its intent to use intransigence as the primary tactic to implement a strategy of growth through attrition in this 114th Congress.  And the only hope for securing Democratic support to bridge the voting gap left in their wake will be if those Democrats subscribe to Ms. Pelosi’s edict of not reading healthcare legislation before voting on it. Because if they actually read it, they will in all likelihood not be happy at the entitlement program cuts needed to fund the fix.

Alternatively, funding offsets could be achieved on the backs of other clinical providers and Medicare recipients. Those have always been pushover constituencies with poor lobbying representation, right? Or, to steer clear of that minefield legislators could assume funding offsets will come from expanding value-based payment models and continued implementation of other ACA reforms (e.g., lowering of hospital readmissions). That should be an even easier sell with Conservatives in Congress (yeah, more sarcasm).

And let’s not forget the public and private enterprise investments made into ICD-10 implementation, which Republican lawmakers would probably seek to delay as part of SGR repeal. That will be a contentious ideological battle separate from not having $174 billion at hand.

See what I’m getting at?

All this has to be worked through before physicians face an average reduction of 21.1% in Medicare payments in less than three weeks. Physicians who are already nearing their human capacity and ability to fight through the regulatory obstacles that impede helping their patients.

So don’t buy into the hype: 2015 looks a lot like 2002, 2003, etc. – time once again to kick the can down the road.

Cheers,
  ~ Sparky

OBAMACARE: Was The Runner’s Knee Down?

NFL-REF-WATCH-BREAKING-BAD-bigger-300x211The play lasted only eight seconds out of 3,600 in the entire game. The distance traveled roughly 16 inches out of 3,600 across the field. Yet what occurred during those 8 seconds and 16 inches could make the difference between immeasurable joy or profound sadness. It all depends on how the referees view the play.

Of less substantial consequence in the minds of most Americans, starting tomorrow the Supreme Court will begin hearing arguments over 6 words of the Affordable Care Act – out of roughly 382,000: “through an exchange established by the State.” In November of last year when the Court determined (or at least four Justices did) to hear King v. Burwell I wrote, Does Legislative Negligence Trump Legislative Intent? I discuss there the background and ramifications of this case.

Here I am more interested in briefly sharing some thoughts on the relative influence of sociopolitical factors in SCOTUS’s review and consideration of this case. Whereas our historical view of the Court is one of great reverence and respect – the last bastion wherein ethics and morality trump politics – I think the image I chose for this post today more accurately reflects public opinion of that institution today – right or wrong.

I am not about to argue that politics has only recently become an unsightly element of the Court. Justices are appointed and approved by those who are elected, and they don’t get to the position of being considered by living out an apolitical professional career. From accusations against President Grant for court packing to FDR’s proposal to add members (conjectured to dilute a conservative bench) to more recent skirmishes over presidential nominees (e.g., Bork and Thomas) the Court has been steeped in political undertones for decades.

But what we are witnessing today is beyond just the politicization of appointees and the legacy influences of political ideologies. Like all things touched by our modern media the Court is engulfed by a sea of opinions and editorials in anticipation of a “wrong” decision – having not even heard one word of oral argument. How can the justices not hear the deafening crowd noise any less than the referees on the field looking under the video replay monitor. What influence, if any, will that carry on how they view King v. Burwell?

Regardless of how you hope the case is adjudicated you must see the irony in 8 million lives potentially being negatively impacted by 9 individuals out of 320 million based on the arbitrary interpretation of 6 words among 382,000.  Welcome to 21st century democracy in America.

Cheers,
  ~ Sparky

Value-Based Payment: The Rush is On!

The most opportune time to jump off a bandwagon is just before the next person jumping on tips it over. If the accelerating movement toward value-based payment (VBP) models in healthcare could be metaphorically thought of as a bandwagon, then its passenger weight increased dramatically this week with two major announcements.

First, on Monday HHS Secretary Slyvia Burwell announced that within four years half of all Medicare spending will be VPB oriented (e.g., bundled payments, ACOs, capitation models). Then yesterday several of the country’s largest healthcare systems and insurers announced the creation of a Health Care Transformation Task Force whose stated goal is to shift 75% of their business to VBP type contracts by 2020 (as in 5 years).

I have been an acknowledged student and disciple of Michael Porter’s work on value in healthcare and have written about that subject here in the past. Porter and colleague Elizabeth Teisberg wrote the seminal work, Redefining Healthcare, which buttresses much of the practical theory that has been espoused in support of VBP. In my study, however, I came to believe the underlying structural challenges of our current delivery system would take a great deal of time and effort to overcome before value could work the magic as intended. And so when I read these two announcements I had to wonder whether fools are rushing in where angels fear to tread.

In other words, it’s not the direction of the bandwagon I find concerning but the pace of acceleration. There is so much unknown and so much to be learned regarding the organizational dynamics of healthcare delivery that putting deadlines on the pace of that knowledge-building is pure folly. To illustrate, let’s just look at Porter’s strategic agenda for creating a value-based healthcare delivery system and consider each in context of what we are witnessing today.

1. Organize care into integrated patient units around patient medical conditions.
Porter has travelled the world lecturing and observing healthcare delivery systems in other countries. He provides examples of structural reorganization for patient conditions (e.g., the West German Headache Center) that have achieved substantial improvements in patient outcomes at lower cost. The concept isn’t entirely new (e.g., MD Anderson Cancer Center reorganized its outpatient care services in the early 90s under the auspices of an IPU), but still rather rare and so not very well understood.

2. Measure outcomes and cost for every patient.
Another way of saying this is be able to measure cost and quality/satisfaction at the patient level. This is without a doubt the most difficult and controversial aspect of Porter’s agenda.
In June of last year I wrote a post that addresses the inherent subjectivity of patient outcomes and its impact on the value equation. If this cannot be worked out in a manner and fashion that achieves broad understanding and acceptance across patients, providers and insurers – well, see bandwagon discussion above.

3. Reimburse through bundled prices for care cycles.
When Porter talks of bundling his focus is on tying the bundle definition to the value achieved on behalf of the patient – e.g., the patient’s experience, impact on family, lifestyle functionality, etc. What I hear about mostly are efforts to define, articulate and divide up processes and procedures related to a diagnosis and/or condition, put some probability bookends around that understanding and then compare projected average payment to cost. The ability of value to be successful as a catalyst for aligning incentives has already been lost because the focus is on process – not the patient.

4. Integrate care delivery across separate facilities
The many challenges of integrated clinical care notwithstanding, improved performance through specialization is really the key concept here. Research has shown that volume in a particular medical condition is positively correlated with patient value. This runs counter to the notion that all healthcare is local. While every day we culturally become more comfortable with this notion – e.g., international medical tourism – there are still substantial social and political obstacles to overcome.

5. Expand areas of excellence across geography
We are seeing systems like the Cleveland Clinic, Geisinger and the Mayo Clinic exporting their knowledge and expertise across geographies. But the expansion has been primarily revenue-driven (relatively more patients with the financial ability to afford services). If value is to be the driver of alignment, then eventually those organizations will also have to demonstrate how knowledge exporting not only improves outcomes at the local level but also lowers costs (much harder to achieve).

6. Build an enabling information technology platform
Hoo boy, right? The challenge here, of course as I have written before, is properly utilizing IT to facilitate and enhance the productive value of human processes. If the underlying organizational structure and processes aren’t in alignment with the goals and objectives manifested through the five agenda items above, then all we will be doing is automating a system that we said we wanted to change.

I realize some of these concepts are above my pay grade, and I continue to believe the value concept – Patient Outcomes/Cost – is the key fundamental principle of structural system reorganization. But when I step back and compare the payment and care delivery models being pursued in the name of “value” against the strategic agenda that Porter laid out I worry greatly that we are not willing or prepared to take the time or effort to understand and address fundamental areas of concern.

It’s like building a pyramid. The more time you take to create a solid and expansive foundation, the higher you will ultimately be able to build. As much as I have supported the value driving structural change paradigm I would encourage all industry stakeholders and participants to be both pragmatic and cautious in advancing on VBP models. Take the time to observe, learn and adjust – and don’t let your timeline be driven by outside sources with no vested interest in your organization – or your patients!

Cheers,
  ~ Sparky

Standing At The Gates of Hell

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

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

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

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

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

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

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

Cheers,
  ~ Sparky

Sorry Charlie: Too Many Sharks at the Trough

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

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

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

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

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

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

What do you think is missing?

Cheers,
  Sparky

Is Being Ignorant Better Than Being Stupid?

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

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

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

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

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

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

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

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

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

Happy New Year!
  ~ Sparky

Hpapyy Hlodiyas

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

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

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

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

Cheers,
  Sparky

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