The Day After

On December 9th, 1980 this image was hastily taped to a window in a basement dorm room of Pacelli Hall at John Carroll University. It was a Tuesday. I was living in the basement of Pacelli Hall. Or supposed to be, anyway.

The evening before I spent upstairs at my parents’ house where I had been studying (or what then I thought was studying) and listening to WMMS. DJ Denny Sanders interrupted a song to share that John Lennon had been shot. It didn’t sink in. It couldn’t.

A bit later another broadcast interruption shared that John Lennon had died. DIED? As in, he’s not going to be here tomorrow? Who would want to kill John Lennon? What did he ever do to someone to deserve that?

I will never (hopefully) forget the image of that dismal day in Cleveland. It was the kind of day that you have to live here long enough to despondently appreciate the experience. Dark. Rain. Fog. Just cold enough to where rain doesn’t turn to snow.

God had brought forth the perfect ambiance for mourning. John Lennon had died. And with him another slice of our youthful innocence. December 8th is rightly remembered as a tragic day in our country’s lexicon. December 9th was the day we had to begin reconciling a shared tragedy with our own will to live.

Of Medicaid and Pork Belly’s

There is an old saying that’s been around in DC for years that goes something like,

Don’t tax you
Don’t tax me
Tax that man behind the tree.

So goes the thinking in private conversations around Washington about the duplicity of elected officials wanting to reduce constituents’ tax burdens while at the same time providing valuable public services to those constituents.

The simple reality is we will – eventually (next year? next decade?) have to pay the piper in the same way Greece has. To the extent that reality causes angst it’s understandable why a Federal budget proposing to slash millions in spending would be embraced.

The issue, of course, is whether and how spending reductions should be effectuated. With today’s release of the Administration’s “proposed” budget the gauntlet has not been laid down so much as the effort has been made to call attention to the man behind the tree.

The sad reality in our country is the Federal budget could very likely be cut by a third without touching Medicaid (might even be able to expand it). But then, at least half, if not more, of current members of Congress would likely lose their seats for failing to bring home the bacon.

Knowing their potential absence probably doesn’t bother most of us should tell you all you need to know about the huge systemic challenge we face in correcting the best form of government this world has ever seen.

~ Sparky

Let’s Take A Breath . . .

AP_17137623354997-1280x960The James Comey Oval Office conversation looks like a witch hunt to me.

Frankly, if Trump said what he is alleged to have said to Comey, I could really care less. That a sitting president should be called into question over a remark that “could” be interpreted as coercive I guess is in keeping with the 24-hour news cycle and social media landscape that now litters our country. Pragmatically, I could very well see Trump having said what he is alleged to have said without having any sense of desired influence whatsoever. 

But that’s because he is so clueless that he says whatever words he is able to muster at the time. If you listen to him enough, how could you not believe he rarely says anything with forethought – let alone malice of forethought. I listened to his commencement address to the Coast Guard Academy this morning, and it was truly sad. I think he only has three or four adjectives in his repertoire that he uses time and again.

“Really” is the big one, though technically an adjective preceeding another adjective is considered an adverb if memory serves.  Everything is really good, or really great, or really wonderful. And beyond, good, great and wonderful things fall off quickly. And of course, there’s the show stopper: “believe me.” At least George W had the presence of mind to pause and take flack for not being quick enough to get the right words out rather than just filling the void with adolescent banter.

The more you listen to Trump the more two realities become self-evident: he does not take the time or effort to gain even a basic understanding of the policy issues about which he speaks – regardless of what position he may favor on those issues. And second, he has no sense of himself outside of how he is self-actualized by his audience and the sycophants clamoring around like remoras attached to a shark. That must be why he craves those rallies so much. Without them he has no self worth nor understanding of why he ran for president.

But being obtuse and narcissistic are not impeachable offenses. Rushing to judgement on the basis of what should have been a private and confidential conversation between a president and his direct report is folly and only serves to fan the flames of political irreverence. Let’s maintain some common sense of decorum and see if we can’t still find the better angels of our nature to guide us through these troubling times.


Role of Wrongful-Life Cases In Palliative Care


11SPAN-master768Earlier this week Paula Span wrote in the New York Times about the increasing number of lawsuits being filed on behalf of patients being kept alive. Counterintuitive? Not when you consider they were kept alive only to endure more pain and suffering – against their known wishes.

If you’ve ever read or heard about a court case involving whether, how, why or why not an individual’s advance directive was carried out as intended by the patient, then you are no doubt familiar with the myriad circumstances and events that can lead to great confusion at the time of death. It’s an area of healthcare painted with a thousand shades of grey.

Unfortunately, an advance directive often gets twisted and manipulated nine ways to Sunday in the hands of numerous stakeholders standing bedside, whilst the person in the bed is most often unable to advocate for their own interests. This is when doctors begin envying lawyers because lawyers don’t have to practice medicine.   

I have yet to meet the physician who wants to cause his or her patient harm. They even swear an oath not to. There are other areas of the Hippocratic Oath wherein its fulfillment brings into question – absent an informed directive – to just what lengths are necessary and appropriate to save the life of a dying soul in the knowledge that such actions may cause increased suffering.

Allowing for the presumption of innocence, however, doesn’t change the very real consequences suffered in those cases shared in the article. I suspect attributing the failures to a breakdown in communication is a safe bet in most of those cases since that is a phenomenon, which continues to plague our healthcare delivery system despite the investment of billions into information technology.

Of course, the broader discussion this story touches upon is addressing life and death in the context of quality of life – and who determines the subjective nature of “quality.” To that point, we have much to benefit from the continued awareness and education of the role palliative care can play in treating severe and terminal illnesses.

In this country we are culturally adamant about resisting and ignoring the realities of death. One needs look no further than the hysterical idiocy that surrounded death panels. Perhaps these cases will help advance the broader conversation we need to have on how we can best protect individual patient rights while providing them the best possible life while still on earth.

  ~ Sparky

Accelerate! ~ Or Be Eaten

Originally published in November 2012.

Sparky's Policy Pub

John Kotter makes his latest contribution to an already authoritative body of work on organizational change management in the article,

that form the backbone of a strategy network, which he suggests should work in parallel with an organization’s existing operations. The accelerators differ from the eight steps in their being nonlinear, more organizationally encompassing and ideally facilitated independent of the traditional organizational hierarchy.

), while the other is a network framework that is able to leverage the organization’s group genius in ways that facilitate rapid strategy deployment.

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What’s Your Performance Improvement Strategy?

If you are a post-acute/long-term care provider still sitting on the sidelines waiting for a clearer understanding of how Healthcare Reform is going to impact your organization’s future, well then all I can say is, “Good luck with that – let me know how it works out for you.”

In an article published this past weekend (Medicare Seeks to Curb Spending On Post-Hospital Care), Kaiser Health News’s Jordan Rau reported on the wide variability in Medicare spending on post-hospital care across the county – and the attention that it is getting from CMS. Attention that is quickly turning to targeting: as in even more deeper cuts in reimbursement.
Several of the examples included:

Medicare recipients in Connecticut are more than two-times more likely to be admitted to a nursing home than residents in Arizona.

Medicare spends an average of $8,800 on a patient’s home healthcare in Louisiana – while spending $3,800 in New Jersey.

The rate at which beneficiaries receive post-acute services covered by Medicare in Chicago is three times the rate in Phoenix.

And the aggregate economic impact of variability in per capita spending is substantial. As the growth in post-65 age cohorts continues to accelerate both the inherent cost contribution (demand) as well as cost-push inflation (a result of seeking to satisfy that demand with scarce resources) is increasing. As reported in the Kaiser article, Medicare spending on PA/LTC, “has grown at 5 percent a year or faster in 34 of the nation’s 50 most populous hospital markets in recent years.”

The article goes on to describe the perceived reasons behind the variability that has captured CMS’s attention:

Misaligned incentives: Hospitals have not historically been economically impacted by the consequences of post-hospital care delivery, while PA/LTC providers have been incentivized to drive utilization based upon maximizing reimbursement rather than the appropriateness of the setting.

Information asymmetry: Very often PA/LTC referrals are a function of personal relationships and familiarity between those responsible for discharge planning and those responsible for marketing available beds.

Provider ambiguity: The evolution and confusion that today characterizes post-acute care services and settings (and the impact technology is having on care settings – e.g., telemedicine) often impairs market competition.

Lack of care coordination: While post-discharge readmissions have captured the popular media’s attention because of the ACA payment penalty, it’s the underlying lack of care coordination between acute and PA/LTC providers that results in cost inefficiencies extending well beyond avoidable readmissions.

These concerns, taken together with other indicators of potential waste and inefficiency (please refer to the article cited), will drive tremendous pressure in the years ahead to lower Medicare post-hospitalization expenditures (thus the chainsaw metaphor). How PA/LTC providers address these pressures will mean the difference between staying in business – or not.

When thinking about performance improvement as a vehicle to address this challenge remember this: more than any other singular criteria, successful PA/LTC organizations that survive the next decade will have learned to trade on value. Value in healthcare is quite simply the patient’s satisfaction with the care delivery experience divided by the cost to provide that experience (with the notable understanding that a patient’s satisfaction is typically augmented by their families’ satisfaction). With or without the Affordable Care Act, that is where the industry is headed.

But what does it mean to, “trade on value?” To help Pub visitors begin thinking about that I have provided a few fundamental questions that you might want to ponder – or discuss with colleagues:

  1. What’s most in demand?
    If Medicare, Medicaid and private insurers were to evaporate tomorrow, what core service offerings that you provide would be the most likely to still generate revenue? What distinguishes those services from others?
  2. Where do we fit in the care continuum?
    Forget the fancy charts and graphics of think tanks and consultants showing you where you fit. Think about the patients you care for every day from the perspective of their overall care experience: where does your organization provide the greatest value to that patient’s recovery along the care continuum?
  3. Who wants to work with us?
    How do potential partners in your market determine their value? Based on that understanding, can you enhance their value? What are the risks that you would lower it? Can you effectively address those risks?

  4. How do we protect and enhance our core value?
    In healthcare, more than any other industry, the innate ability to produce value is primarily attributable to direct caregivers. What should you be doing today to ensure you protect that most valuable resource? And what should you be doing tomorrow to help those caregivers increase the value you provide to patients?


A Moment Please ?

image_thumb2Dear Colleagues:
This is a short reminder to those intellectual policy wonks out there who are interested in debating US Healthcare public policy that my firm, Artower Advisory Services, sponsors and underwrites the cost of a private Listserv discussion group. The group was created out of a remnant of what was once known as HEALTHRE – begun back in the mid-90s.

It is free to join, free to participate – and free to just lurk (read the posts of other contributors). Approval is required to help keep the list free of “junk,” but that is an automated process. Participants receive e-mails only from other registered participants that are discussing US healthcare public policy issues (i.e., no solicitation, no advertising, no spam). To sign up, simply click on the link below. You can unsubscribe just as easily if you determine it’s not for you.

Join the Debate!!
  ~ Sparky

Click here to sign up for the HC Policy Discussion Group

“Ambient Despair”

I started Sparky’s Policy Pub back in May because I believed it would be a productive and enjoyable means of sharing information, thoughts, opinions and insights on public policy issues likely to impact providers of affordable housing, aging services and post-acute/long-term care. 

Four months and 27 posts later, rather than write about the what, the how and the wherefore of healthcare policy, I want to pause and focus on the why.  The only significance of my chosen timing is the recent availability of an interview on Terry Gross’ Fresh Air: Advocate Fights ‘Ambient Despair’ In Assisted Living.   In this program she interviews Mr. Martin Bayne, a long time consumer advocate of long-term care – and current resident of an assisted living facility.

In the early 90s Martin started a web site called, Mr. Long-Term Care.  Back then while the world wide web was still in its infancy Martin was years ahead of his time in recognizing the tremendous value the Internet would offer in sourcing, aggregating and organizing content.  He embraced this vision by not only providing – but producing, through both written and audio interviews – what was widely recognized as the definitive online knowledgebase on all matters relating to long-term care in the United States.

I met Martin the way many did – through being first attracted to the tremendous resource that was Mr. Long-Term Care.  It became an indispensable means of quickly accessing statistics, research, opinion – anything that existed or was being developed to help better understand the market, operational and financial characteristics of the long-term care delivery system.

Fortunately for me, my relationship with Martin went beyond just accessing his web site.  In 1998 we cofounded the National Long-Term Care Policy Institute as a reflection of our shared passion for believing there was more needed to be done in terms of taking an honest, objective and candid look at what was working – and what was not working – in our delivery system.

To compare my passion to Martin’s beyond that, however, would be a disservice to him and his life’s work.  I wanted to see change – Martin has effected change.  Some years on now, I still look fondly on the time I spent working with him.  And while we each in our own way continue to fight the good fight, as you listen to Terri Gross’ interview, you will understand why my deference is not humility but personal pride in not only having had the opportunity to learn from Martin – but being able to still consider him a friend.


Click on Mic to listen to interview . . .


Welcome to the Policy Pub

Greetings, and welcome to Sparky’s Healthcare Reform Policy Pub!!

This is my first installment, while our team is still working feverishly to create initial content for the Artower Advisory Services Web site.

Eventually – and hopefully sooner rather than later – here you will find a timely, informative sharing of knowledge, information, opinion and debate on public policy issues impacting senior housing, aging services and post-acute/long-term care organizations.

If I am successful in achieving my overarching goal, this blog will become top of mind with industry thought leaders desiring to stay at the cutting edge of awareness, understanding and insight of how Healthcare Reform policy initiatives will impact the industry and their organizations.

I know that success will depend on how diligent I am on keeping content fresh, how well I can provoke meaningful participation from others – and whether Healthcare Reform continues to offer tremendous business challenges – and opportunities.  Well, I’m pretty confident Healthcare Reform isn’t going away, so I guess it’s mostly on me.  I welcome the challenge.

So please come on in, grab a spot and let’s have some fun learning from one another in ways that will ultimately help those organizations providing life-improving housing, services and care for seniors and disabled individuals in our society.

See ya inside!

  ~ Sparky