May 9, 2013

Turning Up the Heat on Medicaid Expansion

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There was a study published last week in the New England Journal of Medicine that is getting a lot play in the popular media – which as I have written before is the sharpest of double-edged swords where issues of truth and reality are concerned. Nonetheless, the timing of the research reported is well done in light of a number of states still wrestling with whether or not to accept the Affordable Care Act’s Medicaid expansion.

The Oregon Experiment — Effects of Medicaid on Clinical Outcomes

Back in 2008 approximately 90,000 individuals in Oregon signed up for a lottery that would subsequently provide Medicaid coverage to approximately 30,000. In doing so, Oregon created two randomly selected groups that could be analyzed to determine the comparative effects of having access to health insurance via the state Medicaid program there.

Two years later the relative impact of being insured through Medicaid produced what on the surface appears to many as conflicting results. Use of medical services (i.e., physician services, medications and hospital services) by those covered by Medicaid increased 35%, while access to preventative services and screenings increased by 50% or more. The rate of depression incidence in the Medicaid covered population was reduced by 30% compared to the control group. In addition, the financial impact on families was dramatic – e.g., it was reported the probability of having to endure financial hardship to pay medical bills was reduced by more than 50%.

On the other hand, the health impact in terms of outcomes for those individuals covered by Medicaid was less impressive. In fact, while those receiving the Medicaid benefit were more likely to be diagnosed with diabetes as compared to the control group, their blood sugar levels were not markedly impacted. And the same held true for blood pressure and cholesterol levels.

So in a nutshell, what the research shows is that having health insurance can drive higher access and utilization of available medical services. If you provide it, they will use it – a good thing. But it very well may not have a significant impact on health outcomes – particularly outcomes that are largely influenced by chronic conditions such as obesity, diabetes and hyperlipidemia (high cholesterol). Providing it won’t change lifestyle behaviors – a bad thing.

As this research demonstrates, addressing the behavioral elements that impact health outcomes is far more difficult and far more complex than just an access issue. But I think it is certainly shortsighted and faulty logic to fail Medicaid based on health outcome data alone. Improving access and utilization of medical services by the un- and underinsured population is a progressive advancement that has merits independent of outcomes, which is further reinforced when considering the relatively short time period covered by this research.

But the more salient if not subtle point of these results is that chronic disease management requires a coordinated effort of social, educational and medical influences that clearly place expectations of behavior modification beyond the sole responsibility of healthcare practitioners. That reality neither bolsters nor detracts from the arguments being made in support of state Medicaid expansion under the Affordable Care Act despite what you may read or hear otherwise.

Cheers,
  Sparky

Filed Under: Medicaid · Tagged: , ,
Accepting the Realities of Aging
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: ,
Apr 4, 2013

The Rising Costs of Dementia Care

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Research published today in the New England Journal of Medicine – Monetary Costs of Dementia in the United States – describes the projected economic consequences of caring for an aging population afflicted with various forms of dementia, including Alzheimer’s disease.

Separating the caregiving related costs attributable to dementia is challenging, if not impossible, because of the prevalence of comorbidity in individuals having dementia and because of the lack of quantifiable data reflecting the financial burden associated with informal caregiving. Using data from the University of Michigan’s Health and Retirement Study, the study’s authors sought to adjust for such phenomena by parsing out data that is believed to reflect the marginal costs associated with dementia.

Their methodology looked at how these costs could vary over the spectrum of probability within a given population that an individual would be afflicted with dementia. Costs were stratified according to:
     Out of Pocket Spending
     Spending by Medicare
     Net Nursing Home Spending
     Formal and Informal Homecare

If the intuitive concern that the economic impact of an aging society will be dramatic, the aggregate cost projections from this research certainly reinforces that concern. With a prevalence rate of 14.7% of the US over the age of 70 having dementia, the current (2010) cost of care (not including the valuation of informal caregiving) is $109 billion. By 2040, if prevalence rates and utilization of non-informal services and care are held constant, that amount is projected to more than double.

The authors note that dementia is one of the most costliest diseases to society, yet 75% to 84% of attributable costs of dementia are related to institutional care (e.g., a nursing care facility) or home-based long-term care – i.e., as opposed to medical care. Healthcare providers in that space should recognize the challenges and opportunities of that consequence.

I think it is important to remember that the inherent subjectivity of the dataset – and the data elements represented – is a reality that cannot be overlooked. In addition, even if there wasn’t the inherent subjectivity, I’m not really sure of the article’s value, nor whether it is deserving of the attention received in the press. Perhaps there’s something there I missed.

Counting the number of teeth a shark has and noting their regenerative capabilities is a fascinating exercise, but it’s the shark that can kill you – not its teeth.

Cheers,
  Sparky

Special Note: last summer I shared with Pub visitors a webinar, Emerging Trends and Drivers in Dementia Care, presented by my Artower colleague, Lori Stevic-Rust, PhD ABPP, Board Certified Clinical Health Psychologist and nationally recognized authority on Alzheimer’s disease. Another plug here seems appropriate.

Filed Under: Alzheimer's/Dementia Care, In the News · 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 21, 2013

Medicine Storm Clouds

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Trying to connect the dots in healthcare delivery can be a lot like stringing beads in a windstorm: the time spent getting even a few in place often comes at the expense of losing track of many others. Over the past few days I came across three articles that feel like they should be strung together because they share an unintentional common theme: what will the practice of medicine look like in a decade from now as more and more medical knowledge is captured and made available in the cloud: the Medicine Cloud.

The cloud I refer to of course is a metaphorical description of electronic computing resources (i.e., data storage, hardware and software) that are accessed by users through web browsers and light-weight desktop and/or mobile applications. There are significant advantages to healthcare providers leveraging cloud-based computing, notably a significant reduction in upfront investment – both in terms of time and capital. Lower maintenance costs, improved reliability and the facilitation of greater data sharing that can enable more efficient integrated care delivery and provider interoperability are also big advantages.

The three articles I reference above include:

    Through a Scanner Darkly: Three Health Care Trends
    for 2013 written by Dr. David Shaywitz in the
    Healthcare Blog;

      Brain Awareness, by Dr. Thomas Insel, Director of the
     National Institute of Mental Health; and

      the third was an article shared by Dr. William Palmer
      in our HCPolicy online discussion group: Online
     learning: Campus 2.0 by M. Mitchell Waldrop in
     the March 13th edition of Nature Magazine.

From different perspectives each of these articles represent key trends and drivers likely to impact how Medicine is practiced in the future – and in particular, the impact information technology will have. And while there are reasons for optimism in how advancements in technology can lead to improved access, efficiency and productivity – information technology has so far not proven to be the panacea many practitioners had hoped for.

Sourcing, capturing and aggregating medical-based knowledge – and then making that knowledge readily available to clinicians (e.g., including physician extenders) can be incredibly enabling and empowering for both the clinician and the patient, particularly when it is made available in real time. But there are hugely challenging concerns and substantial public policy issues that I think we should be discussing.

For example, one major challenge – as shared by Dr. Shaywitz in his blog post – is finding balance between the current push toward practice standardization that information technology naturally enables and maintaining the valuable non-standardized realities of practitioner experience. Dr. Insel’s article succinctly explains just how far we are from understanding how the human brain functions. To the extent we come to view an electronic knowledgebase as replacing a trained and experienced clinical practitioner’s brain, I think we do so at great peril.

On the other hand, making more medical-based knowledge available at a lower cost (i.e., as shared in the Nature Magazine article) has the potential to address the looming challenge of primary care physician access. Indeed, knowledge is power, and we should never be afraid to pursue any opportunity that empowers more people with knowledge.

Of course, online courses cannot replace medical practicums, and we must not be led to believe that the accumulation of didactic knowledge can replace practice and experience. There are two ways to view this: as an obstacle that inhibits expansion of provider availability – especially the expansion of physician extenders – or as a reality that requires proactive planning to try and ensure practical alignment between provider capabilities and patient needs. And then we have to assess whether this is a phenomenon that should be addressed through public policy, and if so how.

Now throw into this mix the markedly different attitudes and perceptions of younger clinicians on the role information technology can (and should, in many of their minds) play in the future practice of medicine – and you have the makings of a public policy maelstrom. Even in the face of the recent recession, Gen Xers and Millennials still are looking at work-life balance as one of their primary concerns. While there is a lot to be said for the benefits to society in taking more time for the family and less for the fortune, I do fear the potential implications this can have if it precipitates an overreliance on the Medicine Cloud as a replacement for the Medicine Man/Woman.

Cheers,
  Sparky

Filed Under: In the News, Information Technology · Tagged: , , ,
Mar 14, 2013

While Rome Burns . . .

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This post was intended to be written and shared on Sunday, March 17th, while much of the rest of America will be either celebrating being (or pretending to be) Irish. Such foolishness was always strongly discouraged in my family: the reason I spell my name with one “t” is because that was my father’s way of reminding me that I am Scottish. And I’m pretty sure the only day my grandfather seriously frowned upon drinking was St. Patrick’s Day.

But the real reason I am sharing this today instead is that I watched Escape Fire: The Fight to Rescue American Healthcare last night. I had planned on giving myself a few days to get through it, but  I stayed up much later than I wanted – or should – because I found it compelling, disheartening and yet, incredibly inspiring. The feature film’s title has an interesting foundation, and I share that at the bottom of this post.

The one-hour-and-forty-minute documentary, produced and directed by Matthew Heineman and Academy Award-nominee Susan Froemke, provides candid and balanced insights into the inherent structural and systemic elements of our country’s healthcare challenges. For those intimately involved in healthcare delivery there is nothing here that will necessarily surprise you – though I personally found coverage of healthcare delivery in the military to be both enlightening and very concerning from the perspective of national defense.

The storyline organizes and weaves together a root cause analysis from first hand perspectives of various industry stakeholders, e.g., patients, caregivers, industry executives and journalists. It features commentary from holistic health experts Dr. Andrew Weil and Dr. Dean Ornish, Safeway grocery chain CEO Steve Burd, medical journalist Shannon Brownlee, Cleveland Clinic cardiovascular chairman Dr. Steven Nissen, and former Director of CMS, Dr. Donald Berwick.

Unlike Michael Moore’s documentary, Sicko, in which balanced research and evidence were largely supplanted by rhetoric and well-positioned emotion, this film is not an effort to indict, lay blame or point fingers. As Dr. Berwick offers, “between the healthcare we have and the healthcare we could have lies not just a gap but a chasm … I don’t blame anybody – they’re just doing what makes sense – and we have to change what makes sense.” The film does a wonderful job of fairly explaining without getting technical how we got into this situation – and how if we do not make fundamental changes the system will ultimately collapse under its own weight. A lot of lives are going to be lost in the rubble of that collapse.

From a healthcare policy perspective our debate should be focusing on who gets to define what makes sense and who is responsible for making the changes necessary to create individual incentives that align with desired systemic outcomes. A consistent theme in the film is the incredibly impactful power that individual action and accountability can have in healthcare. While at the same time, the inbred allegiance between industrial and political powers in this country are culturally embedded in our social psyche and represent enormous obstacles to change.

If you are even a little concerned about the future of healthcare delivery in the United States, I strongly encourage you to watch this film. And then I encourage you to share your thoughts and insights with us in the HCPolicy Discussion Group (see the picture icon at the top of this blog).

Escape Fire can be seen this weekend on CNN @ 8pm and 11pm EDT (and again at 2am on the 17th – in case you’re already up getting ready for the parade).

Cheers,
  Sparky

On the Film’s Title
In an interview with Sundance Film Festival’s Nate von Zumwal,  Matthew Heineman explains how the movie received its title:

For over a year, we struggled to find a title for the film. How could we synthesize this complex problem and potential solutions under one label? We were stumped. Then we came across Dr. Don Berwick’s healthcare manifesto, “Escape Fire: Lessons for the Future of Healthcare,” delivered years before he became head of Medicare/Medicaid.

Dr. Berwick draws a striking parallel between our broken healthcare system and a forest fire that ignited in Mann Gulch, Montana in 1949. Just as the healthcare system lies perilously on the brink of combustion, the forest fire began to burn out of control, threatening the lives of 15 smokejumpers.

On the spot, the leader Wag Dodge came up with an ingenious solution: he lit a small fire that consumed the fuel around him. He urged his men to join him, but they ignored him, clinging to what they had been taught. The fire overtook the crew, killing 13 and burning 3,200 acres. Dodge survived, nearly unharmed. He had invented what is now called an “escape fire,” and soon after it became standard fire-fighting practice.

Dr. Berwick applies the “escape fire” analogy to healthcare, exploring how our system is “burning,” while there are solutions right in front of us. Upon reading the manifesto for the first time, we realized how perfectly it fit our subject matter. We knew we had our title, and soon after we contacted him about taking part in our film.

As Dr. Berwick says in the film, “We’re in Mann Gulch. Healthcare, it’s in really bad trouble. The answer is among us. Can we please stop and think and make sense of the situation and get our way out of it?”\

Filed Under: Good to Know, Healthcare Reform · Tagged: , ,
A Failure to Communicate
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: , , , ,
Why Can’t We Be Friends?
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: , , , ,
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