What’s Next for the Tea Party?
Oct 17, 2013

What’s Next for the Tea Party?

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550px-Remove-a-Stuck-Tongue-from-a-Frozen-Surface-Step-3One might think the graphic accompanying this post was leaked from Sen. Ted Cruz’s political strategy playbook: the next chapter in The Tea Party’s Fight to Repeal the Affordable Care Act. It’s not. Could be though, right? The metaphor holds of doing something foolish to gain popular attention and then suffering the individual consequences of that foolishness.

Of course, Tea Party advocates will no doubt claim I am being foolishly satirical and hypocritical for not recognizing my own ignorance in understanding the dramatic importance of standing up for liberty, fiscal responsibility and apple pie. If they truly believe those were Senator Cruz’s motivations, well then what can I say – they must see a political reality in this country different than the one I see.

Even if we were to believe the efforts of Senator Cruz and other Tea Party congressional enthusiasts – to hold the country fiscally hostage for over two weeks in an effort to defund the ACA – were nonpolitically motivated, the overall reaction of the American public can hardly be what they were hoping for. According to a Pew Research Center poll released yesterday, the Tea Party is less popular than ever, even among many Republicans, with nearly half (49%) of survey respondents having an unfavorable opinion. This is up from 37% in June of this year.

On the other hand, Senator Cruz’s popularity among Tea Party respondents has risen from 47% to 74% since July. I’m not sure how well that bodes for his future political aspirations (at least outside of Texas, if that was of interest), but I am being sincere when I say that I respect the all-in approach of any elected official because it represents a refreshing departure from governing by opinion polls.

My view of the Tea Party, for better or worse, is largely based on the individuals I know personally who are either sympathetic to, intellectually aligned with or proud to be members. I find them to be generally well informed on political issues and passionate about protecting individual liberties. Things go downhill when we start debating who gets to define which liberties should be protected and by whom, which I interpret as the Tea Party being discerningly different than many Libertarian viewpoints.

They are very concerned – and I think rightly so – with the economic future of our country and seem to understand more than most that both political parties are guilty of sustaining special-interest budgeting despite whatever expressions of concern we may hear to the contrary. That’s where a large part of the inherent challenge to the Tea Party’s future lies. As shown in the Pew Research poll, there is a lot of confusion, disagreement and debate over whether and how well the Tea Party “fits” within the Republican Party.

I personally hope it finds its national voice apart from the GOP. If it has something meaningful to offer in the nation’s political discourse – it could hardly do worse – then it should seek to do so through the existing construct of our democracy and not by resorting to Machiavellian tactics whereby it seeks to bend the will of a majority to its beliefs (again, I refer you to the Pew Research poll).

I admit, there is a real attraction to a grass roots political movement in an age where electoral helplessness – whether learned or systemic – has become anathema to a democratic form of government. But waxing nostalgic for the 18th century and expecting that same apathetic electorate to embrace the social and cultural norms of men in wigs and women in hoops is a very tough sell.

And that’s where I find the greatest difficulty in accepting my Tea Party colleagues’ personal political platform. To me it feels like hidden below the surface of, “strike a blow for liberty,” “defend the Constitution” and “balance the budget” is an observable pattern in their logic and debate that belies a commiserate longing for the good old days.

I think all of us over a certain age find ourselves quite often reflecting on a past that was less stressful, less fearful, less threatening and certainly less complicated. Today we live in a world of constant change that just one generation removed couldn’t possibly have imagined. In his book, Managing at the Speed of Change, Daryl Conner talks about the Beast: a metaphor of the challenge each of us faces in adapting to constant change in our environment. It takes incredible resiliency to maintain good mental health in the 21st century.

I do not believe effective public policy – including Healthcare policy – can or should be based on what worked in the good old days. As Don Henley wrote, “those days are gone forever – [we] should just let ‘em go but…” Today we live in a society that is aging at an accelerated rate, that is growing in ethnic and cultural diversity and is inundated on a 24-7 basis with technological advancements that introduce hope and terror in equal measures.

With that understanding of reality, my primary concern with the Tea Party is the perceived sense of moral intransigence and impractical political dogma that transcends their beliefs. We should be focusing our efforts on how best to practically adapt a constitutional style of government to the world we live in today – not expecting today’s society to mirror that of the 1700s. I think I share just as much angst and anxiety over our nation’s future as do my Tea Party colleagues. I just don’t believe that going backwards offers much hope in addressing the problems we face today and tomorrow.

Cheers,
  Sparky

Filed Under: Editorials & Opinions, Tea Party · Tagged: , , ,
Sep 26, 2013

It’s About Value, Stupid

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The title of this post is a reminder to myself and not intended to offend the millions of other participants in healthcare to whom its application may or may not apply. I remind myself of this assertion quite often – primarily because I believe it provides the singular most important connection between the practice of healthcare and the business of healthcare. It also has the theoretical advantage of transcending many of the political realities of public policy because it reinforces commonly held beliefs regarding individual liberties, morality, as well as social consciousness.

That is why I am very excited about a new initiative I wanted to share with Pub visitors: last week, the New England Journal of Medicine announced a new collaborative publishing initiative with Harvard Business Review. Beginning on September 17th, new articles are being shared daily via the Insight Center for Leading Health Care Innovation.  Over an eight-week pilot period new articles will be posted daily, “from numerous experts across health care and business communities.” The content shared will be free during this pilot phase, so I strongly encourage you to at least take a few minutes to peruse the variety of information and insights offered there.

One of the most prominent initial contributors, Michael Porter, has written and spoken at length on Value in Healthcare. In fact, he and his coauthor, Elizabeth Olmsted Tiesberg, published Redefining Healthcare in 2006, in which they argued that historically health care systems have competed to shift costs, accumulate bargaining power and restrict services – rather than create value for patients. To address this shortfall Porter and Tiesberg have offered specific policy recommendations they believe can help reposition the potentially positive effects of market competition from between health plans, networks and hospitals to where it would be a lot more effective in producing value: i.e., at the level of diagnosis, treatment and prevention of high cost illness and conditions.

I should also note (and recommend) Porter’s latest article featured in the October issue of HBR and coauthored by Dr. Thomas Lee (CMO at Press Ganey), The Strategy That Will Fix Health Care. Porter and Lee rightly argue that healthcare providers are the only ones who can ultimately reframe the US healthcare delivery system into one that delivers high value. They discuss six interdependent components:

1. Organizing around patients’ medical condition
     rather than  physicians’ medical specialties
2. measuring costs and outcomes for each patient
3. developing bundled prices for the full care
    cycle
4. integrating care across separate facilities
5. expanding geographic reach and
6. building an enabling IT platform

I think they purposely left off #7, pushing the camel through the eye of a needle. Please don’t take my sarcasm for lack of interest and support, but I am of an age where I tend to be a realistic chap. Between the theory espoused on the pages of HBR and the practice that is often manifested in care providers’ growing frustration with the obstacles they face in caring for their patients lies the enormous ball of yarn, which has been healthcare public policy in the US for the past 50 years.

I do believe, however, the value paradigm offers great promise in building a healthcare system where lower cost and higher quality are not viewed as a diametric choice but rather complimentary results of market competition. But there are indeed miles to travel before any such paradigm shift can be realized.

Value is not a foreign concept to healthcare, so I want to be wary of conveying the sense that a silver bullet exists, just waiting to be found so that in a single shot our delivery system can be cured. But value – whether seen through the prism of a patient’s ability to assess a surgical procedure, an insurer’s ability to assess the quality of an outcome or a nurse’s ability to assess the fairness of his or her employment contract – is way too often obfuscated to the point where it cannot serve the purpose of driving competitive performance.

I am hopeful the contributors to the new Center will be mindful of this observation as they seek to promote the potential benefits of a value-driven healthcare system.

Cheers,
  Sparky

Filed Under: In the News, Value Driven Healthcare · Tagged: , , , , , ,
LTC Mainly About Dementia Care
Sep 21, 2013

LTC Mainly About Dementia Care

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Today is World Alzheimer’s Action Day. And this past week Alzheimer’s Disease International issued, World Alzheimer Report 2013 ~ Journey of Caring: An Analysis of Long-term care for Dementia. As noted there, “ Long-term care for older people is, mainly, about care for people with dementia. Dementia and cognitive impairment are by far the most important contributors, among chronic diseases, to disability, dependence, and, in high income countries, transition into residential and nursing home care.”

Recognizing how integral dementia care is to developing public policy that address the needs of seniors in need, I thought this was a good opportunity to make available again the webinar my Artower colleague Dr. Lori Stevic-Rust did a little over a year ago.

Organizations that are interested in getting out ahead of the curve on developing care programs for individuals with Alzheimer’s/dementia that bring high value to integrated care delivery models under Healthcare Reform will benefit from watching this presentation.

Enjoy,
   Sparky

                                            
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The Realities of Defunding
Aug 29, 2013

The Realities of Defunding

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obamacarefingerbitingLG-300x158Last week the once relevant political operative of right wing influences, Karl Rove, wrote an editorial in the Wall Street Journal, Republicans Do Have Ideas for Health Care. In case you were concerned that defunding the Affordable Care Act would leave the country’s healthcare system in chaos and peril you can now rest easy – the Party of No has a plan. Except they don’t if you go by Mr. Rove’s article.

Before I continue I should note that high hopes of defunding the ACA may reflect a personal perception of authentic patriotism but for most those hopes belie an understanding of our healthcare delivery system, the Affordable Care Act – and most pragmatically, political realities. At the request of Tom Coburn (R-OK), the Congressional Research Service recently published Potential Effects of a Government Shutdown on Implementation of the Patient Protection and Affordable Care Act.

As discussed in that memorandum, defunding of the ACA via government shutdown would not have the intended consequence of stopping much of its implementation while risking the consternation of various constituencies that the Republican party has yet to alienate. Of course, that won’t stop Senators Cruz (R-TX), Lee (R-UT) and Rubio (R-FL) from making political hay out of an issue that strikes a harmonious chord with their conservative bases, and why should it. Those who look for sincerity in the motivations of either (any) political party fail to accept the realities of campaigning and democratic elections in the 21st century.

I should also note that Mr. Rove is on record of disagreeing with these senators. He believes defunding the Affordable Care Act through a government shutdown would give the President, "a gigantic stick with which to beat [Republicans]." I tend to agree and would hope the Republican party could spend more time on developing new ideas that reflect the realities of our current delivery system instead of just being against the ideas of others (and sometimes their own).

In his editorial, Mr. Rove points out several Republican policy initiatives that taken one by one have some merit – both within the context of ACA implementation and under the unlikely hypothetical assumption of its outright repeal. But it is beyond a stretch to suggest that even taken together those several examples he cites constitute a legitimate alternative to the comprehensive approach of the ACA. And therein lies the challenge that many (most?) political wonks, talking heads and sound bite artisans face when discussing healthcare policy. Our healthcare delivery system is complicated and complex beyond reason, and certainly way beyond necessity. But you have to play the game on the field you’re given not on a chalkboard.

Several of the policy initiatives Mr. Rove cites deal with health insurance: portability of policies, employer risk pooling and selling premiums across state lines. I think these are plausible modifications and/or addendums to the ACA approach that are worth circumstantial testing.  But part of the recognized challenge up front is that these approaches are dependent upon employer-based insurance, which most policy experts agree was never a good idea to begin with. And they leave out a wide swath of the population that doesn’t receive employer-based health insurance. If we didn’t think there was merit in providing healthcare benefits to those unable to afford such coverage, then these would be top of mind ideas.

Another initiative cited, medical liability (or tort) reform is a bit like the weather: everyone complains about it but nobody really ever does anything to change it. Perhaps that’s because of the preponderance of Congress who are also lawyers. But there is another line of thought that believes increasing quality and safety might also be a pragmatic approach to lowering malpractice liability. What would we rather have: the forbearance of frivolous suits that also risk restricting justice to individuals – or the reduction in the basis upon which such suits are brought. In reality, we probably need both.

Of the several reform initiatives Mr. Rove shared transparency has to be the weakest example of meaningful policy. Pulling the cover off of the Invisible Man won’t change your view of him. And mandating that meaningless provider charge rates (prices) be published won’t enable better decision making by consumers (patients). I addressed this back in February in a post I entitled, Pick a Price.

Moving on, allowing Medicaid patients to apply their governmental benefits toward private insurance sounds reasonable enough. Unfortunately, it would be bad policy. Although there are already a number of states seeking to leverage private insurance capitation models as a hybrid compromise to Medicaid expansion within the context of the ACA, those models still maintain control over risk pooling so as to address adverse selection.  While allowing funds to be indiscriminately repurposed may sound like an idea promising to partner individual choice with market efficiencies, as Naomi Freundlich addressed in her Healthcare Blog post, the reality of implementing such an idea is another matter entirely.

Finally, Mr. Rove writes that, “the president and his liberal posse have a fundamental, philosophical objection to conservative ideas on health care. They oppose reforms that put the patient in charge rather than government, that rely on competition rather than regulation, and that strengthen market forces rather than weaken them.”

Disingenuous assertions like this do little to advance meaningful healthcare policy discussion. This is no different than liberal talking heads claiming that conservatives seek to advance healthcare policies that benefit (or are structurally biased toward) the wealthy at the expense of the poor. More generally, asserting that the ACA’s hidden agenda is to abscond personal liberty in favor of governmental control misses the point of the real debate entirely. Both the theoretical and practical debate is not over whether the government knows better than the individual what is best for the individual. The debate is in how public policy can best balance the protection of personal liberties while morally advocating for the rights of those individuals with far less ability to secure affordable, quality healthcare. Some feel healthcare is a basic right secured by the Constitution. Others do not. What do you believe?

Cheers,
  Sparky

Filed Under: Affordable Care Act, Editorials & Opinions · Tagged: , , , , ,
ACOs, Innovation and Edison
Jul 13, 2013

ACOs, Innovation and Edison

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070209_edison_bulbUnited Healthcare announced this week that it will double to $50 billion annually over the next five years the value of contracts it has with doctors and hospitals based on quality and outcome measures. United is currently paying over $20 billion annually to doctors, hospitals and ancillary care providers under contractual arrangements based on value produced (i.e., quality outcomes over cost).

United’s Chief Medical Officer, Dr. Sam Ho, notes that “any bonuses will have to be earned and no longer a product of turning a page on a calendar – this is not a passing fancy for us. The United Healthcare strategy basically has expanded the accountable care concept to an accountable care platform.” Beyond just the symbolic importance, United has the largest provider network in the U.S. and already has accountable care relationships in place with over than 575 hospitals, 1,100 medical groups and 75,000 physicians.

Now, the glass-half-empty folks in healthcare are going to look at this move by United as somewhere between tyrannical, prehensile or just plain foolish, depending on individual perception, as well as position. They will argue this is just another example of non-provider influences in healthcare stealing more power from the patient. They will remind us again how HMOs failed and that ACOs are but profiteering wolves clothed in retrofitted HMO attire.

Of the two most significant challenges that ACOs face, creating financial incentives that are theoretically aligned with less care instead of more is certainly reminiscent of managed care circa 1990s – and it is a risk that must be aggressively monitored and mitigated. The other primary challenge – the inherent subjectivity of measuring patient outcomes – will have a dramatic impact on many areas of future healthcare delivery, not just provider networks and insurance contracting. It’s a challenge that will have to be effectively addressed if we ever have any hope of increasing access without bankrupting the country.

I think there are two ways to look at these challenges: in the context of the past where abundant evidence of failure exists – or in the future, where evidence of failure has not yet been created. There is a critically important difference between the two. The former is the world of intellects and philosophers, while the latter is the world of innovators and entrepreneurs. Case in point: Thomas Edison.

In failing continually to invent the light bulb Edison once remarked, “I have not failed. I’ve just found 10,000 ways that won’t work.” In similar fashion he once said, “negative results are just what I want. They’re just as valuable to me as positive results. I can never find the thing that does the job best until I find the ones that don’t.”

I am not suggesting that unbridled experimentation is either wise nor prudent when the results impact human lives. But I also choose to resist the defeatist attitude among folks who become overly dependent upon history as a means of defining the future. While those who fail to learn from the past may be damned to repeat it – those who live in the past are damned to avoid innovation for fear of failure.

The underlying premise of the ACO model – financial reward for keeping people healthy, rather than reimbursement of costs for trying to make sick people well – represents a dramatic paradigm shift in thinking for this country that transcends all aspects of healthcare delivery. We should not expect it to be widely embraced in the short run. We should rightly expect a healthy amount of skepticism. And we shouldn’t be shocked if the model fails.

Those allowances, however, should not be permitted to thwart progress toward achieving expanded access to quality care, particularly for the least fortunate among us. If the failures of the past weighed most heavy on the efforts to define the future, we should not have to worry about how to make quality care available because there never would have been the advances achieved worth making available. Edison also once said that, “the doctor of the future will give no medication, but will interest his patients in the care of the human frame, diet and in the cause and prevention of disease. ~ ”

Will he be right?

Cheers,
  Sparky

Filed Under: Accountable Care Organizations, In the News · Tagged: , , , ,
Mandate Delay: Chuckhole or Sinkhole?
Jul 11, 2013

Mandate Delay: Chuckhole or Sinkhole?

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AARepublicans have failed to thwart it. The Supreme Court refused to kill it. A majority of Americans decided not to abandon it through a national referendum election. And it would appear Nancy Pelosi has still not taken the time to find out what’s in it.

Earlier today when asked whether there could be, “any virtue” in last week’s announcement that businesses with 50 or more full-time employees will not have to begin complying with ACA reporting requirements until 2015 (a year delay), she responded, “no – absolutely not.  I don’t think it’s virtuous at all.  In fact, the point is, is that the mandate was not delayed.  Certain reporting by businesses that could be perceived as onerous — that reporting requirement was delayed, partially to review how it would work and how it could be better. It was not a delay of the mandate for the businesses, and there shouldn’t be a delay of the mandate for individuals.”

Mind you now businesses are being exempted from the codified penalty associated with failing to report how many full-time employees they have, the number of hours they work and how much those individuals have to pay for company-sponsored health insurance coverage. While employers are, “encouraged” to provide affordable insurance for their workers in 2014 there will be no penalty if they do not. That’s not a delay? Who is her policy advisor anyway? Dennis Kucinich?

Aside from the side show of political haberdashery that is by no means the singular purview of Ms. Pelosi nor the Democratic party there are some potentially critical ramifications of the Administration’s decision to delay implementation. On the one hand, because a majority of businesses with 50 or more employees already offer healthcare benefits (e.g., 94% of businesses with 50-199 workers offer coverage while only 1% of US workers are employed by companies with 50 or more employees that do not offer health benefits) the delay’s impact on coverage expansion is not going to be significant.

On the other hand, the delay is nothing less than a giftwrapped political grenade in the hands of the GOP and every interest group in opposition to any element of the ACA. Now called into question will be the workability of not only the employer mandate but other elements of the Act, such as the all-important Individual Mandate, Insurance Exchanges, Medicaid expansion and on and on. If critics are right that the ACA is a bureaucratic house of cards built on a shaky table, well then this delay could be viewed as removing the matchbook from under the table’s leg.

There is also the pragmatic side of this discussion that argues it is better to delay and use that time wisely to ensure implementation is as effective and economical as possible. But it would seem to me the implementation of the IM will be more complicated than the EM because of numbers and nature: there are a lot more individuals than businesses, and by their very nature many (most?) of those individuals don’t have the inherent technical wherewithal to collect and provide the information that will be required for the IM. Delaying implementation of the Individual Mandate would, I believe, be a death knell for the ACA, and I think most Democrats (and, of course, Republicans) share that view now.

It may be a monumental task for many Democrats next summer having one foot on the campaign trail and one finger in the Capital Hill dike that is holding back a full repeal of the Affordable Care Act. If they are not already in place, the Administration had better abandon all hope of allowing partisanship to influence resource decisions. Not getting the right people in the right place to withstand the oncoming attempts to sacrificially slaughter the IM and exchanges before they even get started will be a political nightmare for the Democratic party that may take several decades to overcome.

Cheers,
  Sparky

Filed Under: Editorials & Opinions, Employer Mandate · Tagged: , , ,
Healthcare Strategy Lesson From Gettysburg
Jul 9, 2013

Healthcare Strategy Lesson From Gettysburg

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GThis past weekend my son and I traveled to Gettysburg to partake in the 150th Anniversary celebration. It was our third trip together there, the last being four years ago when he was six. I have been there at least eight times myself dating back to when I was his age.

You have to be of a certain ilk to enjoy returning to a small town in the summer sweatbox of southern Pennsylvania so many times expecting it to offer more than the time before. Yet for me it has – and did so again this time. Now, I am admittedly one those individuals whose interest and fascination in the Civil War has been manifested in owning more books on the subject than I should ever hope to read.

That perceived restriction is in good part due to the other areas of interest that compete for my attention. Chief among those, I am particularly interested in most all aspects of military strategy. The word, strategy, after all is from the Greek word, stratēgia (στρατηγία), meaning the art of the troop leader or general – to command and provide generalship.

To be sure, I have learned a great deal about organizational strategy and strategic planning from contemporary writers such as Porter, Mintzberg, Ansoff and Chandler to name but a few, but in due time I have found most of their thinking reflects new ways of viewing the foundational principals of strategy that can be found in the works of military strategists such as Sun Tzu, Alexander, Napoleon, Bismarck – and Robert E. Lee.

On my visits to Gettysburg what I enjoy most is walking the battlefields and just looking at the surrounding countryside. Beyond its purely aesthetic benefit I try to imagine what faculties, training and experience it would have taken to translate observation into action (i.e., if I were a commander, how would I have deployed my forces). What makes that three-day conflict so intriguing for the military historian are the strategies employed by both sides in seeking tactical advantage through positioning. Who familiar with the Civil War has not heard of Little Round Top?

If you are an organizational strategist, you cannot help but appreciate the dynamic relationship of planning and positioning. Effective planning is measured by the ability to achieve a future position while being developed based upon current position. And this is where very often strategic planning at healthcare organizations falls well short of its promise. In my experience, the inability – or perhaps unwillingness – to develop a comprehensive and realistic understanding of their organizational current state before engaging in planning efforts is the single biggest mistake healthcare organizations make. It is also the singular key to successful planning efforts.

Too often healthcare organizations get caught up in the chaos that defines their environment. They spend significant amounts of time and effort trying to understand what is happening around them, unfortunately at the expense of understanding what is happening within their own organizations. The old saying of, “if you don’t know where you are going, any road will get  you there” has recognized validity. But the blinding attraction of imagining a better future can also serve as a siren to organizational leadership causing them to lose sight of practical realities.

The key lesson that was reinforced for me on this latest trip to Gettysburg was that while the ability to envision how infrastructure and topography could be utilized to establish tactical advantage, in order for underlying strategies to be effective the commanders of both armies had to first understand the capabilities of their forces. They had to understand the relative effectiveness of munitions based on distance, angle and elevation. They had to understand how and when troops could be deployed and redeployed between positions. They had to understand why holding a position is ultimately critical to being able to achieve a position.

From a strategic planning perspective, these are lessons I think have tremendous applicability to healthcare organizations, particularly as they seek to make sense of the ever changing regulatory environment in which they operate. If I were to borrow from the old adage, “measure twice – cut once,” I would offer that in organizational strategic planning it is wise to spend one hour envisioning where you want to be for every two hours assessing and understanding where you are right now.

Cheers,
  Sparky

Filed Under: Editorials & Opinions, Strategic Planning · Tagged: , , , ,
Will the Truth Destroy Us?
Jun 30, 2013

Will the Truth Destroy Us?

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Julian-Assange-Cuero1In the New Testament (John 8:32) it was written that, “you will know the truth, and the truth will set you free.” That certainly hasn’t been the recent experience of Julian Assange and Eric Snowden, but then discretion is not always the better part of valor where personal bravery involves risking the lives of others without their knowledge or consent.Snowden

This post is not directly about healthcare public policy, but I don’t think Pub visitors will have to search too hard to see relevant application. And if you bear with me, I try to bring it back home in the end.

In the history of our world great strategic advantages – as often manifested in terms of wealth, power and influence – have been gained through the ability to possess (and then act upon) knowledge and information that others do not. And unfortunately, a lot of public policy throughout history has been crafted and enacted for similar purposes with varying degrees of actual or perceived intent.

Now consider that historic reality in the context of what we are witnessing today with the accelerating proliferation of intentional (and unintentional) electronic content being made available to millions upon millions of individuals at the click of a mouse. Consider it too in recognition of the rogue efforts of Messrs. Assange and Snowden who have ensconced themselves in cloaks of social consciousness that to many of us look a lot more like what Andy Worhal had in mind when he coined the phrase, “in the future, everyone will be world-famous for 15 minutes.”

Whether this emerging phenomenon is couched in the recreational context of social media, the enterprise context of online marketing and promotion or the aforementioned often invoked public policy context of transparency – the resulting abject conundrum facing modern societies and public policy makers is mind boggling. Whosoever has said they would like to know the mind of God has only to reflect upon this reality a bit to know how impossible that is to even begin imagining.

As I see it, there are three aspects to assessing this phenomenon: access, discernment and reasoning. Of these, I think access is the most difficult to assess in terms of its ability to be socially impactful. On one level, it is the great equalizer – the rallying cry of anyone who believes oppression is caused by those who withhold information for the sake of power and influence. On another level, its true value is primarily dependent upon the other two aspects.

To demonstrate, think of the game of Poker. Playing a hand of five-card stud with all cards up ensures everyone has the same information at the same time – yet anyone who has ever played knows there is much more to winning than just knowing what everyone else can see. I am again reminded of that most famous quote from Sun Tzu: “All men can see these tactics whereby I conquer, but what none can see is the strategy out of which victory is evolved.” From a public policy perspective, the point is not to confuse promoting access with promoting equality: one does not infer the other without discernment and reason.

Discernment, in turn, cuts the value of access in half, or worse. It represents the ultimate double-edged sword of information management because it is just as easy to manufacture disinformation as it is to make available factual information. Actually, it is in fact easier to create disinformation because the burden of proof is relieved. Being able to discern one from the other, therefore – and to do so more quickly than the next person – will have tremendous strategic advantages in the future. And those who innovate the means to accelerate the process of reliable discernment stand to be very rich.

In what is a sad irony, a key role of government based on history should be the promulgation of public policy that helps effectuate discernment. But the relationship between information and power referenced above is a vicious and virtual simultaneous equation in this electronic age, and nowhere is that relationship more complex and threatening than where it involves elected officials. Just throw corruption into the mix and not only do you have the fox guarding the hen house but now also the lack of any accountability for who put the fox in charge.

And finally of course, although access and discernment may go a long way to at least conceptually equalize the playing field in providing the information needed to make decisions and judgments, that certainly does not ensure everyone of having the same ability to perform either. And this is where I think the unenlightened disconnect of the Gen X and Gen Y generations becomes truly evident. That is not a criticism, but rather a factual reality just as much as one day equals 24 hours while two days equals 48.

To my understanding, the human mind cannot be trained through study or discourse to accomplish the same functional abilities that can be gained through experience. For a wonderful treatise on this subject-matter I once again refer Pub visitors to Malcolm Glawell’s work, Blink. To state this point more plainly, data becomes information when it is organized; information becomes knowledge when it is analyzed; knowledge becomes wisdom when and only as it is allowed to age and gain from the benefit of life’s experiences.

Thus, having more data (i.e., Big Data) can advance the creation of more knowledge and information – but it cannot advance the creation of wisdom, at least not human wisdom (Watson and the like are another story). And this now brings us back full circle to healthcare policy. A lot of people have benefitted and been able to live healthier lives because of the wisdom of healthcare providers, and in particular nurses and physicians. If there were one guiding principal I would like to posit with respect to the development of policies that will impact the storage, dissemination and flow of electronic information in the future, it would be that such policy should not seek to promote the advancement of knowledge and information at the expense of wisdom.

Cheers,
  Sparky

 

 

Filed Under: Editorials & Opinions, Social Media · Tagged: , , , , , , ,
Mental Health Policy: It’s Not As Hard As You Don’t Think
Jun 19, 2013

Mental Health Policy: It’s Not As Hard As You Don’t Think

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Mental-health-problems-007In my work with healthcare providers and community-based services organizations over the past two years there is one recurring theme that continues to present itself at multiple levels – i.e., personally, professionally and socially: that is the growing awareness of how critically important it is to  integrate mental and behavioral health services with primary care.

Unfortunately, at a popular level mental health in the US has long been synonymous with a disease state – something that needs to be fixed, or at least treated.  The irony of this of course is that we have spent decades worrying about how to fix our healthcare system while all the while forgetting that what we have really had for years is a sick-care system. We care for people when they are ill – we don’t really have an effective system in place to keep them well.

And yet there really isn’t compelling evidence that indicates social investments in health and wellness provide good return on those investments. Education and awareness haven’t had the intended impact. Why?

Could it be that the same underlying drivers impeding the success of health and wellness activities are also manifested as root causes of a variety of physical illness and disease? In other words, in only regarding mental health as a means to cure a problem rather than the promotion of a desired natural state of being are we neglecting a critical element of healthcare reform? I think so.

Admittedly, the policy considerations surrounding mental and behavioral health services are extremely complex, in large part because they interact with so many other policy areas; e.g., Housing, Employment, Criminal Justice and FDA Oversight – just to name a few. Nowhere is this more evident than with one of the most proliferate and threatening elements of mental and behavioral health in America today: addiction.

Rather than try and put forth a meager attempt here to explain the hows and wherefores of addiction, mental health and public policy, I would rather refer Pub visitors to a wonderful post by the One Crafty Mother, Ellie Schoenberger.  In what she titles the most important post she’s ever written, Ms. Schoenberger does a fantastic job of putting a framework around the impact addiction has on society – and how it must be understood from an individual, social and public policy perspective if we are to develop effective policy to address this growing epidemic.

I think it’s a great place to start a discussion, and I hope you will take the time to read it.

Cheers,
  Sparky

Filed Under: Behavioral Health and Substance Abuse · Tagged: , , , ,
May 19, 2013

At What Price Transparency

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

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

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

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

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

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

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

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

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

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

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

Cheers,
  Sparky

 

Filed Under: Editorials & Opinions, Transparency · Tagged: , , , ,
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