While Rome Burns . . .

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).


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?”\

Shoots & Ladders and US Healthcare Delivery

imageI just wanted to share a quick thought before I lost it.  Do you remember playing Shoots & Ladders as a kid? Do you remember playing Shoots & Ladders with your kids?

Well I was thinking recently of how I would try and graphically depict  our current US Healthcare System to an alien with whom language would be a decided communication barrier – and this is the image that came to mind: a virtual salmagundi of disjointed pathways that individuals are required to navigate during periods in their life when they are least able to do so.  Throw in  the moving staircases of Hogwart’s Castle in the Harry Potter series, and you probably have a pretty accurate depiction of what our healthcare system looks like from a patient’s vantage.

Imagine though if the Shoots & Ladders game board were redesigned.  Instead of having equal squares representing a static and linear path that must be followed – left to  right, going up a row at a time, hoping that you get the care you need by landing on the right space and hoping you don’t get shot off into the wrong direction – what if there were one square (or better yet, circle) in the middle.  That would be where the player (patient) starts.

Then imagine we get rid of the ladders, because although they represent the benefit of jumping ahead in line, they also represent having to climb; and there are, of course, OSHA considerations.  Let’s instead keep the shoots, but make them work to our advantage.  Realign all the shoots so that they flow out from the center and to the several destinations that represent that element of the healthcare delivery system the patient needs.

Around the board then you have the physician’s office, the hospital, the clinic, the lab, the specialist’s office, post-acute/long-term care facilities …  You get the picture, and one can only take a metaphor so far when the subject matter you’re trying to explain has the reality of life and death attached to it.

Of course, what I am describing here is a holistic system of care delivery that puts the patient at the center of all providers and services – all the time; instead of being the center of attention of one provider at a time, 15 minutes at a time, as his or her time allows.  Instead of the patient having to navigate the system, the patient is surrounded by the system and controls the system.

So what has to happen to realize this vision? For starters, we need to find some common public policy ground as a nation.  What neither political party seems capable of accepting – motivations notwithstanding – is that being in the middle of a battlefield is worse than being on either side.  The inability, or rather unwillingness, to compromise is killing this country, and along with it the hope of having any type of a person-centered healthcare delivery system.  The winning-at-all-costs attitude that pervades our political conscious is quite ironically going to end up causing us all to lose a lot.

There are also substantial and difficult individual behavioral changes that need to take place in our country as well, and these aren’t confined to any individual constituency.  Providers need to tear down the silos that have long stood as obstacles to sharing knowledge and information.  Insurers need to accept those providers as partners in striving for shared goals and objectives.  And patients need to assume a much greater level of responsibility for their health – and the consequences of decisions made from which their health suffers.

Often lost in the political maelstrom that has become Healthcare Reform of the 21st Century are the underlying trends and drivers of which the Affordable Care Act was as much a codification of as it was the creation of any bold new initiatives.  Good things happen when people communicate effectively.  Healthcare costs less when production is streamlined and coordinated.  And people contribute their greatest talents when their environment is stable and they feel safe.  So simple even a four-year old could play the game.





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