The Pain of Mental Illness

Hidden not far at all beneath the tinsel and tapestry of joy that retailers and their ad companies ask us to gorge upon is the painful reality this “season” means to millions of individuals whose conscious awareness of emotional pain and loss is heightened at this time of year. For most of us in that boat it’s a time of year you just try and suck it up and get through. But for the millions of Americans and their families living with mental illness there is no emotional reprieve awaiting as the calendar page flips to January 1.

In June of this year, CNN reporter Wayne Drash was invited into the home of Stephanie Escamilla and her family to observe and understand the trials and tribulations of caring for a child with a mental illness. Her 14 year-old son Daniel (not his real name) has been diagnosed as having bipolar disorder with psychosis. Their story – of the deep emotional pain that attends mental illness – is chronicled in Drash’s story, My Son is Mentally Ill So Listen Up, featured on CNN’s web site.

Stephanie’s invitation was her way of trying to bring greater awareness and understanding of the challenges and caregiving concerns that have a tremendous impact on the informal caregivers of the mentally ill. And it was also her way of drawing attention to the tragic reality we face in this country that way, way too often treating mental illness is entirely reactive.

I’m not going to add anything here that hasn’t already been better articulated by clinicians and mental health practitioners in terms of advocating for the same proactive approach to diagnosing and treating mental illness as has been given to heart disease or breast cancer, as examples. I just wanted to share this story with you and hope you will take the time to listen. I think it is tremendously important.



Will the Truth Destroy Us?

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.




“The Doctor Will Skype You Now . . .”

healthcare-marketing2-300x199In this month’s edition of the McKinsey Quarterly is an insightful article: Six social-media skills every leader needs.  If you are either currently – or aspiring to be – in a position of managerial leadership at any level of your organization and plan to work for more than a few more years, this is an article you need to read.

And if you are working in healthcare, I think you will find the personal and organizational ramifications of the Six Dimensions of Social-Media-Literate Leadership model presented in the article to be particularly exciting – and troubling.  Because of the inherent nature of the industry’s product (i.e., human health), the potential benefits and threats presented by social media are accordingly heightened.  When messaging distribution spins out of control and goes viral at a manufacturing concern someone could lose face.  When messaging gets convoluted in a hospital someone could lose their life.

The opportunities for creating organizational value through social media are vast and still largely untapped.  For example, the ability to engage and capture a broad spectrum of individual thinking; the ability to facilitate collaboration and engagement across social and cultural barriers; the ability to build brand loyalty through direct communication; the ability to accelerate innovation.

The other side of the social media sword is just a sharp – and even more so in healthcare.  Risks of individual privacy are at the forefront.  But there are also tremendous risks associated with distribution of disinformation, as well as the misuse and/or misunderstanding of credible information.

As the article points out, “the leader’s task is to marry vertical accountability with networked horizontal collaboration in a way that is not mutually destructive.”  How is this done? I have highlighted below the key points I took out of the article.

Accept Reality
Whether appreciated or not, social-media is a transformative disruption that is changing the way organizations operate (their structure, their strategic positioning, their business models).  The article describes McKinsey’s work with General Electric’s leadership in their social-media-transformation.  It is not a fad of the entertainment-minded pre-Baby Boomer generations.  Ignore its implications on the future at your own peril.

Learn to Let Go
The days of being able to carefully plan, construct and deliver your message via traditional forms of media (i.e., whether through print, e-mail or video) are quickly waning.  Today’s distribution network has been turned upside down: the message often starts with social communication and then gets crafted, molded and morphed into new meaning as it cascades upward through organizational hierarchies.  Recognize sooner rather than later what this means for your ability to control messaging.

Embrace – and Learn – Media Technology
In social-media risk mitigation, the best offense is a good defense.  The sheer volume of information bits from e-mail distribution, networking and news aggregation is overwhelming for most of us.  Being able to use tools that help navigate and focus your attention on highest priorities is essential.  Also being able to understand when, how and in what context your messaging will be received should help guide your communication style.  There are some wonderful software applications to increase your abilities in this area.

Stay Tuned In
Part of GE’s Leadership Explorations program includes reverse mentoring, where senior leadership is able to engage with media-savvy millennials to accelerate their knowledge and understanding of emerging social-media technology and applications.  Staying on top of the social-media evolution takes precious time that has to be diverted from more meaningful endeavors.  In other words, time has to be made to stay on top of it.

Be Cognizant and Be Careful
If you are familiar with the old adage, Some things are better left unsaid, then internalize that phrase and broaden its application to any potential means of sharing a thought via social media.  I have been personally mindful of the line from Kipling’s poem, If: “If you can bear to hear the truth you’ve spoken twisted by knaves to make a trap for fools . . .”  Unfortunately, that
is an inherent risk that comes with raw and transparent communication. 

Healthcare organizations – and their leadership teams – that “get” the socially and culturally transformative implications of social-media will note in the model presented by McKinsey aspects that reflect their own evolution.  They will be able to recognize and identify with the opportunities and challenges presented because they have already begun to experience both firsthand.

For those who don’t get social-media, well as was written in a Western Union internal memo in 1876, “this ‘telephone’ has too many shortcomings to be seriously considered as a means of communication.  The device is inherently of no value to us.”


Chaos Theory & Doc Shortage

A major concern of policy analysts regarding the Affordable Care Act is whether and how the country will be able to produce a sufficient supply of primary care physicians (PCPs) to meet the projected demand arising from extending healthcare coverage.  But to what extent future demand for PCP services will be owing to demographics versus expansion in coverage requires the use of some rather subjective assumptions.  While it is plausible to assume that removal of cost as an obstacle to healthcare utilization would increase demand among that portion of the population unable to afford coverage, such thinking can also be counterintuitive.

According to a 2012 article published in the Annals of Family Medicine, Projecting US Primary Care Physician Workforce Needs: 2010-2025, “with nearly 209,000 PCPs in 2010, the United States will require almost 52,000 additional PCPs by 2025—about 33,000 to meet population growth, about 10,000 to meet population aging, and about 8,000 to meet insurance expansion.”  There are numerous similar studies using different methodologies and approaches and different (hypothetical) assumptions, but most all I have seen support the challenging reality that demand for PCP services is going to substantially outpace supply given the historical rate at which new physicians enter the workforce.

In reaction to this concerning challenge, the journal Health Affairs recently published a paper that argues the projected PCP shortage can be largely addressed by using teams, better information technology and sharing of data, and non-physician professionals (i.e., physician extenders, such as Registered Nurses, Physician Assistants and/or Nurse Practitioners).  I fear again, this may be a situation where the reliance on subjective assumptions produces desirable findings from sound research practices that won’t bear out over time.

I think it also illustrates – and this is really the larger point I wanted to make with this post – where very often healthcare policy research methodologies inherently rely upon linear dynamics to study problems that really require a nonlinear dynamics approach.  And understandably so.  If you want to produce a movie using a still frame camera, you had either be extremely fast or quite imaginative.  You work with the tools at your disposal.

As advances continue in information technology computing power and capacity (i.e., Big Data), the ability to model nonlinear relationships will increase.  But the nature of unpredictability in human reactions to environment and circumstances will still be a difficult challenge.  There is quite a body of interesting literature suggesting ways in which nonlinear dynamics (e.g., Chaos Theory) can be adapted in social policy research, which is well beyond my purpose here.  But to be sure, the observations I offer on the subject are neither unique or original.

As a more practical matter, however, I think the ideas presented in the Health Affairs paper are viable and will probably result from being as much a function of necessity as requiring support of public policy.  But the nature of how these clinician-patient relationships form and whether or not they will be sufficient to meet the projected demand for PCP services really cannot be predicted because of the modeling constraints of linear dynamics.

Unfortunately, there are usually significant limitations to what healthcare policy research can offer in terms of predicting the future benefit of what appear to be good ideas.  On the other hand, fortunately, the lack of a projected empirical benefit has not been an obstacle to the pursuit of good ideas throughout the history of mankind.  The historical resolution of these two realities has always been the economic reward for the risk taken in pursuit of an idea that lacks a demonstrable benefit.  The challenge we face today is our inability to accept the consequences when that pursuit does not bear fruit.

We love being rewarded.  Paying the Piper – not so much.


The Politics of Dying in America

Please take a few minutes to read the post, One Example of End-of-Life Care in America, written by Dr. John Henning Schumann on his blog, GlassHospital.  It relates the real life story of a general internist’s experience treating a frail 94-year-old female patient with advanced Alzheimer’s disease and multiple medical issues.  It shares the difficult, non-medical oriented challenges that cut a wide swath across the care continuum when dealing with end-of-life care: the patient, her family, the hospital administration, the attending physician and other clinicians at the hospital.

Several healthcare policy themes are also inherent in this story: the apparent shortcomings of clinical integration and misalignment of incentives that are too often manifested in simply poor communication between clinicians, the challenges with assignment and fulfillment of responsibilities pertaining to an advance directive, the relative effectiveness of evidence-based medicine and how to meaningfully and consistently define transparency in lieu of individual privacy and respect for the patient.

Well over a decade ago I first heard the phrase, “the challenge with our healthcare system is not that we live too long – it is that we die too long.”  I wish I knew (or could remember) to whom that remark should be attributed, as I think it aptly describes the ground zero crossroads of public policy discourse we face in healthcare.  For all of its publicity and ability to bring out the rancor worst in ideologues, the Affordable Care Act is anything but a comprehensive policy solution.

The modest attempt made in the 2009 pre-ACA bill, HR 3200, which would have compensated physicians for providing voluntary counseling to Medicare patients about such demonic concepts as living wills, advance directives and end-of-life care was chastised as being tantamount to Death Panels by the hopefully soon-to-be-forgotten Sarah Palin.  Incidentally, the use of that characterization was given “Lie of the Year” honors by Politifact, considered one of FactCheck’s, “whoppers” and referred to as the most outrageous term of 2009 by the American Dialect Society.

Nonetheless, the characterization continues to resonate in American culture and it highlights the to-be-expected tremendous difficulty in developing a rational policy approach to what for most of us is a very irrational subject: death and dying.  And as Dr. Schumann’s post demonstrates by example, those involved in making such policy are most often not those traversing the ground zero crossroads on a daily basis and having to face the difficult choices with patients and their families.

On the other hand, that I am writing to share with you a blog post expressing the firsthand frustration of a physician in the trenches I think reflects a paradigm shift in our society and culture where the art of medicine is emerging out from under the shadow that has been generations of members-only collegiality and exclusivity.  I found the candor and directness of Dr. Schumann to be both refreshing and constructive.  That it is made available for public consumption is an example of many such blogs now being written on a daily basis by clinicians across the country.

Like many of the healthcare policy issues facing us, end-of-life care holds little hope of ever having a likeable policy solution.  The issues surrounding it are just too emotionally laden with undesirable choices.  But policies that have the best chance of broad support and sustainability will be those developed under the full light and disclosure of the realities that clinicians like Dr. Schumann are willing to share.


Speak Up!! Join the Policy Discussion Group

1336950133_1 Happy New Year!!

As we turn the page on 2012 – a year that, for good or ill or somewhere in between as is yet to be determined, will likely be looked back upon as the launching of tremendous change in the US Healthcare Delivery System – I wanted to begin 2013 by thanking those who have taken the time to stop by the Policy Pub, particularly if you have taken time to read my contributions.

Since I started this blog in May of last year I have received over 2,040 visits from 25 countries by latest count.  From what I have researched, that is a rather modest beginning but nonetheless sufficiently encouraging from my perspective (because I truly enjoy writing).

I also want to take this opportunity to remind pub patrons and visitors that Artower Advisory Services is sponsoring a Healthcare Public Policy Discussion Group.  Participation is free, and registration is as simple as providing your name and e-mail address.  You will not receive any solicitations or promotional e-mails by joining.  You will, however, have the opportunity to participate in a lively discussion of current and emerging topics impacting US healthcare policy with industry colleagues representing a wide variety of backgrounds, interests and concerns.

To join the US Healthcare Policy Discussion Group just click on the hyperlink above – or the Join the Debate image just to the left of this post.  Also check out my earlier post if you’d like more background on the discussion group.

Looking forward to sharing more thoughts and insights – and hopefully challenging your thinking regardless of ideologies and/or beliefs.


Announcing New Discussion Group

Artower Advisory Services is pleased to make available for free participation a new online discussion group on the subject of US Healthcare Public Policy.  A number of the initial members, including myself, represent a cadre of individuals that have participated together in a similar discussion group for well over a decade.  Registration is open now, and the group will officially kick off on November 24th.

For my own part, I first joined that predecessor group in 1996 (if challenged memory serves).  And over that span I have learned more useful knowledge on a variety of topics related to Healthcare Reform and Healthcare Public Policy than any other resource.  The reasons for this have to do with the diverse backgrounds, experiences and ideological vantages represented by the group participants – as well as the unfettered and forthright manner in which ideas can be shared, challenged and debated.

I had initially hoped that the Policy Pub would serve as a platform for creating an online environment where clients and colleagues of Artower Advisory Services could participate in an online community and learn from one another’s experiences, thoughts and ideas.  While I have been more than pleased with the attention this blog has received, I have thus far been unable to translate that success into an online community.

So I took advantage of a recent opportunity to germinate a new discussion group with individuals that I know from personal experience are very knowledgeable, very passionate and very eager to tackle fresh meat (perhaps that is stating the case a bit harshly – but please join and decide for yourself).  To join the group, just click on the picture above, and you will be taken directly to the online registration page.  All the information you need to read and share posts can be found there.  Before joining, please read the Discussion Group Guidelines.

As for the Pub, I will continue posting what I hope you will find interesting, useful and maybe occasionally entertaining.  I will also continue to focus my posts on affordable housing, home-and-community-based services and post-acute/long-term care, while the discussion group will encompass topics in healthcare much more broadly.  While there may be future opportunities to cross reference the Policy Pub and the discussion group, they are independent initiatives, and the success of either is not dependent upon the other.

I hope you will consider joining the US Healthcare Policy Discussion Group and benefit from such participation as much as I have during my professional career.