Wednesday, March 31, 2010

Berwick for CMS: the good… and bad news

berwick_4_.JPG(photo from The Boston Globe)

It seems like a no brainer.  Health care quality and safety guru, accomplished crusader on behalf of cutting costs without reducing (or actually while increasing) quality of care, noted author (if you’re in this business, Crossing The Quality Chasm is required reading) and balanced (i.e., non-partisan) Donald Berwick is the President’s likely candidate for head of the Centers for Medicare and Medicaid Services (CMS).  Given all that, who could oppose his candidacy?  And why?

First, though, the administrator of CMS oversees a nearly $800 billion budget and would sit squarely in the center of the health reform implementation.  If fact, much of the ultimate responsibility for realizing the goals of the new law would fall on his shoulders.  To gain an appreciation for all that Dr. Berwick brings to this task, see his bio page at the Harvard School of Public Health (where he serves on the faculty) here.

Why might his nomination be opposed?  A few reasons:

  • Republicans, bent on defeating/repealing/delaying the implementation of the law, could use an opposition strategy simply as a road block approach.
  • Republicans, bent on turning the tide in the upcoming elections, might relish the opportunity to highlight Dr. Berwick’s views, which they may characterize as particularly “liberal” – see below.
  • Dr. Berwick has often cited the fact that medical supply drives demand, increasing costs without improving outcomes.  Some corners of the industry won’t enjoy having this perspective at the helm of the primary governmental health policy and payment organization. 

I don’t know Dr. Berwick but I’ve followed his accomplishments and contributions for a long, long time.  And when I heard about the possibility that he could be the next chief at CMS, I thought “yes, of course.” 

But not everyone thought that.

Tuesday, March 30, 2010



Cerberus, in Greek and Roman mythology, is a three headed serpent-dog that guards Hades, the underworld.  Its role is to prevent escape.

Interesting name for a company.

The announcement that the investment firm named Cerberus is acquiring the not-for-profit Catholic hospital chain, Caritas, seemed to catch everyone by surprise late last week.  The investment company has agreed to invest $830 million into the six-hospital organization and will assume pension obligations, debt requirements, operational funds and $400 million for capital projects.

What were they thinking?

And can they compete with a local and very established not-for-profit hospital economy fueled largely by Partners, itself embarking on a $4 billion capital improvement campaign to further enhance its market leading position in the industry?  Under the leadership of CEO Ralph De Le Torre, Caritas has been on a roll, turning the corner in terms of profitability, repositioning itself with managed care payers, expanding profitable surgery lines and cutting expenses.  But, to compete, further capital investments are necessary in their facilities throughout Eastern Massachusetts.

Caritas gets the $830 million it needs, but what does Cerberus get?  In all likelihood, they’ll have a chance at revitalizing a network that will be worth even more in a few years when they will most assuredly look to sell… assuming they can.  The real carrot here could be Dr. De Le Torre himself, who will stay on and advise the firm on hospital acquisition possibilities across the country.  The buzz on Wall Street is that Cerberus is betting that the new health reform law will help to improve the viability of underperforming hospitals who have tended to care for the historically underinsured populations and, therefore, have struggled financially.  If there are a bevy of such facilities throughout the country, then the time to buy could be right now.  Having a proven medical leader in De Le Torre may just prove to make an $830 million investment in a six hospital Catholic chain in Massachusetts seem like pocket change. 

The three headed beast is taking quite a chance on that possibility.

A follow-up from yesterday’s post

Bruce Bullen (of Harvard Pilgrim and Massachusetts Medicaid fame) commented on the primary care physician shortage issue (see my earlier post here).  First, a word about Bruce.  He has a new blog called “Health Reform Musings”, which I’ve provided a link to in the banner to the lower right below.  I had an opportunity to work with and for Bruce during the most eventful days of the Harvard Pilgrim turnaround and I can’t think of someone more qualified to provide “musings” on the health care industry and current pressing reform issues.  His insight is balanced and informed.

The potential impact on the primary care physician shortage of the new reform law may, per Bruce, “… certainly slow the development of accountable care organizations and other forms of managed care.”  This is important because while the reform law directly paves the way for expanding coverage for the uninsured, the road is less clear cut in terms of the economic implications.  There are pilot programs envisioned in the law which would call upon networks of providers to form “accountable care organizations” or ACOs to more forcefully and directly manage the health of a defined population and the associated resource requirements.  Individual state efforts, including here in Massachusetts, will likely pick up the slack in terms of payment reform, again prompting ACO development.

But… if the primary care shortage results in a shortage of critical gatekeepers and care coordination personnel, then ACOs could be stalled coming out of the gate.  This is a trend worth watching.

Monday, March 29, 2010

Less doctors... getting more done.

The Associated Press reported today:

WASHINGTON — Primary care physicians already are in short supply in parts of the country, and the landmark health care overhaul will bring them millions more newly insured patients in the next few years.
Recently published reports predict a shortfall of roughly 40,000 primary care doctors over the next decade, as physicians are increasingly drawn to the better pay, better hours, and higher profile of many other specialties.
Provisions in the new law are aimed at easing the strain, including bonus payments for certain physicians and expansion of community health centers, but a growing movement to change how primary care is delivered may do more to help with the influx, advocates say.
The “medical home’’ approach would enhance access to care, with a doctor-led team of nurses, physician assistants, and disease educators working together. Such teams could see more people while giving extra attention to those who need it most.
“A lot of things can be done in the team fashion where you don’t need the patient to see the physician every three months,’’ said Dr. Sam Jones of Fairfax Family Practice Centers, a large Virginia group of 10 primary care offices outside the nation’s capital that is morphing into this medical home model.
Only 30 percent of US doctors practice primary care. The government says 65 million people live in areas designated as having a shortage of primary care physicians, places already in need of more than 16,600 additional providers to fill the gaps. Among other steps, the new law provides a 10 percent bonus from Medicare for primary care doctors serving in those areas.
The Massachusetts Medical Society reported last fall that just over half of internists and 40 percent of family and general practitioners were not accepting new patients, an increase in recent years as the state implemented nearly universal coverage.
Nationally, the big surge for primary care will not start until 2014, when the bulk of the 32 million uninsured starts coming online.
The shortage of primary care physicians in this country has been long anticipated and the report above makes the point that millions of newly insureds will soon be gaining access to needed primary care (a good thing), thus stressing the already strained primary care system (not so good).

I'm reminded of a meeting I attended about six months ago when I was with a group discussing the possibility of developing a new large endoscopy center.  The various individuals were reviewing the need, financial impact, resource requirements and trends in endoscopy utilization.  One of the participants, a noted and highly respected physician, said that within the next few years, gastroenterologists, the physicians presently performing endoscopic procedures, would soon find themselves situated at control panels upon which there would be multiple live video feeds from several endoscopic procedures.  The GI would sit at the panel and monitor each procedure which, in this new world, would be physically conducted by "GI techs", individuals trained to handle the more routine aspects while the physician could be "extended" by allowing him or her to tend to the more cerebral and taxing aspects.  This would, said the noted MD, dramatically increase the physician's productivity, lower costs, contend with expected shortages of physician resources and maintain high levels of quality.

The medical home concept, in many ways, is no different from this scenario.  Increasing the use of "physician extenders" (I dislike that term) is also the same idea.  Ultimately, we'll need to eliminate the various factors contributing to the shortage of key primary care physicians... or quickly figure out how to extend the ones we do have.

Sunday, March 28, 2010

Health Reform: The Experts Speak

BNET has reported on comments from the faculty of Harvard Business School on the recent passage of the health reform law.  Per BNET:

  • Bill George "The bill addresses only one of the four essential elements of health care. Beyond insuring the uninsured,cost, quality, and lifestyles are not addressed. Unless we focus on all four, we will continue to have a dysfunctional system with unaffordable costs."
  • Richard Bohmer "We need to make a distinction between debating how it will be paid for and what the 'it' is that is paid for." He argues we need more change around how health care can be delivered, citing experiments with disease management programs, substituting nurse practitioners for physicians in certain circumstances, in-store clinics to treat simple diseases, and "experiments with IT to enable precise electronic communication between patients and doctors so that real medical discussions can be had at a distance."
  • Regina Herzlinger "The costs of this legislation, more than $900 billion, will put another nail in the coffin of the U.S. economy and open the door to a government-controlled health care system that gravely injures the sick and the entrepreneurs who could help them, along the way. The problem? The absence of a way to control the costs that already cripple U.S. global competitiveness."
  • Robert Huckman "The good news is that the bill tackles many important issues related to insurance coverage. The more sobering news is that addressing coverage issues shines a bright light on the more fundamental reform that still needs to occur -- improving the process by which medical care is actually delivered to patients."

In summary: Some good will come of this, but there are deeper issues which remain unaddressed.  Professor Herzlinger's comments are particularly sobering.

Becoming familiar

This kid rocks

Thanks for sending this, Jean.

It's enjoyable enough just watching this kid bang away, but if you zip ahead to about the last 40 or 50 seconds, watch his facial expressions.  If that's not enough to make you smile, nothing will.

Need a third word! Help...

Just below the VNA CEO header above, there's the tagline for this blog: "home health, images, etc."  So far, this blog has covered home health, images, and etc., though that third word in the line has remained elusive and as a result has changed a few times.  I'm trying to capture the fact that while the bulk of what's here pertains to health and home care, as well as photography, I've also covered a pretty broad gamut.  I've not worried about it too much because it's never been clear whether this was going to be a short-lived experiment or something more.  Since tapping into the Google Analytics functionality that the internet geniuses have created, which allow me to track the number of visitors (unique and repeat) as well as where they're coming from (greetings to my reader in Dushanbe, Tajikistan), it looks as though it's worth keeping this thing going.

But... what do do with that third word?

home health, images, etc.
home health, images, miscellaneous
home health, images, musings
home health, images, reflections
home health, images, life
home health, images, baggage
home health, images, contrivances
home health, images, kit and kaboodle
home health, images, paraphernalia
home health, images, trappings
home health, images, accessories
home health, images, thoughts
home health, images, yada yada
home health, images, blah, blah, blah

What about: home health, images, kitchen sink?

Too goofy?

On the theme...

Wrote this comment to a friend in an email and then minutes later came across this image from yesterday.

To me they seem timeless, constructed painstakingly ages ago and ready to stand for ages more.

They were created for a precise and valid reason.  To mark a border.  To keep something in.  Or out.  

But now, many stand without reason, where there are no borders and the separating is no longer needed.

Saturday, March 27, 2010

New look for VNA CEO

Google has introduced some new tools (long awaited and desperately needed) to modify the look and layout of blogs and so I'm taking advantage.  I'm hoping the new look is a bit more modern and clean, while allowing a bit more flexibility in adding visual content, such as large photos.  Such as this one below from today's unexpected walk through nearby Moose Hill.

As always, comments welcome.


Moose Hill

Immediate... but unfamiliar.

Friday, March 26, 2010

Will iPad or won’t iPad?

verizon-prepping-the-ipadReaders of this blog know that I’ve commented (longingly perhaps) on the significance of Apple’s forthcoming iPad device.  I’ve described the features, benefits and “game changing” characteristics and have even been so bold as to predict the eventual significance of this technology on society.

But the question has been: will I actually buy one?  And if so, right away… or will I wait for a second or third generation version?  The answer is forthcoming.

But first, industry analysts have been tracking the pre-sales of the iPad, which won’t be available until next Saturday (April 3rd) in wifi version and then later in the month in 3G (cellular connectivity), utilizing obscure methods based on the sequence of Apple’s order number distribution scheme.  If you can believe what these folks have been saying, the iPad is going to be big.  Huge, in fact.  That hundreds of thousands of individuals would order a device without actually seeing one or physically touching it bodes well for a product from a company whose products typically induce even more lust once you do see them in person and physically handle them.  In short, very soon, you’re going to see Apple iPads on the train, at airports, in Starbucks and all around us. 

I’m getting one… though I have decided to wait for the 3G version because the lure of all-the-time connectivity is more appealing to me when you’re actually connected all-the-time.

Why did I flash the plastic?  Six reasons:

  • I like convergence.  It seems that increasingly I’m packing my blackberry, an iPod Touch and my laptop wherever I go.  I take periodicals, instruction manuals, the newspaper (or two), and depending upon my destination, one book or more.  The iPad will allow me to scale all this down significantly.  And I like that iPod and iPad peripherals (earbuds, AC adapters, etc.) will be interoperable, allowing me to cut down on the miscellaneous paraphernalia that increasingly accompany my main cargo.
  • I’m going digital anyways.  I read the Globe on my computer via paid subscription, I take notes in a computer program called Evernote, I actually do read books on my iPod Touch, and I frequently prefer on-line forums and content over magazines and physical hardcopy.  For me, paper isn’t dead… but its blood pressure is really, really low.
  • Not just for play.  Some are estimating that the greatest use of the iPad will be for personal use and fun and games.  I’m not a gamer.  My iPod Touch is great for playing eye candy visual games but it’s not something I do.  I do, however, take notes on digital devices (and have since the late 80s, often annoying people in meetings who think I’m checking stock quotes, reading emails, playing sudoku… when I’m really taking notes… really) and use Gotomypc software to access my work computer from other computers.  Gotomypc isn’t available for Apple devices (my guess is they’re working on it) but Logmein Ignition (a competing product) allows for full access to your work computer from your iPhone, iPod Touch and now, iPad.  Why carry a full laptop when you can carry an iPad?  Speaking of which…
  • Why do I even need a full-sized computer?  This is a legitimate question.  Given the above point, I’m increasingly wondering how or why I’ll want to have more computing power with me.  Apple is readying their version of Microsoft Office (called iWork) for $30 for the iPad.  I use iWork almost exclusively (don’t get me started on Office) and the thought of being able to use it on a small, handheld and lightweight device is tantalizing.  All the social networking stuff?  Linkedin, Facebook, Twitter all have free and very functional versions available for iPhone and iPad.  Browsing the web?  Check.  Emails?  Check.  Online banking?  Check.  Digital photography?  See below.
  • Digital photography.  The iPad version of Apple iPhoto, a program I use, is going to be nice.  Others are developing complete versions of their photo manipulation programs for this platform as well.  Apple will sell an inexpensive kit that will allow users to upload photos from their camera’s SD or CF cards directly to the device where they can be manipulated and then uploaded directly to hosting sites.  And I believe that the iPad will become a preferred means of showing photos to others.  Slideshows will be far more compelling on a bright and glossy 10 inch screen you hold in your hands than with any other technology.  We’re going to get used to seeing photography via this platform and all other vehicles are going to seem old school and outdated by comparison.
  • It’s just cool and I can’t wait.  Hey, I’m honest.

User reports will follow.  I’ll be posting soon.  From an iPad, of course.

Thursday, March 25, 2010

Health Reform = Increasing Costs?

This from today's Wall Street Journal:

Democrats dragged themselves over the health-care finish line in part by repeating that voters would like the plan once it passed. Let's see what they think when they learn their insurance costs will jump right away.
Even before President Obama signed the bill on Tuesday, Caterpillar said it would cost the company at least $100 million more in the first year alone. Medical device maker Medtronic warned that new taxes on its products could force it to lay off a thousand workers. Now Verizon joins the roll of businesses staring at adverse consequences.
In an email titled "President Obama Signs Health Care Legislation" sent to all employees Tuesday night, the telecom giant warned that "we expect that Verizon's costs will increase in the short term." While executive vice president for human resources Marc Reed wrote that "it is difficult at this point to gauge the precise impact of this legislation," and that ObamaCare does reflect some of the company's policy priorities, the message to workers was clear: Expect changes for the worse to your health benefits as the direct result of this bill, and maybe as soon as this year.
In its employee note, Verizon also warned about the 40% tax on high-end health plans, though that won't take effect until 2018. "Many of the plans that Verizon offers to employees and retirees are projected to have costs above the threshold in the legislation and will be subject to the 40 percent excise tax." These costs will start to show up soon, and, as we repeatedly argued, the tax is unlikely to drive down costs. The tax burden will simply be spread to all workers—the result of the White House's too-clever decision to tax insurers, rather than individuals.
A Verizon spokesman said the company is merely addressing employee questions about ObamaCare, not making a political statement. But these and many other changes were enabled by the support of the Business Roundtable that counts Verizon as a member. Verizon CEO Ivan Seidenberg's health-reform ideas are 180 degrees from Mr. Obama's, but Verizon's shareholders and 900,000 employees and retirees will still pay the price.
Businesses around the country are making the same calculations as Verizon and no doubt sending out similar messages. It's only a small measure of the destruction that will be churned out by the rewrite of health, tax, labor and welfare laws that is ObamaCare, and only the vanguard of much worse to come.
Copyright 2009 Dow Jones & Company, Inc. All Rights Reserved

I expect that one of three things is true about this assertion that the immediate impact of the new reform package will increase health care costs:
  • It's completely true.
  • This is politically motivated, designed by corporate executives to begin to put pressure on employees in the hope that employees will channel their anger toward upcoming elections.
  • It's a diversionary tactic by companies essentially already expecting escalating costs, but now finding an easy target in the new law.
Pick your poison...

Wednesday, March 24, 2010

Who do you trust? What do you fear?

boston-red-sox-redsox-feiern-alcs-2004-1004311Rancor.  Animosity.  Malevolence.  Ill will.  How many other ways are there to say it?

The debate leading up to Sunday’s vote was bad, but it’s been worse since.  Don’t get me wrong, spirited debate is good.  Opposing perspectives duking it out is how this is supposed to work.  But all this?  Really?

My index finger has been tap dancing between two radio presets in my car.  One is on WBUR (the local NPR station) and the other is on WTKK (the local… uhm… opposite of NPR).  What I’ve been hearing could only be compared to the airwaves in Boston and New York on October 21, 2004*.  The single greatest day in history.  The single worst day in history.

I’ve been in about 20 different conversations, mostly by email, between groups of friends, family members, and colleagues over the past two days.  Those on the left have thought that my post of a few days ago was an attempt to criticize the plan and those closer to the right have considered my views to be apologetic and overtly pollyannish.   And that’s only what my family is saying!

And here I was thinking I was walking a balanced path down the center.

What follows is a philosophical observation… not about health reform, but about the nature of the current debate.  On one of the radio stations I listen to, there seems to be a fundamental belief that a benevolent, typically incorruptible Government gives us the best chance at improving our lot.  We have this health care crisis, as it’s called, and it’s Government that can help us find our way out of it.  On the other station, I hear a fundamental belief that free market forces, Big Business, ever guided by the Invisible Hand, will sort through this and eventually get things right for us.  Team Government expects that profit motivated, nay obsessed, capitalists (in the form of Pharmaceuticals, Insurance Companies, Hospital Systems) are greedy and want only to increase costs.  Team Big Business argues that incompetent bureaucrats and politicos drunk with power want only to preserve that power and will stop at nothing, including flushing their own values and ideals down the drain, if it means saving their own backsides.

NPRists trust government and fear big business.  TKKers trust big business and fear government.  You know and I know that that’s a fundamental basis for our differences of opinion.

For those who dislike being categorized in these sharp and exaggerated corners as I’ve described them above would ordinarily prefer some type of partnership or hybrid approach between the private and public sectors.  To me, that’s what this health reform bill represents.  It’s a middle ground.  But the burgeoning middle ground population (witness the steep climb in number of “unenrolleds”) does not seem to like this plan.  Why?  Because it is perceived as being propagated by one side and jammed down the throat of the other.

Philosophers and theologians have long told us that the two most powerful forces (evils, corrupters) are POWER and MONEY.  Government and Big Business.  It’s who we trust.  It’s what we fear.



* The day after the Boston Red Sox defeated the New York Yankees after being down 3-0 in the 2004 American League Championship Series.

Monday, March 22, 2010


Ten things about Health Reform

20090105_obama_pelosi_33It happened.  And the ink will go onto the paper in the next 24-48 hours marking the end of one of the most historic and contentious legislative battles in recent history.  But the fun is just beginning.

I’ve been asked all day: “what do you make of the health reform vote?”  This is the first chance I’ve had to sit in front of a computer (this post seemed worth specifically not pecking out on my blackberry), and so… here are ten things worth knowing about health reform:

  1. The winners and losers have faces and names.  When Massachusetts passed its universal coverage legislation a few years ago, a jubilant Mitt Romney stood arm in arm with an equally jubilant Ted Kennedy and everybody claimed victory.  The opposition voice was faint, miniscule.  And now that some are pointing to the fact that health care costs have risen sharply as a result in Massachusetts and the early promises of containment haven’t proven out yet, nobody has gone on the offensive.  There’s nobody to say I-told-you-so at the first sign of trouble.  In the current case, there are clear proponents (the President and Speaker of the House are tops on that list) and if/when trouble comes (as it always does), the opponents are going to point fingers.  The vitriol of the debate may wane in the coming days and weeks, but with the November elections looming, look for finger pointers to come out en masse.
  2. The selling game.  Typically, the best selling efforts come before passage.  But again, with elections coming, the President and Democratic leaders are going to hit the podiums, town halls, airwaves, twitter boards and blogs touting the benefits of this legislation.  They have roughly seven months to prove their point and they will get started soon.  Today in fact.
  3. Something is better than nothing.  This was a major political and philosophical distinction in this battle.  Proponents said that the bus is headed for a cliff and we need to do something, anything, to divert.  Some opponents said there is no cliff coming, but most agreed that trouble looms without passage of major reform.  BUT, they said, that this particular diversion is not the one we need.  Ultimately, I think that your own position on this fundamental question is as important as personal politics in terms of whether you support or loathe the weekend’s turn of events.
  4. Who will this benefit right away?  Described on NPR as the IPP (Incumbent's Protection Plan), White House officials and top Democrats are already out touting the immediate benefits of the new law.  What happens this year?  Dependent children can remain on their parents’ insurance plans until age 26, seniors can get help for drugs in the Medicare program, and people with health problems who are uninsurable can now quality for coverage.  The question is whether this group is large and loud enough to sway public opinion.  (Remember, the biggest provisions, including the creation of health insurance exchanges, don’t happen until 2014… an eternity from now.)
  5. Republicans aren’t done yet.  The Senate still needs to vote on the amended portions of the original Senate bill which the House passed.  Though they don’t have the votes or parliamentary muscle to derail, the debate will continue.  Some are claiming that Republicans have a few tricks up their sleeves and that this is not yet over.  Doubt they’re right.  But…
  6. Republicans aren’t done yet.  Ok, so there might be an overtime in this playoff game after all.  If the Republicans are able to muster up enough sway to change some of the language, that might force this to go back into the House for further debate, something Democrats want to avoid at all costs.  Democrats need 60 votes (which they no longer have) to avoid any and all parliamentary challenges and though the prospects of House reentry seem slim, it’s worth watching… just-in-case.
  7. Doing the right thing.  32 million uninsured Americans will now have access to reasonable health insurance coverage.  32 million of these Americans could access the health care system today via safety net providers, the most notable and expensive of which is called the hospital ER.  Without basic primary care coverage and preventative services, these individuals often end up in care when diseases have progressed and/or more expensive treatments are necessary.  Not only does this improve quality of life for these individuals, but it should (should) over time save money.  It’s the right thing to do.
  8. But it’s complicated.  And expensive.  The expansive health bill is poorly understood.  Comments by Massachusetts Reps Lynch and Capuano last week punctuated the fact that the legislation is complex, highly nuanced and implications are poorly understood.  And while most applaud the coverage offered to uninsured Americans, many wonder how we’re going to pay for it all.  I defer to the point made in #7 above, however… that this should save us in the long-run.
  9. Who does this benefit?  The bill is long on provisions for providing coverage to under and uninsured.  It’s fairly short on specifics on how rising health care costs will be controlled.  Proponents argue that the mechanisms are now in place to solve this problem and that that will be the true measure of success of this plan.  Time will tell, but it’s worth noting that some of the big health care stocks (pharmas, insurance companies) are up on Wall Street today.  Up because of relief that the uncertainty in the industry is gone… or up because of a long-term belief that these companies will benefit from the bill?  Hmmm…
  10. He staked his Presidency on this.  That may prove to be an overstatement… but perhaps not.  Politics aside, you have to be impressed with President' Obama’s sheer will and drive in moving this forward.  Again, politics aside… please.  I cannot recall a time when a public leader was so willing to place his own reputation, future prospects and perhaps even legacy out on the line in such a manner.  Clearly, he believes that this is in the best interests of the United States and the majority of its citizens.  Clearly, he understands the consequences, noting a few weeks ago that “that’s what elections are for” when confronted with the suggestion that there was a heavy opposition to this bill.  As always, history will record how all this turned out, but here in the moment, without the benefit of any historical perspective, I suggest that this President’s tireless and risky upward climb on this issue and the fact that we have today a new health care package nearly ready for implementation is testimony to what one person can do to change an entire nation.  Amazing.

Thursday, March 18, 2010

A memory of summer

Didn’t see this one coming…

Massachusetts Rep. Stephen Lynch has declared that he is voting against the President’s health reform package, stating that this bill doesn’t go far enough in holding insurers’ feet to the fire.  According to an interview he gave the Globe:

“We’ve paid the ransom, but at the end of the day the insurance companies are still holding the hostages,” Lynch said in an interview with the Globe early this afternoon. “This is a very good bill for insurance companies and pharmaceutical companies. It might be good for Nebraska, I don’t know. Or Florida residents…But it’s not good for the average American, and it’s not good for my district. Or for Massachusetts.”

This despite intense and constant pressure coming from Speaker Nancy Pelosi and the President himself. 

Some are speculating that Mr. Lynch is preparing for a Senate run against Scott Brown or that he is just worried about holding onto his current seat against an anti-incumbent tide.

In any event, I think this is fairly shocking and might not bode well for Democrats who are worried that on-the-fence House members and especially Senators might tip the wrong way.

Representative Lynch was due to meet with the President this afternoon to discuss his new position.  What would you pay to be at that meeting?

Wednesday, March 17, 2010


“Boston Globe” Salute to Nurses Section

From VNAB’s The Connector publication:

The Boston Globe currently is seeking patients and/or family members to nominate a special nurse who provided them or their family with superior care and comfort.  By accessing the link below, patients can describe their experience.  Specifically, how their nurse demonstrated compassion, strong clinical skills, excellent communication, trust worthiness and patient advocacy.  The application is due March 22, 2010.

If Reform Passes

HealthAffairs (Oakman, Blendon, Campbell, Zaslavsky and Benson) report:

The partisan split in Congress over health reform may reflect a broader divide among the public in attitudes toward the uninsured. Despite expert consensus over the harms suffered by the uninsured as a group, Americans disagree over whether the uninsured get the care they need and whether reform legislation providing universal coverage is necessary. We examined public perceptions of health care access and quality for the uninsured over time, and we found that Democrats are far more likely than Republicans to believe that the uninsured have difficulty gaining access to care. Senior citizens are less aware than others of the problems faced by the uninsured. Even among those Americans who perceive that the uninsured have poor access to care, Republicans are significantly less likely than Democrats to support reform. Thus, our findings indicate that even if political obstacles are overcome and health reform is enacted, future political support for ongoing financing to cover the uninsured could be uncertain.

If health reform passes, especially via the proposed parliamentary razzle dazzle procedures, longer range support for it may wane quickly.  Particularly true if repeal becomes the battle cry of opposition candidates during the coming election season.

If you’re pro-reform, that has got to take the wind out of your sails.

The cost of immigrant health care

According to a post on HealthAffairs (Stimpson, Wilson, Eschbach):

The suspected burden that undocumented immigrants may place on the U.S. health care system has been a flashpoint in health care and immigration reform debates. An examination of health care spending during 1999–2006 for adult naturalized citizens and immigrant noncitizens (which includes some undocumented immigrants) finds that the cost of providing health care to immigrants is lower than that of providing care to U.S. natives and that immigrants are not contributing disproportionately to high health care costs in public programs such as Medicaid. However, noncitizen immigrants were found to be more likely than U.S. natives to have a health care visit classified as uncompensated care.

The cost is lower on a per person basis, but it’s more likely to be uncompensated care.  Both conclusions seem obvious: (1) cost is lower because those without insurance are likely to put off needed services and (2) recent immigrants and the undocumented population are proportionally more likely to be under/uninsured.

If we provide reasonable insurance for all, including preventive services and basic primary care, then won’t we save money in the long run?  This has been well documented but completely absent from the current health reform debate.

I can’t figure out why…


I remember when this guy had hair and a waistline (as he does in this video).  And I always thought this song was great in concert. 

As my iPod churned through the randomly selected playlist during the drive in this morning, and just seconds after hearing a news report on health reform, this is what I heard:

Let’s say you’re an undecided (on health reform that is) Democratic senator or rep and you drive by a large crowd holding signs telling you (by name) NOT to vote for the President’s health reform package.  Later that day, you receive a personal call from Mr. Obama asking you to support him.  Wow.

The media is buzzing today with reports of the pressure that Congress is feeling as we ramp up toward a historic moment in U.S. history.  Will we or won’t we reform health care this year?  Will President Obama or won’t he get a victory on his top domestic (and symbolic) initiative?

It strikes me as a uniquely American (maybe I should have said “democratic society” instead… but I didn’t) dilemma and dynamic: the politician who is stressed and trying to decide between supporting a leader and/or voting his or her conscience and a seemingly growing number of angry voters from their state or district who vehemently disagree.

“This is a historic moment. I think that if we can achieve this, we can be proud of it,’’ said Massachusetts Representative James McGovern, whose office in Worcester was the scene of such a protest yesterday.  Other reps are less sure, including those who worry that they will pass a bill and then have it flounder in the Senate.  “I wish there were tablets where they could sign in stone their commitment,’’ said Virginian Representative Gerry Connolly, an undecided Democrat.

I'm sure you'll have some cosmic rationale
But here you are with your faith
And your Peter Pan advice
You have no scars on your face
And you cannot handle pressure
Pressure, pressure
One, two, three, four

Billy Joel

Tuesday, March 16, 2010

Back to the '80s

A report by The Boston Globe's Liz Kowalczyk today points out that recently released data by Harvard Pilgrim shows the disparities paid to area hospitals and physician groups.  According to the article:
Harvard Pilgrim’s testimony mirrors the results of a yearlong investigation by Attorney General Martha Coakley’s office, which found that the highest pay goes to the providers with the most clout and not as a reward to those hospitals and medical practices that provide the highest-quality care. The attorney general’s report looked at payment rates from all large insurers. Unlike Harvard Pilgrim’s testimony, Coakley’s preliminary report did not identify providers by name.
Repeat: "... the highest pay goes to the providers with the most clout..."

Health care is a 'tweener industry here in Massachusetts.  Back when I was just getting started, we had the Massachusetts Rate Setting Commission that would review and approve hospital prices and the Determination of Need program was a real factor in controlling expansion.  At that time, we were more regulated.  Free market advocates helped to dismantle rate setting controls and the certificate of need policies have since been watered down greatly.  Today, we are less regulated.

In the early days of this new free market reality, some hospitals set out as pioneers and attempted to gain clout through increasing market presence.  Brigham and Women's and Mass General and others formed Partners, Beth Israel and New England Deaconess and others started CareGroup, New England Medical Center connected with Rhode Island Hospital and the Catholic hospitals united as Caritas.  The payers responded, most notably Harvard Community and Pilgrim.

Some of those unions worked well.  Really well.  Others failed and either faded away or disbanded completely.  Some of the systems that formed did exactly what they set out to do - create marketing clout.  What better measure of marketing clout than being able to charge more for your services than other comparable brands?  In short, we got what we wanted.

This is most assuredly not an anti-free market rant.  I wouldn't be so inclined.  But policymakers now need to resist the urge to completely swing the pendulum back toward a rate setting and "more regulated" state without understanding the answers to these questions:
  • What did not work before such that we were all eager to abandon the regulated approach?
  • How can we not destroy the benefits that a competitive approach has gained?
On the second point, such benefits include large scale investments in electronic medical record systems, clinical innovations, investment in research and expansions of capacity in some areas where access was limited or lacking previously.

The Patrick Administration is looking at ways of modifying the payment system.  According to the Globe:
Dr. JudyAnn Bigby, secretary of the Executive Office of Health and Human Services, is leading the effort to develop a new payment system for providers and said while hospitals have legitimate explanations for some of the inequalities, the differences probably should not be so large.
It's time for some changes.  But let's not step back completely to the 1980s, hoping that rate setting and expansion regulation alone will be the answer.

Monday, March 15, 2010

So, so close...

According to data recently released by the Centers for Medicare and Medicaid Services (CMS), health care spending rose last year by 1.1 percentage points, to 17.3 percent of the gross domestic product (GDP).  That marks the single largest increase in any year since 1960.  The reasons cited include the economic recession and resulting rising unemployment, plus the aging of boomers into Medicare.  Average public spending growth rates for hospital, physician and other clinical services, and prescription drugs are expected to exceed private spending growth over the next four years.

By every measure, we are spending a greater and greater proportion of our resources on health care.  With unlimited means, we might conclude that that is a worthy pursuit given better health outcomes and improved quality of life for patients over the past several generations.  But resources are not unlimited and policymakers are right to worry that inaction could result in eventual disaster.  And with public spending exceeding private spending, the pendulum is shifting toward a government (i.e., taxpayer funded) health care system regardless of whether we describe what's happening as "government takeover" or "public option" or "socialized medicine" or not.

Politics aside, the President and his party are taking the position that doing something is better than doing nothing.  Opponents argue that doing nothing is better than accepting the current reform proposal.  The latter group have the easier task because they are able to scare the citizenry with images of second class European-style government run hospitals and conjure up feelings of fear by asking whether we trust our health to "the same people" who brought us the Registry of Motor Vehicles or the Post Office?  Proponents have the harder task because they ask us to envision a world with and without comprehensive health reform.

If the President ultimately loses this battle, it will be because he failed to fully paint a picture depicting what inaction could do to us.  He has not convincingly argued what will happen if health care tops 20 percent or 25 percent or even 30 percent of the GDP.

We may be in the final days of this historic battle.  And this could be as close as we ever get.

Name that movie…

“Who is Keyser Soze? He is supposed to be Turkish. Some say his father was German. Nobody believed he was real. Nobody ever saw him or knew anybody that ever worked directly for him, but to hear Kobayashi tell it, anybody could have worked for Soze. You never knew. That was his power. The greatest trick the Devil ever pulled was convincing the world he didn't exist. And like that, poof. He's gone.”

Saw it again last night for the first time in probably 15 years (it was released in 1995) and it still satisfies.

If you’ve seen it, then you know.

Thursday, March 11, 2010

Why I'm done with the NHL

Go to about the :55 mark and watch what Matt Cooke does to Bruins' Marc Savard.  

When you grew up in Boston during the Bobby Orr years, you could not help but be a Bruins fan, a hockey fan.  And though it's been far too long since the Bruins have seriously contended for a Stanley Cup, I've remained a fan since those days.  

Colin Campbell is a Senior VP of the National Hockey League.  He's a former player and coach and has a son who currently plays for the Florida Panthers.  And he should know better.  His recent ruling that this was a blow to Savard's shoulder, not head, and his therefore mandating no suspension for the culprit, Matt Cooke, is an epic mistake.  And one that will cost the floundering league.  Was it just a few weeks ago that the surging U.S. Men's Hockey Team's performance in the Winter Olympus had many pundits suggesting a boost for the NHL?

By ruling this hit non-flagrant and not worthy of any type of suspension for Cooke, already suspended once this year for a similar hit, the league is essentially saying that this sort of violent action is acceptable. It also leaves the Bruins, who will play the Penguins next week, thinking about vengeance.  Talk shows are buzzing with discussion about their "heart" and "nerve" and whether not exacting a revenge means that they will be pushovers for the rest of their march to the playoffs.  Some are saying that the Bruins will get even with Cooke... or with one of the Penguins' best players (Savard is the Bruins top goal scorer).  One person called in to say that they should go after Colin Cooke's son who plays on another team.  Crazy.  And sad.

Watch it again.  From the :55 second to about the 1:10 mark.  Pathetic.

And I'm done with it.

Wednesday, March 10, 2010

Hospitals and weekends don’t mix

hospital_cartoon An interesting piece on BNET today from Ken Terry.  Click here for the full article.  Here are some snippets (with commentary below):

Patients admitted to the hospital on weekends are 30 percent more likely to die there than those who arrive on weekdays. And guess why? It turns out that most doctors are reluctant to work irregular hours, which in turn delays care for weekend patients.

According to a new study from the Agency for Healthcare Research and Quality (AHRQ), delays in treating conditions such as heart attacks, angina, gall bladder problems and complicated hernias were much more common for patients admitted on weekends than for those hospitalized during the week. Just 36 percent of weekend-admitted patients received major procedures on the day of admission, versus 65 percent of those admitted on weekdays.

Of the 19 percent of all hospitalized patients who were admitted on the weekend, 2.4 percent died during their stay. In contrast, only 1.8 percent of patients admitted on weekdays died in the hospital. To some extent, this reflects the fact that far more patients admitted on weekends (65 percent) than on weekdays (44 percent) came in as emergency cases, rather than scheduled admissions.

But both sets of patients had similar characteristics, and their average lengths of stay and costs per admission were close. So the higher number of emergency cases on weekends does not fully explain the higher mortality rate among those patients. Moreover, emergency cases usually require more prompt attention than patients who come in for elective procedures. Delays in providing treatment may “be an indicator of [low] quality of care,” the researchers said.

In an organized system of care, an adequate supply of physicians would be available to care for acutely ill patients every day of the week. But in the U.S., specialists and surgeons routinely refuse to be on call at the hospital unless they’re paid extra. If they don’t have an inpatient procedure scheduled, they’d rather be seeing patients at the office or operating on them in ambulatory surgery centers. And on weekends, they’d rather be home. So the hospitals pay them to come in.

Making matters worse, many patients are only in the ER in the first place because they have no access to their regular physicians. In the U.S. and Canada, three of five doctors have no after-hours arrangements, according to an international study by the Commonwealth Fund. Not surprisingly, U.S. and Canadian patients also have the highest use of the ER for care that could have been provided by their regular doctor.

I know what you’re thinking: it’s a selection issue with sicker patients coming in via ERs on a weekend than the full and diverse population who come in for a variety of reasons during the week, including scheduled, non-emergent procedures.  Ken Terry does a nice job, however, debunking this.

Focusing on weekend and off hour coverage is a critical issue in home care as well.  The VNA of Boston has done so by providing excellent options for the home-based patient population, whether through our certified home health offerings, hospice programs or private care affiliate.  Click here for more information.

Image courtesy of CFB Borden.

Tuesday, March 9, 2010

Diabetes... nearly 50%... and growing!

Recently, the Visiting Nurse Association of Boston's Joan Fall cited some American Diabetes Association data.  According to the ADA:

  • 17.9 million people in the US have a diagnosed Type 1 or Type 2 diabetes
  • Another 5.7 million have diabetes but  are still undiagnosed
  • 23% of people over the age of 60 have Type 2 diabetes and it is projected by the year 2050 that this will rise to 66% for people age 65 and older
  • Total cost of diagnosed diabetes in the US in 2007 was $174 billion with an additional $54 billion in related costs
  • Diabetes is the leading cause of newly diagnosed blindness and renal failure in the US
The VNA of Boston is launching a new clinical center of excellence designed to improve the care we provide to diabetic patients at home.  Already a leader in the industry, the VNA of Boston is seeking to improve oral medication management, reduce emergent care visits due to hyper/hypoglycemia and make other measurable strides through the development of new practice guidelines and documentation standards, creating new educational programs for our clinicians and formally testing competency based on industry leading standards of care.  Additionally, we're implementing policies that are culturally sensitive and appropriate for the communities we serve.

According to Joan: "Here at the VNA of Boston, over 49% of our patients who are age 65 or older have a primary, secondary or tertiary diagnosis of diabetes.  I believe we can make a huge difference for our diabetic patients' lives by providing each individual with the tools needed to manage his/her own diabetic self care.  The Core Concepts lead presenter starts off her patient teaching sessions by asking the question: 'What is standing in the way of you managing your diabetes?'  What a great question for us to use when starting that discussion with our patients.!"

We'll post our results here and elsewhere as this new program launches.

Spectacular City Skylines

Check out this website for some visually stunning city skyline photos.  Click here.  For you world travelers out there, how many of these cities can you name?

Light Stalking is a very decent photo site.  Worth checking out...

Monday, March 8, 2010

Fire on the Water

An abstraction... which is not my typical thing.  Does it work?

Give the people what they want

Uwe Reinhardt has an interesting piece on Health Affairs Blog (click here for the article) regarding the ideological gulf that exists in this country.  His observations stem from watching the recent health reform “summit” in which said ideological gulf was on display.  In his post, Mr.. Reinhardt describes the gap between leftward leaning politicians and Americans (“plebs” as he describes them) and more rightward leaning ones.  He poses ten health system characteristics shared by most American plebs.  Americans want a system that:

  1. Lets only patients and their own physicians determine how to respond clinically to a given medical condition, never an insurance clerk or, even worse, government bureaucrats.
  2. Limits their families’ out-of-pocket payments for health care to make it “affordable.”
  3. Keeps insurance premiums and taxes for health care low.
  4. Does not ever ration health care, because that is un-American and practiced only by un-American alien nations with inferior health systems.
  5. Does not allow public or private insurers to let “costs” or “cost-effectiveness” ever enter coverage decisions, because that would implicitly put a price on human life which, in America, unlike elsewhere in the world, is priceless.
  6. Does not mandate individuals to purchase health insurance, if they do not wish to do so, if for no other reason than that this would be unconstitutional and, therefore, un-American.
  7. On the other hand, grants every American the moral right – backed up by a government mandate called EMTALA– to receive critically needed and possibly high cost health care from hospitals and their affiliated doctors, even if they are uninsured and could not possibly pay for that expensive care with their own resources.
  8. Controls Medicare spending, which is widely thought to be completely out of control, as long as it does not reduce payments to hospitals or to doctors or to producers of medical technology, or to any other provider of health care.
  9. Provides universal health insurance coverage to all Americans, provided it does not mean raising taxes or cutting Medicare spending or raising premiums on healthy Americans.
  10. Keeps government out of health care but somehow makes sure that insurance companies do not exploit patients through incomprehensible fine print, no one engages in price gouging – e.g., charge $10 for an aspirin — and no one in health care earns excessive profits (or any at all).

To which I would say: Is that all?  Piece of cake.

Sunday, March 7, 2010

Evening Glow

There was a warm and exaggerated glow in the sky this evening.

Saturday, March 6, 2010

Best restaurant in the North End?

I say Massimino's.  Click here for more information.

Three shots from around the North End.  And it all culminated at Mike's.  Of course.

Friday, March 5, 2010

This is what Home Care looked like in 1920!

Nurse 1920 #1

Decor, outfits and interesting “swing set style” hospital bed notwithstanding, it looks pretty much the same today.

Wednesday, March 3, 2010

125 Years of Caring!

Nurse 1956 #1Today, we officially launched our 125th Anniversary Celebration planning initiative.  There are some seriously exciting things coming from the Visiting Nurse Association of Boston.  Stay tuned…

“This is where we’ve ended up.”

A year after President Obama made health care reform his top domestic priority and less than a week after a summit meeting to debate the initiative with emboldened Republican and restless Democratic legislators, the President has stated that the time to act is now.  Experts expect some modest changes designed to acquiesce to the opposition party while not alienating a reluctant Democratic base.  He will be appearing shortly at the White House and it will be interesting to see what kind of public reaction his comments and proposal receive.

The past week’s events and comments coming from Washington suggest that this President does not mind staking his reputation and perhaps prospects for re-election on this one issue.  That he would willingly feed gasoline into Tea Party fires igniting all round the country either means that: (a) he believes that those happy with a shotgun approach to reform legislation will outnumber (electorally speaking) those who are unhappy or (b) he feels there will be enough time between passage and the November elections for Democrats to recover and even sell the positive aspects of the plan.  My suspicion is that Obama the Pragmatist is more in control here than Obama the Idealist and that if the deal is sealed, we’ll see whole scale health reform selling through the rest of 2010.

Republicans are meeting as we speak to deny this President that opportunity.

Tuesday, March 2, 2010

Ten Minutes at the Fort Point Channel

A day full of meetings, including one in the Fort Point Channel area of Boston.  As I made my way to the luncheon, I snapped a few...

Monday, March 1, 2010

Two messages, one future…

merge-700542 From an email to all VNAB staff:

I recently heard some interesting comments from two individuals I respect… and thought I’d pass them along to you.

I first became acquainted with Guy Kawasaki in the 1980s and have been reading his articles since in Entrepreneur and Forbes, among other places. He describes himself as an “early stage venture capitalist” but his most famous experience was working at Apple in the early days. He was part of the team that developed the Macintosh Computer which has always fascinated me because Apple was focused on other products at the time and came very close to not supporting the development of this new platform. Apple experienced many “near death” moments in their history, but persisted and reinvented themselves several times over. Such innovations include the Macintosh itself, the iPod, iPhone and soon, the iPad. Not long ago, Apple was not even in the music business. Today, more people purchase music from the Apple iTunes store than any other place on the planet.

I heard Guy speak a few weeks ago about innovation – a topic he is well qualified to discuss as his resume would surely indicate. He was speaking to a group of home care executives and describing the fact that, in his experience, the most innovative products and services, the ones that significantly alter an industry, are deep (you anticipate what your customers want in advance and try to incorporate that into what you offer), intelligent (cleverness counts… it helps you to offer unique products and services), complete (the more you can minimize handoffs to others, the more likely you’ll succeed) and elegant (there’s a “coolness” factor; people see your product or experience your service and are inherently drawn to it). Guy’s message to the home care industry: it’s time to innovate.

In my four months at the Visiting Nurse Association of Boston, I’ve seen some interesting innovations. I wrote about them here, here and here. In the highly (and increasingly) competitive world of home care, I have little doubt about the importance of our continuing to innovate in this very manner.

Last Friday, I met with John Auerbach, Massachusetts Commissioner of Public Health. I know John, but this was the first time I’ve seen him since joining the VNA of Boston; that gave me a good opportunity to speak with him about our organization and his thoughts about it. I wish I could have recorded what he said as it was most impressive. He stated that we are different from other home care agencies. And different from other health care organizations as well. The term he used repeatedly was “stepped up”. Back when HIV and AIDS were poorly understood and greatly feared, the VNA of Boston stepped up and served patients in their homes. When the Department needed to focus on bioterrorism and emergency preparation nearly a decade ago, we stepped up and more recently, our organization stepped up when the Department was contending with both widespread and contained infectious disease outbreaks. We stepped up. And this is what makes us different.

Our future? Our future stems from the convergence of these two different messages. We need to continue to differentiate ourselves… to innovate. We need to embrace and continue our 125 year mission of being there, of stepping up. We need to do both.

That’s our shared task and responsibility. It’s the key to our future and our success.

And I’d love to hear your thoughts…