Tuesday, September 28, 2010

Southwest with Ed

I recently posted about a favorite local photographer (see here).  Ed is in the Great American West for a few weeks and taking many photos... some with his expensive Nikon rig, some with a cellphone (iPhone).

Can you tell which he used here?

Saturday, September 25, 2010

stunning comeback

Down by 7 with a just over a minute left, Brockton fumbled, setting up a stirring drive and touchdown with merely 40 seconds left.  Xaverian retained its number 1 ranking in Massachusetts by beating number 2 Brockton in this double overtime stunner.

Photo by Joseph.

And it was Joseph's friend Jules who notched the field goal to decisively break the tie.

before the red

Friday, September 24, 2010

Taking Aim at the Middle: a DC Report

This blogger has carped on this theme before (here's an example), but this past week has certainly punctuated the point.  The Visiting Nurse Associations of America gathered in DC to consider a number of legislated and, in some cases, proposed changes to regulations governing the home care industry.  Here's the backdrop:

  • The recently enacted Patient Protection and Affordable Care Act significantly expands coverage and seeks to restrict the growth of health care expenditures.  Some of those latter changes are immediate (e.g., massive cuts to home care) and others are more gradual (e.g., creating pilot programs designed to test changes to how systems of care are reimbursed and creating quality-based provider incentives).  
  • The current political climate is stressing deficit reduction and the rightward-leaning agenda is gathering steam as we barrel toward mid-term elections.
  • Some opportunistic home care companies have been widely profiled (e.g., as in the referenced blog post above) for excesses and rule-bending gamesmanship that has, frankly, given much of the rest of the industry a black-eye.
  • Significant positive Medicare margins have given the Centers for Medicare & Medicaid Services (CMS) reason to consider systematic "corrections" to payment methodologies.
But, here's the rub: many organizations, such as the Visiting Nurse Association of Boston, have built a 125 year-old reputation for caring for all those in our service area without payer status prejudice.  We've also worked hard to differentiate ourselves on quality and outcomes measures.  An example: in the United States, 29 percent of all patients in home care are readmitted to the hospital.  That's not completely surprising because we care for sick patients who are increasingly discharged from hospitals still quite ill.  At the VNA of Boston, 25 percent of our patients are readmitted.  That difference does not happen by accident... and requires directed staff training, specific programs designed to cut unnecessary admissions (and trips to the ER), supporting systems, and a caring, dedicated staff of exceptional caregivers.  Clearly, home care is a far cheaper alternative to hospitalization and that 4 percent differential applied to a larger population adds up to a massive savings to the system.  Unfortunately, organizations such as ours will struggle to maintain investments in such programs when the cuts do hit.

Home care agencies who are selective in who they care for and who have been able to consistently attain 10 to 20 percent positive bottom lines can withstand a 5 percent cut.  Organizations who care for everyone and who routinely reinvest funds into programs for their patients (hence the much smaller profit margins) are not going to fare nearly as well.

In DC, we had an opportunity to meet with Congressional leaders (and their staff) from the Massachusetts delegation.  These include Congressmen McGovern, Markey, Capuano, and Lynch and Senators Kerry and Brown.  Their ongoing support of this industry is widely recognized and most appreciated.  Despite it, however, the policy direction in Washington is to aim for the middle of a lumped together pack, rather than to differentiate based on quality, performance and approach.

Ultimately, this fight is about compassion, quality and exceptional health care services for home bound and vulnerable patients.  It's about doing the right thing.  And... it is about dollars and cents.  However you slice it, though, aiming toward the middle just won't work.

Saturday, September 18, 2010

A favorite local photographer

See this nice piece on one of my favorite local photographers who specializes in "you don't need to spend a lot of money on equipment to make great images".  Ed makes great images...

study hall

More, this time live

I received some emails regarding The Script video I posted recently.  I agree, good, soulful voice.  Here's more, this time live on Letterman.

it could have been the '50s

Saturday, September 11, 2010

Friday, September 10, 2010

It's nice to have friends

The Woburn Friends of VNA Hospice Care are gearing up for the upcoming “Step Out for Hospice” Walk/Run on Sunday, October 3, 2010.  The Woburn Friends of VNAHC, founded in 1992 by retired Woburn school teacher, Miss Doris Lynch, has organized the “Step out for Hospice” event for the past 13 years (thank you Doris!).  The Woburn Friends’ mission is to increase awareness of hospice care in the community as well provide financial support to VNA Hospice Care by conducting informational meetings, creating exhibits, and organizing fundraising activities throughout the year.  The annual “Step Out for Hospice” Walk/Run was started by Co-chair Joe McDonough in 1997 in conjunction with the Woburn Irish American Club and has been generously supported by many Woburn residents and businesses.  The charity event has grown significantly over the years, and last year the Woburn Friends donated a record breaking $45,000 to VNA Hospice Care.  All the proceeds from the Walk/Run benefit VNA Hospice Care, a non-profit organization that provides care, comfort and compassion to patients and families facing the challenges of life-limiting illness and loss. 

VNAHC is an open access hospice which means that the agency accepts all patients, regardless of insurance or cost of care.

Visit www.hospicecarema.org or call 781-569-2888 for more information... or to register for the event.

Thursday, September 9, 2010

And speaking of our hospice...

Patient and family satisfaction surveys of VNA Hospice Care patients recently admitted to care have shown a 100 percent overall satisfaction rating with our care with 97 percent of survey participants saying that symptoms were being “well managed”.  Likewise, a post-service survey of overall family satisfaction (for patients receiving VNAHC’s services January 2010 through May 2010) showed 91 percent of family members rating the care they received as “Excellent” or “Very Good”.

For more information about VNA Hospice Care, call 781-569-2888.

The cost of dying... and "the path of least resistance"

This just in from Carol Keesecker of VNA Hospice Care:
A segment of CBS’ 60 Minutes, titled “The Cost of Dying: End-of-Life Care,” was shown on August 8. The segment includes interviews and patient visits with Dr. Ira Byock, director of palliative medicine at Dartmouth Hitchcock Medical Center, and a professor at Dartmouth Medical School.

Byock estimates that it costs $10,000 per day for treatment in an intensive care unit. “This is the way so many Americans die,” Byock told interviewer Steve Kroft. “Something like 18 to 20 percent of Americans spend their last days in an ICU,” he said. “And, you know, it’s extremely expensive. It’s uncomfortable. Many times they have to be sedated so that they don’t reflexively pull out a tube, or sometimes their hands are restrained. This is not the way most people would want to spend their last days of life. And yet this has become almost the medical last rites for people as they die.”

Dr. Elliott Fisher, researcher at the Dartmouth Institute for Health Policy, told Kroft that so many people wind up in the hospital because it’s “the path of least resistance.” According to the CBS online story about the segment, “Fisher says it is more efficient for doctors to manage patients who are seriously ill in a hospital situation, and there are other incentives that affect the cost and the care patients receive. Among them: the fact that most doctors get paid based on the number of patients that they see, and most hospitals get paid for the patients they admit.” Fisher estimates that 30% of US hospital stays are unnecessary. It doesn’t stop with the hospital admission, either. Fisher says that patients will likely be seen by more than a dozen specialists who will order many tests, many of them unnecessary. Each of those specialists bills Medicare separately. One 85-year-old woman was given a pap smear, “generally only recommended for much younger women, not an octogenarian who was already dying of liver and heart disease.” Fisher adds, “In medicine we have turned the laws of supply and demand upside down. Supply drives its own demand. If you’re running a hospital, you have to keep that hospital full of paying patients. In order to, you know, to meet your payroll. In order to pay off your bonds.”

David Walker, formerly head of the GAO and now head of the Peter G. Peterson Foundation, advocates reducing government debt. Walker sees a major problem in the fact that most people don’t know what their health care costs, because “85 percent of the health care bills are paid by the government or private insurers, not by patients themselves.” Walker says, “Every other major industrialized nation but the United States has a budget for how much taxpayer funds are allocated to health care, because they’ve all recognized that you could bankrupt your country without it.” When asked by Kroft if that means rationing, he replied, “Listen, we ration now. We just don’t ration rationally. There’s no question that there’s gonna have to be some form of rationing. Let me be clear: Individuals and employers ought to be able to spend as much money as they want to have things done. But when you’re talking about taxpayer resources, there’s a limit as to how much resources we have.”

“If you are wondering whether the health care reform legislation passed in March addressed any of the end-of-life issues raised in our story,” says Kroft as he closes the story, “the short answer is no. The new law is designed to slow the growth of Medicare expenses, and includes a pilot program to reward doctors for the quality of care they provide rather than the quantity. But it also reduces Medicare payments for hospice programs that studies have shown to be very cost efficient.

See www.cbsnews.com (CBS News Website, 8/6)

Primary care visits to the ER up. Surprised?

It's been a frequent theme on these pages (see here, here and here): ER usage is up and that's not a good thing.  Costly, frustrating for everybody, and the care that's given is often designed to stabilize and move people along, not necessarily fully treat underlying or longer-standing ailments.  The old gatekeeper model was designed to allow primary care physicians to quarterback the entirety of a person's treatment and to take a longer view, with an eye toward preventative care even.  But, something happened along the way.  We all decided we need maximum choice (rationing... bad) and medical students decided they would rather become specialists than primary care physicians.

Health Affairs is publishing a study this month indicated that 28 percent of all ER visits are for routine care that could (i.e., should) be taken care of in primary care medical offices.  The study, conducted by Stephen Pitts, professor at the Emory University School of Medicine, points out that expanded health care coverage that is not met with a proportional increase in primary care access could spell trouble in the form of longer ER waits and higher costs.  He points specifically to the Massachusetts experience as the proof.

See the summary here.

The health reform good news is expanded access for more Americans.  The trick will be in developing strategies to more effectively manage costs and, as this study demonstrates, expand primary care access as needed.

Tuesday, September 7, 2010

Nailed it!

Debunking the myth of giving in...

I'm still digging out from the firehose of information that poured in when I was on vacation a few weeks ago, but this is one I thought was worth sharing.  From a story that appeared on Boston.com (see here).

I remember my mother-in-law's final year of life.  Joan pursued aggressive treatments for her cancer with a great deal of poise, grace and dignity.  But as the disease progressed, The Question loomed.  Is it time for hospice?  Is it time to give up?

Hospice and palliative care are often viewed as beyond the measures of last resort.  When all hope is gone, then it's time to give in to it, to succumb.  To die.

But a recent study conducted at Massachusetts General Hospital suggested otherwise.  From the piece:
Researchers from the Boston hospital are reporting today, however, that patients with advanced lung cancer who started palliative care soon after diagnosis not only suffered less, they lived almost three months longer than patients not provided these services. And that longer survival came even though the palliative care patients were less inclined to opt for aggressive end-of-life care.
Though these results are yet to be replicated elsewhere, it's important to note that comfort and compassion can bring hope, not signal its loss.

Innovation and Politics

The "recess appointment" of Donald Berwick, MD, as head of the Federal Centers for Medicare and Medicaid Services (CMS) was politically expeditious, perhaps even necessary.  In July, when President Obama announced the appointment, sans congressional hearings, some applauded, some booed.  Fans noted that Dr. Berwick is above reproach, beyond criticism, given his impeccable track record.  They also believed that the CMS chief confirmation hearings would devolve into little more than another public debate on the President's controversial health system overhaul rather than remaining a discussion on the merits of Dr. Berwick as the head of the agency.  Detractors cried foul, describing this as just one more example of a heavy handed President hell bent on pushing an agenda regardless of opposing views. 

The critical issue before us at this point, however, is that CMS stands at the forefront of implementing the most significant health care industry overhaul in history.  Achieving the access goals while maintaining (or working towards) affordability is no easy task, and innovating on matters such as payment reform, accountable care organizations, quality and outcomes, and phasing in changes in sustainable, manageable ways will require great innovation and bold, decisive leadership. 

Boston.com reported yesterday (click here) that Dr. Berwick has taken a decidedly low profile approach during his first days as head of CMS.  That's understandable given the task before him and the manner in which he took office.

But... as we're in mid-term election season (some would say, starting offically today) and poll numbers suggesting that maintining all aspects of the health reform law will be politically tough, it's hard to envision success in this realm springing from a low profile approach.  This will be a politically charged process and many special interests will be sharpening their arguments in the coming months and years.  Dr. Berwick will need strong political backing from both Democrats and Republicans in order to succeed... and to remain in his job after the recess apointment term ends at the end of 2011.

Time will tell whether he is an interim leader or whether he can emerge as the long-term, bold innovator his track record suggests he can become.  Hopefully, pure politics won't prevail.

Wednesday, September 1, 2010

Remember HMOs?

Paul Levy posted an intriguing piece (read here) on his blog yesterday entitled, "W(h)ither health insurers?"  Clever title sure, but also an interesting theory which can be summed up in these two sentences, taken directly from the post:
The talk around the country among health insurance companies is that their insurance business is dying.
The result is that health insurance companies will become financial services organizations more than insurance entities.
I recognize that this may not fascinate you nearly as much as yesterday's seat belt post, but I read it with great interest as I spent over eleven years of my career working directly for two fine health insurers (Harvard Pilgrim Health Care and Neighborhood Health Plan) and would say that the predictions of their demise seemed premature back then... and still do now.

First, a word about back then.  Both of my former employers were founded by innovative individuals driven to improving health care quality and outcomes while effectively managing costs (Harvard Pilgrim) and serving the traditionally underserved (Neighborhood).  Their missions and identities were wrapped up in advancing those distinct objectives, though both missions have been sorely tested through the years.  I was at Harvard Pilgrim during the legendary (i.e., difficult) merger of both former organizations and a battle waged between those who felt as though the best course of action would be to focus on the insurance functions while others fought to keep the initial provider and health care management drivers intact.  Ultimately, when that organization spun off what would become Harvard Vanguard Medical Associates, the insurance-company-as-primary-function types claimed victory... and they were essentially right.  At Neighborhood Health Plan, as its founding community health centers faced increasing funding cuts, many turned to the health plan as a source of new funding (through better rates for providing services and/or direct grants for special projects aimed at improving efficiencies or expanding access to services).  But then downward pressure hit Neighborhood Health Plan, severely testing its ability to continue to meet its mission and serve the provider system that underlies it.

Both of these examples have, for me, shown that there has been and will remain, great pressure between those who are charged with providing exceptional care and those who are charged with controlling the costs associated with that care.  That tension can sometimes become uncomfortable, but it is often quite healthy.  Generally speaking, providers expand and improve services and payers require them to prove effectiveness while creating market dynamics that tend to favor the better performers.  Mr. Levy's premise in his post that insurers are being commoditized (requiring greater scale to survive and compete) is right on, but his suggestion that health insurers will go the way of financial services institutions does not seem right to me.  Organizations such as Harvard Pilgrim and Neighborhood Health Plan employ physicians, nurses and others who develop systems of care and methodologies designed to manage health care costs and to maximize efficiencies (while hopefully driving better outcomes).  If they become merely financial institution commodities, only passing through funds like large exchanges or clearing houses, they will summarily drop their investments in such systems and methodologies. 

Accountable care organizations are attempts to merge the historical "provider mentality" with the "payer mentality", much as provider-based health plans attempted to do in the 1990s (with very little success).  The question remains as to whether the systematic elimination of what I've described here as the healthy tension is ultimately a good thing or not.

I say not.