Four themes for a snowy New Year’s Eve

The short, cheery woman behind the counter at Starbucks this morning declared that the decade will officially be over one year from today.  The hip dude with many tattoos standing next to her argued that the decade is officially over today.  So, regardless of whether the cheery woman or the hip dude are correct, I’ve been thinking about some of the key trends over the past decade… and many relate to technology.  In no particular order, they are:

The iPod changed everything – Ten years ago, if we wanted to buy music, we walked into a music store and purchased a CD.  Today, we (or at least the vast majority of us) download it from iTunes and then play it on our iPod or iPhone, oftentimes through a hookup to our car or home speakers.  CDs are nearly gone.  Standalone music players, gone.  Most music stores, gone.  Most other web-based music downloading services (including the illegal ones), gone.  Apple’s formula?  Easy to use devices.  Easy to use software.  Easy way to connect the device to the software.  Easy, easy, easy.

Convergence counts – Two co-workers today showed off their Christmas gifts.  One displayed her new Amazon Kindle, the other a Barnes & Noble Nook.  And both are great.  For a variety of reasons (including some noted in the iPod paragraph above), digital readers are taking off and in ten years we’ll look back and note that they became the preferred and dominant mode of distributing content.  But, as cell phones get smarter and laptops get better, won’t we want to read books on those instead?  Just as the iPhone showed us that one device can be your phone, portable computer, music player (and for some, your GPS, camera, video recorder, etc.), I think it’s likely the trend toward technology convergence will continue.  So, either Kindles and Nooks will be completely replaced… or, they will need to morph into more capable and versatile devices themselves.

The digital age – Ten years ago, photography pros and hobbyists debated whether digital or film ruled.  It was a religious argument: heated, opinionated, and no one was ever willing to concede to the other.  But here we are on the verge of 2010 and that debate, other than among the esoteric elite, is over.  Walk  into any camera store and try to buy a film camera… just try.  And while film still offers artistic benefits through greater dynamic range and greater subtle variations across the tonal spectrum, it’s all about digital now.  Why?  Prices have fallen, quality has gone up and the convenience of shooting photos, gaining instant feedback on the quality of the image, and then being able to store the best shots (and delete the worst) are far too compelling.  And, now all of us can create holiday cards, high quality books, slideshows, movies, and other vehicles to display our work… and so we’re not going back.

The connected society – We can (and should) argue whether this is a good thing or a bad thing, but today, all of us can and frequently need to be connected nearly 24x7.  Remote access to email systems and gizmo cell phones have made it possible to work from nearly anywhere and at any time.  Social networking and communication websites have given rise to an “always connected” society.  During the next ten years, either this trend will continue… or there will be a backlash such that increasingly people will say that enough is enough.  I predict the former as being constantly connected is addicting, much the same way instant gratification and greater convenience are.  Once you get used to something…

Technology is always touted as making-our-lives-easier and improving-quality-of-life.

True?

Living longer… and paying for it

Who doesn’t want to live longer?

A new study by the MacArthur Research Network on an Aging Society states that: “the current forecasts of the US Social Security Administration and US Census Bureau may underestimate the rise in life expectancy at birth for men and women combined, by 2050, from 3.1 to 7.9 years.”  Here’s the link (click here).  According to the authors, the key conclusion is that: “The cumulative outlays for Medicare and Social Security could be higher by $3.2 to $8.3 trillion relative to current government forecasts.”

BNET’s take on this?

And that’s only the beginning. With anticipated scientific breakthroughs in coming decades, people could eventually live to 150 years of age, says Dr. Steven Joyal, an official of the Life Extension Foundation (LEF), a nonprofit organization that promotes research on how we can live longer and healthier. The MacArthur paper, in fact, says that some experts believe the average life expectancy could hit 100 by 2060.

What’s more, Joyal tells BNET, the conquest of disease and the slowing of the aging process will lead to a sharp decline in disability, allowing people of advanced age to function as well as they did when they were much younger. “In other words, a 90-year-old person could have the same mental and physical capacity as somebody 40 or 50 years old.”

Good news.  But, the current health reform debate began on the note of not only trying to expand coverage for the uninsured but also with a goal of reigning in escalating health care costs.  The culminating House and Senate versions are long on increasing coverage but fairly short on managing costs.  There is movement in the right direction (e.g., quality based reimbursements and the formation of “accountable care organizations”), but health reform, in reality, turned into health insurance reform.

In the current debate about affordability, which has moved into the background as senators re-strategize during the holiday break, if cost estimates are underestimated for the reasons noted above, then the question of affordability ought not remain in the background.

When two worlds collide!

Tweeting makes some sense to me.  It’s a way to announce new blog posts, to promote some professional topic of interest, to follow a specific news story as it develops.  For me, I do all those things… and occasionally throw in something from the other parts of my life, such as a photo or brief comment on a movie or restaurant I recently experienced.

But the holiday season has given me a new reason to ponder the purpose and value of twitter.  Why?  I’ve noticed that many of the twitterers I follow have used the opportunity of a few days off or a year-ending vacation to continue their twittering routines.  Not everyone, mind you.  President Obama has been silent about the good meals he’s had in Hawaii or the medical emergency that recently hit his friend’s child. 

But everyone else?  Among those I follow, I’ve been reading about European vacations, opinions on the year’s best movies and albums, whether Avatar is worth the hype, favored cocktails, and family Christmas traditions.  Right there on my iPhone, I’ve been offered personal glimpses into the lives of people I had previously only viewed through carefully managed professional windows.  Two questions pop up: (1) is this a good idea? and (2) should I throw caution to the wind and begin to peel back the onion publically myself?

On the first point, the Boston Business Journal ran a piece several months ago about CEOs blogging and tweeting, concluding with… no conclusion.  They noted that there are mixed opinions on the subject and that it was, ultimately, too early to tell what kind of impact it might have.  But their stories about CEOs posting their daily weight as part of their weight loss program and discussing whether the latest Star Trek movie is, in fact, the best of the series, made me wonder whether charging full on into a fully transparent world doesn’t have a downside as well.

Personalizing and demystifying those whom we interact with on a professional basis is, inherently, not a bad thing.  In general, I think it’s a good thing.  But when we blend worlds so much, do we lose a bit of the respite and release we gain from maintaining some measure of seclusion and privacy?  We have all learned that balance is important to our health and well-being, but if we’ve blurred the lines so thoroughly between worlds… how will such balance be possible?

Remember George Costanza’s lament, that it’s not good, “when two worlds collide!”

And so despite some occasional lightly personal posts and tweets, I’ll probably keep my own worlds apart for the time being.

Now about my brother-in-law…

The colors of Federal Hill

After seeing a show at the Providence Performing Arts Center, we visited nearby Federal Hill for dinner.  Though it lacks the scale of New York's Little Italy or charm of Boston's North End, there's an intimate and vibrant feeling you get from this small city cluster of Italian restaurants and shops, even on a drizzly winter evening.  This Dolce Villa section, featuring brightly lit pastel colored buildings is a highlight.  The gnocchis at Constantino's next door was another highlight.  Recommended.

From an email to all VNA of Boston employees…

It’s quiet here in Charlestown and I have some quiet music playing in the background (Whitney Houston’s “Do You Hear What I Hear?”… what a voice!).  I thought I would take the opportunity to wish all of you a happy holiday week (Merry Christmas, Happy Hanukkah, Happy New Year, etc.).

Word is breaking now that the US Senate has passed a comprehensive health reform bill this morning.  Though a lot of work remains to try to pull together a combined House and Senate package that is acceptable to all, this feels like a historic moment nevertheless.  And big questions remain, such as how can we pay for all this?  But I do believe that one of the true sparks for this effort comes from a desire to be a compassionate society.  Having working in a community health center and an acute care hospital, I know that we basically do provide services for all… but the services are disconnected and often based solely on urgency.  By offering preventive and basic primary care services to the currently uninsured, we improve people’s lives and, in the long run, make health care more affordable.  As you know, good chronic disease management improves health and cuts costs in ways that frantic visits to the ER never will.

As I’m continuing to meet all of you and to learn about the VNA of Boston, I now have begun to hear more from those who rely upon us.  And from those who entrust their patients to our care.  The true, original spark for the VNA of Boston itself was a desire to be a compassionate society.  We are motivated and inspired by our mission… which was born some 125 years ago on the waterfront of Boston and which is no less relevant or vital today.  No one contests the value of our mission and the role we play, but it’s evident that we can back that up too.  We back it up with state-of-the-art home care services, supporting technologies, and a staff and management team who work hard to make sure we live up to our storied heritage. 

I’ve been focusing over my first few months on our budget for next year, our strategic planning goals, and meeting as many of you as I possibly can.  I’m even starting to remember some of your names (but please be patient if I don’t remember all of them… there are a lot of you!).  We’re well positioned for the future.  But we’ll have some challenges too as we need to critically assess our technology platform in an evolving industry, make sure we’re ready for the changes that national health reform and local payment reform will bring, continue to focus hard on patient and customer satisfaction, and continue to concentrate on improving outcomes and managing our resources carefully.

Thank you for your part.  Whether you provide compassionate care in our patients’ homes (including on snowy days such as last weekend) or work behind the scenes making sure our systems run without a hitch, that our employees get accurate paychecks, report information out properly and on time to regulators, generate good information for managers to make decisions, smoothly process referrals and payments, or make sure our facilities are clean and efficient… you are an important part of the VNAB story, the VNAB mission.  We have a lot to be thankful for in 2009… I know I do.

Wishing you and your loved ones a very happy holiday season and a happy, healthy 2010.  Enjoy the next few days.

Rey

Senate gets it done…

… and now the hardest part of all… fashioning a bill that the House, Senate and White House can all support.

The Senate vote was 60-39 following party lines.  Now, key leaders in both houses must get together to come up with the compromise bill for the President’s signature.  There are pretty significant differences between the two final versions on issues such as how to pay for the expanded coverage, whether there will be a public option or not and, of course, abortion coverage.

As I commented on recently, public opinion is now working against final passage and the Republicans in office, more united than ever, are focused on slowing and defeating any measure of reform.  And although the President played a low key role during the heated Senate deliberations, expect him to step it up in the next phase.  He realizes that his own direct involvement could be the difference maker at this point.  "We hope to have a whole bunch of folks over here in the West Wing, and I'll be rolling up my sleeves and spending some time before the full Congress even gets back into session, because the American people need it now," the President remarked yesterday.

The original hope was to have something in the Oval Office for the President’s signature by year end; obviously that won’t happen.  But, given the wrangling and recent shift in public opinion, it’s pretty remarkable that we’re even this far along by Christmas Eve.  It appears likely that the President will hope to have this all wrapped up by the State of the Union address early next year. 

Now that it’s inevitable

Big business in America is bracing for health reform and with the notable exception of the U.S. Chamber of Commerce which is still calling for defeat of reform, most groups are lining up behind it and saying they want to work to improve it in the final negotiations of early 2010. 

Retailers are hoping for a longer delay before new employees quality for subsidized benefits.  Large employers want to revise the Medicare tax provisions that would limit earnings.  Small construction companies want an exemption from employee coverage.  Nearly all companies are concerned that new taxes and fees will drive premiums up, especially for smaller employers.  Though Democrats want to limit tweaking on the combined bill, expect the business community to continue to speak up.

The new taxes?  Insurance companies, medical devices, high income seniors, deluxe health plans and tanning salons will all be taxed.  If you are a well compensated, aging insurance executive who requires some type of medical device and enjoys tanning…

Never mind…

I'll see you in court?

If you can't win it on the floor, then perhaps it's possible to win it in court. That seems to be the latest strategy of the GOP in its unified attempt to derail the health reform package that is moving to a Christmas Eve vote. The lever? Seeing if it's possible to declare unconstitutional the mandate that everyone in the country must have health insurance. Senator John Ensign (Nevada), a leader in this new assault, has stated: "What's next? Will we consider legislation in the future requiring every American to buy a car? Will we consider legislation in the future requiring every American to buy a house?" (We get your point, Senator... but c'mon...)

Given the Democratic majority in Congress, it's unlikely the Republican charge will gain much steam. But, this could signal the beginning of a multi-pronged legal attack that could tie up the implementation of the new law for years. And given how the legislative branch swings left, then right, then left, etc.... perhaps keeping this in the courts for a while could push this to a time when a repeal of the reform law could be possible.

Apparently, they noticed

Received two wonderful t-shirts from my great colleagues here at the VNA of Boston this morning.

Clearly, they know what I've been up to...



- Posted using BlogPress from my iPhone

Business leaders worried about exchanges

The U.S. Senate is proposing the creation of government regulated "health insurance exchanges" designed to facilitate the introduction and purchase of new insurance products for the currently un/underinsured population. A group of 200 business leaders and university presidents, called the Committee for Economic Development, has warned that such exhanges are likely to fail due to the resultant lack of competition that will emerge in a restructured insurance marketplace. The group has cited a concern that adverse risk selection will occur if the exchanges tend to attract the sickest (and most costly) patients. The House bill includes language prohibiting such selection risk and the committee is recommending adoption of such language. Given how touchy things are on the Senate side and with a few key senators saying they will drop their support if there's movement back toward House language, expect the Senate's version of health exchange language to stick. Let's hope the Committee for Economic Development is wrong then.

What were you doing at 1AM this morning?

Your U.S. Senate was successfully advancing health reform toward a likely Christmas Eve showdown. The early morning vote was 60 to 40 with 58 Democrats and two independents lining up behind the President. All Republicans stood firm in opposition.

Harry Reid, majority leader, said: "We are reshaping the nation. With this vote, we're rejecting a system in which one class of people can afford to stay healthy, while another cannot." Republican leader, Mitch McConnell, described the milestone as "a historic mistake," noting that there was some significance to the "dead of night" wranglings that resulted in the historic vote. According to McConnnell, the "final product is a mess."

The Boston Globe is reporting that Senate rules require three successive votes be held 30 hours apart. This will lead to a 7PM vote on Thursday evening... Christmas Eve. Republicans can allow the final vote to occur earlier, but you won't want to bet your house on it. John McCain announced: "We'll fight until the last vote."

Remaining for the Democrats? Resolving the differences between the House and Senate versions regarding abortion restrictions, the public option, tax requirements, and the issue of coverage for illegal immigrants. All BIG issues. If the House holds firm on any of the major compromise issues, the delicate and fragile alliance among key senators could crumble.

The political implications of all this? With midterm elections coming next year, expect Republican candidates for office to decry the middle of the night deal making and politicking that accompanied this process.

An economic downturn?

You wouldn't guess it based on the crowds at The Natick Collection.

Why are so many people buying pillows at Brookstone and is there ever no line at a Dunkin' Donuts?



- Posted using BlogPress from my iPhone

What can't you do on an iPhone?

I remember reading a review of the 3rd generation iPhone by "Wall Street Journal" contributor and blogger extraordinaire, Walt Mossberg. His take on the device was that not only was it a pretty decent cell phone, but more importantly, it was an exciting new platform... a platform developers would want to write programs for and which users would increasingly desire to use not as an ancillary computing device, but as their primary computing device.

Walt was right. And the thousands upon thousands of apps being distributed by the bucketload every hour of every day from Apple's App Store prove it. My most recent case in point? You're witnessing it right here and right now. BlogPress is an application that allows you to fully manage your blog from your iPhone. The possibilities seem endless as it's now completely possible to post at any time and in any place you can use your cell phone. Note that this post is my first attempt at blogging while taking my Lhasa Apso, Shadow, for his nightly walk.

And assuming I don't walk into a tree or get hit by a car, this could be pretty cool. Now if they would just write an app that would let you control the weather, both Shadow and I would be much, much happier right about now.


- Posted using BlogPress from my iPhone

Public souring on reform?

As the Democrats and Republicans continue to spar on health reform, there's another party who wants to get into the mix: the general public.

According to a new Wall Street Journal/NBC News opinion poll, for the first time since conducting the poll, more Americans are saying they'd rather keep the system we presently have intact rather than passing the current Democratic sponsored bill. 44% of respondents prefer to take a pass on the proposed system overall while 41% want to enact the current bill. Just two months ago, the numbers were reversed with 45% wanting a comprehensive reform package and 39% hoping to stick with the current system.

Legislators who are coming up on reelection bids will watch polls such as this very closely... and that's bad news for the White House.

Could not have said it better myself...

From a NY Times letter to the editor, written by New York Home Care Association President, Joanne Cunningham.

Home health care has received much attention lately as part of the national health reform debate — and rightly so. These services are a vital component of the health system, caring for the elderly, people with disabilities and the chronically ill, and helping patients avoid higher cost service use, like acute-care emergency room visits, lengthier inpatient stays or premature nursing home admission.

Unfortunately, and ironically, even though home care is a proven cost-saver, federal health reform measures would cut disproportionately from in-home services. At approximately 4 percent of overall Medicare spending, home care is slated for cuts as high as 10 percent under the House and Senate plans.

Mr. Leonhardt claims that home care profits warrant such enormous cuts. Not so in states like New York, where a recent analysis of independently certified financial statements found that an alarming two-thirds of home care agencies are now operating in the red. For the last seven years in a row, these agencies have been losing money treating Medicare beneficiaries because Medicare has underreimbursed home care services.

In many respects, home care is a victim of its own success, self-innovation and responsiveness to health delivery trends. The level and types of services delivered in the home today are increasingly complex. Providers have also witnessed a significantly greater number of patients with intensive health needs; more home care patients today are aged 85 or older, require skilled services, suffer from chronic conditions and exhibit cognitive deficits.

These trends, while having increased our reliance on home care, have also shortened hospital lengths of stay, averted acute-care E.R. visits and allowed people to remain in their own homes — all at a significant savings to health care, and to the benefit of patient health and well-being.

Reform hanging on by a thread...

Listen to the chorus coming from both proponents and opponents. It seems that everyone senses that the health care overhaul package is skating on very, very (!) thin ice and the rhetorical jousts coming from both sides appear to be trying to do one thing - push the bill off the balance beam over to the desired side.

Former Democratic National Committee Chair Howard Dean stated, after the collapse of the age 55-64 Medicare buy-in option designed to appease Connecticut Senator Joe Lieberman: “This is essentially the collapse of health care reform in the United States Senate.” Nebraska Senator Ben Nelson is refusing to sign the bill without strong anti-abortion language and others are similarly acting as though their vote is the only one that counts. With the balance of yays and nays so tight, each vote is actually that important.

Meanwhile, Majority Leader Harry Reid is expressing confidence that the bill will pass while the President is tweeting that the Senate is "on the precipice of a historic decision."

We ought not forget though that even with the increasingly watered down version that is emerging, there are some significant changes coming (assuming the bill gets to a vote and survives). These include: Medicaid program expansion, movement toward outcomes-based (or at leased influenced) reimbursement for providers, consistent removal of the pre-existing condition clause and the inclusion of some 30+ million Americans who today do not have comprehensive health care coverage.

So... depending upon whether you are a glass-is-half-full or glass-is-half-empty kind of person (i.e., liberal leaning or conservative leaning), you may be getting ready to declare victory for having passed the most comprehensive health reform package in history... or having defeated the most ambitious health reform package in history by successfully diluting down all of its ill effects.

I guess it all depends on how you look at it.

The end of the personal touch?

As recently as just a few years ago, by this time of the season, the credenza behind my desk would already be stacked full of Christmas and holiday cards, full of good wishes for the coming year, expressions of appreciation for having done business together, or just simple messages of warmth and good cheer. My VNA of Boston colleague, Jeff Smith, recently commented on how different this all seems now compared to years past when such cards were commonplace. For a time, it appeared as though paper and pen were being replaced by digital versions - emailed messages with links to clever, typically animated versions of holiday cards. Though I've received a few of these this year, it does not appear that these "eCards" are poised to become the new Hallmark.

Living in an email, Facebook, instant messaging, texting, Twittering world where communication is fast and instant, taking the time to select, order, pay for, prepare and mail handwritten correspondence seems archaic, prehistoric. Maybe even ridiculous.

But perhaps it is because of the lightening pace of communication today and the fact that credenzas everywhere lie bare, that taking the time to send old fashioned holiday cards does make the most sense, now more than ever. Perhaps today a holiday card expresses a deeper sentiment. While a "thanks for your business" note on a card a few years ago might have seemed perfunctory, superficial... maybe now it suggests that the sender really does appreciate the business and that his or her willingness to take that time to do what seems antiquated and even unnecessary is propelled simply by a timeless sense of true appreciation. And maybe that lone card sitting in someone's office stands as testimony and tribute to the personal touch that seems increasingly rare.

I think I'm on to something here. I'm going to Tweet this out to all of my followers right away...

Health Reform Lite

It will take 60 votes in the Senate to move a major reform package through and with votes so tight, every senator has the equivalent of a veto power. Witness Connecticut's independent senator, Joe Lieberman. Though he had suggested previously that he would support the public option and then the watered down version whereby Medicare eligibility would drop to age 55, his comments over the past few days that he'd have a "hard time voting" for the provision has ultimately led to its being dropped from the bill.

And so, the major, groundbreaking health reform initiative seems to be shrinking each day.

Even so, Senate Democrats are putting their best faces forward. "There's enough good in this bill, that even without those two (things), we've got to move it," said Tom Harkin of Iowa, Chairman of the Senate Health, Education, Labor and Pensions Committee. With Christmas and the self imposed deadline of the year-end approaching, the question remains: will there be much left before the final vote?

All quiet on the health reform front?

Mostly, but not completely. Some conservative commentators have been postulating that the current health reform movement is fundamentally unconstitutional because it will infringe on state's rights. Over the past several days, an organization called the American Legislative Exchange Council (ALEC), comprised of rightward leaning state legislators, has been busy working on a variety of bills to be introduced in various states. These proposals are designed to reassert state authority over the health insurance industry... thus short-circuiting the Federal health reform push.

According to ALEC's website (link here), their goal is to provide: "State Legislators with the Tools They Need to Fight ObamaCare". One cornerstone of the movement is to oppose the creation of health insurance exchanges for individuals and small business. They've been actively opposing the public option, but that has now been taken off the table. On the first point, according to ALEC: "a federal exchange would undermine states’ oversight role in health insurance and cause a substantial shift in the regulation of the health insurance market from the states to the federal government."

The internet is buzzing with reports that the force behind ALEC is the self-interested private health insurance industry. The Blue Cross Blue Shield Association has been specifically and repeatedly called out. Their response has been to admit the ALEC association, but also to point out that they maintain numerous relationships with a number of groups to advocate for their interests. It's no surprise that the insurance industry has long been warning against the ill effects of health reform, namely that private insurance costs will skyrocket.

So, front pages are suddenly absent reports about health reform. But that does not mean that those who oppose it have given up the fight.

A great night!

At our holiday party last night at the Boston Radisson, we celebrated and honored our 10, 15, 20 and 25 year employees. The Boston VNA is full of great individuals who have dedicated a significant portion of their lives to our mission and cause. Here are Mary Helen, Michelle and Sue... all celebrating their 25th (!) anniversary. Congratulations to them and to all of our honorees last evening.

Going back to iPhone

In one of my first posts (click here), I commented on my frustrations with my new Microsoft Windows Mobile "smartphone". I even went out on a limb and likened my anxiety with the emotional roller coaster patients sometimes experience in our complex and frequently disconnected health care system. I described the iPhone as the perfect example of when everything comes together just so. The various parts (applications, operating system, hardware) work together. Simply. Reliably. Even beautifully.

Well, it's weeks later and the frustrations remain. Actually, it's worse as the phone increasingly has a habit of freezing right when a call comes in. I'm sure I don't need to tell you that that can be... disrupting. But, thanks to the some good work by our IT Department, relief is on the horizon. Blackberries are coming, and soon. Next week. I jokingly tell our CIO that my present phone has a date with the hard surface below the Lenny Zakim (if you're from Boston, you understand).

So, even with this... I must tell you that I've returned to the iPhone. I'll be one of those guys you see carrying two cellphones. On my Bat Belt, I'm sure. Why? I miss the functionality of the apps I once used. I miss the ability to quickly look information up on-line and to communicate easily with people I work with and family members. I miss being able to see when movies are playing at the local theater, getting walking directions to a downtown restaurant and being able to to jot down notes that will mysteriously, automatically and reliably synchronize over the air (Evernote) with the software I run in the office. The Blackberry is great, but it too is no iPhone. This is a costly move for me, I know. Maybe too costly and one I'll regret. But I don't think so. The iPhone, obviously, has got me and good.

If you're interested in this topic, you might find this article (click here) to be interest. The author details how Microsoft has really missed the boat when it comes to handheld technology and how the future will come down to an Apple vs. Google battle.

Worthwhile

According to the Family Violence Prevention Fund:

• On average, more than three women a day are murdered by their husbands or boyfriends in the United States. In 2005, 1,181 women were murdered by an intimate partner.
• In 2008, the CDC published data showing that women experience two million injuries from intimate partner violence each year.
• Nearly one in four women in the U.S. reports experiencing violence by a current or former spouse or boyfriend at some point in her life.
• There were over 248,000 rapes/sexual assaults in the U.S. in 2007, more than 500 per day, up from nearly 191,000 in 2005.
• The U.S. Justice Department's Bureau of Justice Statistics estimates that 3.4m persons were victims of stalking during a 12-month period in 2005 and 2006.

I'd like to introduce you to an organization that has worked hard to educate the general public, policy makers and government officials on the impact and prevalence of intimate partner violence. It's the Family Violence Prevention Fund. Their website is here.

This is a great time of year to remember this organization and to consider making a donation. Perhaps you can make a gift in someone's name. More information here.

The time is now. Right now!

From an email I just sent to our staff and board members:

On Tuesday, Sens. John Kerry (D-MA), Debbie Stabenow (D-MI), Susan Collins (R-ME), Olympia Snowe (R-ME), Blanche Lincoln (D-AR), Ron Wyden (D-OR), Arlen Specter (D-PA), Tim Johnson (D-SD), and Kirsten Gillibrand (D-NY) filed a bipartisan amendment to reduce the home health cuts in the Senate health care reform bill by nearly $5 billion. This comes on the heels of another amendment by Sen. Kerry — which passed the Senate by a vote of 96 to 0 — to prohibit any reductions in Medicare home health benefits.

National Association for Home Care & Hospice (NAHC) members are encouraged to contact their Senators to urge them to cosponsor the Kerry-Stabenow-Collins-Snowe-Lincoln-Wyden-Specter-Johnson-Gillibrand-Nelson amendment to reduce the home health cuts in the Senate's health care reform bill. Note that additional cosponsors can be added after the amendment is filed; Sen. Ben Nelson (D-NE) has just agreed to add his name as a cosponsor.

We’re fortunate to have Sen. Kerry’s support and leadership in this effort. Soon enough, we’ll have a new Junior Senator in Massachusetts… but in the mean time, interim Senator Paul Kirk will likely have an opportunity to weigh in as well.

Please call or email each of our senators, noting the following:

> Tell them that you work for the Visiting Nurse Association of Boston

> Thank them (particularly, Sen. Kerry) for their longstanding support and leadership in protecting home health benefits

> Urge him to continue the fight on behalf of the many thousands of patients we serve in and around the Boston area

Their contact information:

Kerry, John F. - (D - MA)
Class II
218 RUSSELL SENATE OFFICE BUILDING WASHINGTON DC 20510
(202) 224-2742
Web Form: kerry.senate.gov/contact/email.cfm

Kirk, Paul G., Jr. - (D - MA)
Class I
317 RUSSELL SENATE OFFICE BUILDING WASHINGTON DC 20510
(202) 224-4543
Web Form: kirk.senate.gov/contact/

It will take maybe 3 minutes … but the time to act is right now. You can make a difference!

Thanks very much,

Rey

Public option no more

The "Boston Globe" is reporting that the public option has not survived the latest flurry of Senate negotiations. Fearing that the loss of moderate Democrat votes could topple reform efforts, party leadership has given in on one of the last remaining contentious issues in the debate: the public option. Majority leader Reid suggested that passage is near.

Instead of a true public option, the Democrats have agreed to form a new Federal agency that would oversee private insurers. Additionally, the arrangement calls for Medicare to become available to unsureds over age 54; this marks a critical expansion of the program currently available to those over age 64.

Saving home care?

From a press release by Senator Mitch McConnell (R):

"In voting to cut a half trillion dollars from the Medicare program for seniors, our Democrat friends undercut not only the roughly 40 million seniors who depend on Medicare. They also undercut their own promises about reform." U.S. Senate Republican Leader Mitch McConnell made the following remarks on the Senate floor Saturday regarding the importance of getting it right on health care reform: “The U.S. health care system is in serious need of reform. Costs are too high, they’re rising, and if we do nothing they’ll continue to consume a larger and larger share of federal dollars and of the budgets of millions of middle class American families, of young workers trying to get their start in life, and of seniors.

“For months, the Administration and its allies in Congress promised a solution to these problems, a solution they said would lower costs and help the economy. They assured us that under their proposal anyone who likes the health care plans they have would be able to keep them. And they said their proposal would save Medicare.

“But, in the end, what matters isn’t what we say. It’s what we do. And this week, the proponents of this plan did more with a single vote than they did all year in talking about all the things that their health care plan would do. How? Because in voting to cut a half trillion dollars from the Medicare program for seniors, our Democrat friends undercut not only the roughly 40 million seniors who depend on Medicare. They also undercut their own promises about reform.

“As I said, the President and Congressional Democrats have noted again and again that under their measure those who like the plans they have will be able to keep them. After Thursday’s vote, even Democrats are admitting that’s no longer true. Here’s how one of our Democrat colleagues put it: “We’re not going to be able to say that ‘If you like what you have, you can keep it.” And then he added, “… and that basic commitment that a lot of us around here have made will be called into question.”

“As for the oft-repeated pledge to save Medicare, well, nobody buys that one after Democrats voted Thursday to cut it by half a trillion dollars. These Medicare cuts will impact the quality of care for millions of American seniors. Nearly 11 million seniors on Medicare Advantage will see a reduction in benefits. Hospice care will see massive cuts. Hospitals that treat Medicare patients will see massive cuts. Nursing homes are cut. And more than $40 billion is cut from home health agencies — agencies that provide an appealing alternative to seniors who would rather receive the care and attention they need in the comfort and privacy of their own homes.

First Snow... from Bird Park in Walpole

Boston After Hours

A filibuster? Almost.

Republican senators aren't filibustering, formally, just yet. But you can feel it in the air. Budget Committee member Judd Gregg (NH), in a published letter to his GOP colleagues, has instructed that the party must, "use the tools we have under Senate rules to insist on a full, complete and fully informed debate on the health care legislation...." Gregg notes that the Republican senators much be prepared to claim "certain rights before measures are considered on the floor as well as certain rights during the actual consideration of measures." One wonders what exactly "certain rights" means.

The Democratic response? Senate Majority Leader Harry Reid noted that rather than offering their own comprehensive plan, "the first and only plan Senate Republicans bothered to draft is an instruction manual on how to bring the Senate to a screeching halt."

As the Senate considers amendments, the critical question is whether the process can serve to strengthen the bill... or merely delay it.

The President's Two Wars

Republicans have been unable to slow the health reform momentum largely created by the President's insistence that a package be prepared before the end of the year (and the beginning of the next year, an election one). The recent Get-In-Big, Get-Out-Fast announcement regarding the war in Afghanistan may have given reform opponents just the opportunity they were looking for. Already, Senate Republican leader Mitch McConnell has stated that there's too much on the agenda to wrap up a unified health reform proposal this year. Citing the 30,000 troop build-up (no one is using the word "surge" for obvious political reasons), Senate Republicans are noting that there's no need to rush the reform package. Behind that logic comes a hope that slowing the bus could ultimately halt the bus... thus leaving the President with two important wars on his hands.

"You're going to die sooner..."

So says Senator Tom Coburn, a former obstetrician. Yesterday's Senate debate was heated as proponents and opponents of the health reform proposal clashed over the likely impact of the proposed changes. Describing comments such as Coburn's as merely "scare tactics", Senator Max Baucus argued that the cuts would strengthen the Medicare program's ability to secure lower fees for services provided to seniors.

Senator John McCain, an active tweeter on the subject, has proposed an amendment that would eliminate $400b in Medicare cuts to hospitals, hospices and home care providers. U.S. Seniors are clearly concerned that expanding coverage to the presently uninsured will result in reduced coverage for them. Any and all suggestions of "rationing" are being rebuffed by those who cite the bill's long-term positive impact on cutting costs.

Another amendment has been introduced that would cover expanded preventive services for women, clearly designed to quell fears prompted by the recent recommendation that mammograms could begin for most at age 50.

The good news here seems obvious, but the bad news? The bill's already shaky financial footing is beginning to feel even more shaky.

New York to Boston?

A couple more from the NYC B&W series. Thanks for the comments/emails on these pictures. A few have asked why I've not posted any photos of Boston, aka "the most photogenic city on the planet." Fair enough. Stay tuned.

Health reform budget neutral?

The Congressional Budget Office has said that the net effect of health reform, based on their analysis, will be budget neutral. Many, upon hearing this, are raising their eyebrows and saying "seriously?"

Paul Levy wrote about this yesterday (click here), speculating that the implementation delay is intentional by the Obama administration... pushing the politically charged work out past the next Presidential election cycle. Here are a few other items worth considering:

• The proposed independent Medicare Advisory Board will recommend changes in Medicare reimbursement with limited Congressional oversight. Recommendations impacting hospitals or physicians are off the table through 2019. Expect other providers to be hit hard.
• Between 1 and 2% of hospital Medicare payments will be subject to quality and efficiency targets. Will the savings generated here be enough to offset the higher costs of the overall program? Payments to physicians could be altered based on utilization patterns, but the potential for that will be impacted by the usual process and it will take more political will than government leaders have been able to muster thus far.
• Accountable Care Organizations (ACOs) are introduced, but the currently fragmented system makes implementation difficult. If ACOs become hospital dominated systems, one has to wonder whether hospital systems will be able to effectively take the lead in driving costs down.

There's plenty to like about the proposed health reform legislation... and plenty to be worried about as well.

One more from The City

And now for the amendments

Senate majority leader Harry Reid has his hands full. Again. He's busy today asking lawmakers to keep amendments to a minimum, knowing that a lot of amendments to the health reform bill will do two things: (1) delay action and (2) give the Congressional Budget Office more numbers to crunch. Knowing that time is of the essence, he's asking his colleagues to restrain themselves. Right.

On George Stephanopoulos' Sunday show, Senator Bernie Sanders (VT) said: "I've got about ten separate amendments." Senator Sanders is not alone as the amendments begin to line up. The home health industry is hoping Senator John Kerry comes through with one that will minimize the negative impact on reimbursement for services. And interested parties everywhere are calling and writing their favorite senators asking for help. Reid, the President and other leaders will be busy over the next few days asking Senators to exercise caution for fear that the process may slow or even halt.

The future of print media?

A few weeks ago, I posted about a conference regarding finding opportunity in turbulent times. That post is here. Bennie DiNardo, deputy managing editor for The Boston Globe, spoke about how the Globe struggled at first to understand how moving to the web could be a sustainable strategy for the newspaper. When they started, they had no idea how they would "monetize" the strategy... but that didn't stop them from jumping in head first.

Much has been written and said about the demise of print media as the Internet with its instant access, real time delivery of information and flexibility in medium (computer, cellphone) takes over. Well, for the past few weeks, I've been experimenting with the Globe's new "GlobeReader" service. More info here. This is a paid service whereby every morning a fresh copy of that day's paper is downloaded to your PC (or Mac). Unlike www.boston.com, you have full access to the paper (including crossword puzzles), can increase or decrease font size, email links or full copies of articles, retain seven full days of content, easily navigate full articles, and "subscribe" on multiple home computers. You need Internet access for only the few minutes it takes to download that day's news.

Ultimately, we'll see if this service flies and whether the Internet generation, accustomed to reading news for free via web browsers, will find this a valuable way to get information. My own conclusion, after just a few weeks, is that this makes sense. Saving (i.e., clipping) articles is a snap, I can read the news wherever I can access a laptop (which is nearly most places these days) and I don't mind that this is environmentally friendly as well.

I'll let you know how it goes after another few weeks.

Thanksgiving in NYC

Three million people watching the Macy's Thanksgiving Day Parade and I'm pretty sure at least half of them stepped on my toe. Huge crowds, but completely worth it. See the entire b&w shoot here.

Accessing child mental health services in Massachusetts... from bad to worse...

At tonight's South Shore Mental Health Board meeting, CEO Harry Shulman cited a recent Blue Cross Blue Shield Foundation study regarding Massachusetts' mental health workforce (sorry, I don't have the specific reference). Though we have a significantly higher rate of psychiatrists and social workers per 100,000 population than most other states, a survey of nearly 2,000 children's mental health providers found that advocates, pediatricians and families report difficulty in accessing care. Of note:

• 216,000 children in Massachusetts have a diagnosable mental health disorder, 70,000 of which are deemed "severe"
• 32% of providers are not accepting new patients and another 39% have only 1-2 open slots available for new patients

And here's the one that caught my attention:

• 54% of providers of children's mental health services between the ages of 35 and 54 plan to leave direct care or Massachusetts within 5 years

Perhaps too much can be read into such statistics, but they do point out that the current problem of difficulty in accessing child mental health services is likely to get worse. Patients with untreated mental health concerns experience a greater number of health problems, a shorter life span, and suffer from a deterioration in quality of life.

What's the solution?

Calling Senator Kerry

Last week, I wrote about the possible implications of health reform on home care. I noted the great support of Massachusetts Senator John Kerry. See the post here. As I summarized in the previous post from today, leadership has introduced a bill for consideration by the full Senate and the pressure to restrict revisions will be intense. Nevertheless, we need Senator Kerry to advocate for this industry. All it takes is a simple phone call. His office can be reached at 202-224-2742. Massachusetts callers are especially encouraged to call (they will ask for your zip code); it only takes 10 seconds. Please thank the Senator for his support of home care and ask for his help in preserving payments for these critical services.

The Senate's Turn...

Harry Reid had a simple threefold task: (1) get a Senate bill out ASAP, (2) keep total costs below $900b and (3) make sure at least 60 senators would go for it. Here's his attempt:

• Major provisions of reform (e.g., creation of health care exchanges, expansion of Medicaid to 133% of Federal poverty level) delayed from 2013 to 2014
• States can opt out of the government run public health plans (via individual state legislation)
• Beginning in 2014, most Americans will be required to purchase health insurance or face fines of $95 that year, growing to $750 by 2016; note that many worry that the fines are not stiff enough to motive enough to purchase insurance
• Employers are not mandated to provide insurance, but firms of greater than 50 employees who don't will pay a penalty if workers receive government subsidies to purchase coverage through one of the new exchanges
• New taxes? 5% on elective cosmetic surgery, an increase in Medicare payroll tax on individuals earning over $200,000 a year and couples over $250,000.
• High cost insurance plans (with yearly premiums of $8,500 for individuals or $23,000 for families) will be subject to a 40% excise tax - - a provision designed to reduce health care costs
• CHIP program not eliminated as some had speculated
• Rescissions (i.e., when insurers cancel policies once holders become sick) no longer possible
• Medicare will remove all copays and cost sharing on preventive services

The Senate could begin debate on this as soon as tomorrow.

Compassion comes, but sooner

When you think of hospice care, what comes to mind? If your answer involves the final days of life, waiting for the end in a somber deathbed scene, and enduring the painful conclusion to life... then you do not understand.

I had an opportunity today to join Andy, an RN in our hospice affiliate, on a home visit. I'll admit that when I heard I was about to meet a 90 year old CHF patient who, by definition, was likely to be within her final six months of life, I formed an impression, a vision, of what I would see when I got there. Upon entering the home, we were greeted by two energetic and friendly twentysomething grandsons. They were happy to see us, and they clearly did not mark the entrance to anything resembling a deathbed scene. Proceeding through a narrow hallway, we entered a well worn kitchen and then living room where the patient and two friends were visiting. Claire (I'll call her) bounded up out of the chair and greeted Andy. She approached me and said: "Are you married?" I told her I was and she shrugged her shoulders. "That's too bad for me," was her reply. Claire then excused herself for a moment while she adjusted the television set for her guests and told them she'd be right back after her visit with the nurse. The perfect host.

I watched Andy dress a wound and tend to other tasks. All the while, Claire told me about her children and grandchildren. There was a lot of joy in the history lesson, but also suffering and disappointment, including the unexpected recent death of one of her sons. Claire was sharp and thoughtful and had I not known, I would have guessed that she is 70, not 90. Andy recited instructions and left behind various supplies and papers, plucked on his laptop for a few minutes and then we left. Given the progression of the disease and the likely course of the next several months, it struck me that Claire and her family will benefit tremendously from a well established relationship with Andy, based on familiarity and trust and respect. The kind of relationship that forms, over time.

Later in the afternoon, I had a chance to meet the talented staff of the VNA Hospice Care (website here). While there, one of the nurses mentioned that a referral had recently come from a major teaching hospital for a patient who was clearly within the final few days of life. The nurse rolled her eyes, suggesting what was clear to me based on my earlier visit with Andy and Claire. Hospice care is not for the final few days of life. By then, the ability to accompany, to teach, to care and bond and to exhibit the deepest kind of compassion is all but lost.

Do you know where this was taken?

Deep Divide

The Washington Post reported on the significant gulf that exists between those who support the overhaul of the health system and those who oppose it. According to the piece: "Over the past few months, public opinion has solidified, leaving Obama and the Democrats with the political challenge of enacting one of the most ambitious pieces of domestic legislation in decades in the face of a nation split over the wisdom of doing so. In the new poll, 48 percent say they support the proposed changes; 49 percent are opposed." See the entire article here.

Tracking numbers such as these will become even more important as we head into next year's election cycle. The Senate is working feverishly to come up with a plan that will support the President's top domestic priority... but which won't prove too costly politically. And time is of the essence.

Mammograms and the Swift Boat?

I think most of us were surprised to learn of the U.S. Preventive Task Force's recommendations that routine breast cancer screenings be postponed until age 50, barring identifiable risks. Conventional wisdom has long held that such screenings begin at age 40. I've been struck by the heated response from within the medical profession, most especially by MGH's Dr. Daniel Kopans, a noted radiologist and cancer expert. According to The Boston Globe (11-17-09), Dr. Kopans said that these new guidelines: "will condemn women ages 40-49 to unnecessary deaths from breast cancer." Strong words.

I heard Dr. Kopans speak on WTKK this morning and learned that most (70%+) of newly discovered cancers come in patients with no prior "identifiable risks". So, those women without such risks, i.e., family history, are not recommended for screenings until age 50, which could be too late. On NPR, Rachel Zimmerman of WBUR's Commonhealth blog) spoke of personal experience and a decision that points out that although guidelines such as the ones promulgated by the Preventive Task Force are necessary and appropriate, when the decision is personal, it's easy to justify ignoring them. See Rachel's piece by clicking here.

I was fascinated by some of the comments on the radio after Dr. Kopans departed. One caller stated that the new guidelines will be utilized by managed care and other payers as justification for not covering mammograms before age 50. Another noted that this is what we can expect from a "government takeover" of health care, a la the public option. An interesting and unsettling discussion ensued regarding the Federal Government's possible heavy handed role in the new health care system.

This may have been an isolated and narrow view expressed by only a few during a drive time radio program. Or... the proposed new mammogram guidelines could inadvertently become a banner for health reform opponents to wave in the coming weeks. Swift boat anyone?

Why are we doing health care reform again?

NPR had an interesting piece regarding the shifting focus of the debate. When the President launched the effort many months ago (during the campaign, actually) the impetus related to expanding coverage for the un- and under-insured and to make health care more affordable for everyone. According to NPR: "The health bill passed by the House - and a similar measure pending in the Senate - boost the number of people covered by health insurance. But critics from across the political spectrum say the legislation does little to rein in runaway health care costs." See the entire article here.

The more recent focus has been on the payer side of health care, hence the fact that many if not most discussions now describe this as health insurance reform. Big difference. The question is: why the change?

Cynics may answer that the powerful provider lobbies (AMA and AHA) and big businesses (i.e., the pharmas and equipment manufacturers) have found a way to successful apply pressure on legislators. Maybe that's true, but I wonder if the lawmakers have rediscovered the longstanding challenges associated with reigning in health care costs. The challenges pertain to the fact that while there are some excesses and inefficiencies in this sector (show me one where there are not), cost cutting efforts quickly get into the sticky issues of negatively impacting quality, limiting choice, and restricting care to some (aka rationing - and no public figure wants that association).

Early rhetoric, including the President's, centered around driving improved quality as a way to appropriately shift incentives and lower overall costs. Evidence strongly supports this general idea, but the current House reform bill and the pending Senate one don't seem to support these concepts as much as the early arguments indicated they might.

Reform Bill Contains Key DV Provisions

On average, four women are killed in the US every day by a current or former partner. Every day. In 2008, the CDC reported that women experience two million injuries from intimate partner violence each year. According to data published by the Family Violence Prevention Fund, this violence can have lingering health consequences: one study reported that women who experience DV are 80% more likely to have a stroke, 70% more likely to have heart disease, 60% more likely to have asthma and 70% more likely to drink heavily than women who have not. And in 2003, a study reported that 37% of women who experience DV talk to their health care provider about it.

Here's some good news: The House version of the Health Reform bill contains a provision that all insurers must reimburse health care providers who assess patients for DV and provide initial counseling and referrals. The bill also contains an important measure to prevent insurers from treating DV as a pre-existing condition and, thus, discriminate against victims.

Hopefully, these provisions will survive the ensuring debate and make it into the joint bill.

Massachusetts Home Care Cuts?

Yes and no. Last week, MassHealth moved to eliminate a $300m budget gap with cuts to adult dental benefits and limitations to the personal care attendant program. See a "Boston Globe" article about it here. The headline to that story noted that the cuts impact home care... which certainly grabbed my attention. But, there's more to this story. The personal care attendant benefit will no longer be available for patients who require such attendants for less than 15 hours per week. Additionally, a benefit that covered pre-screening for mostly hospitalized patients designed to educate them about nursing home and home care options was completely eliminated. While these cuts are unfortunate for those who have benefiting historically, it's good news that the announcements haven't detailed any new cuts to home health services for MassHealth beneficiaries. As with many announcments about budget cuts, however, there were some ominous remarks about additional cuts perhaps being necessary. So, we'll wait and see... but it's good news for now.

Different look, same exact mission...

Health reform and home health care

Just listened in on a conference call sponsored by the Visiting Nurse Associations of America (website here) regarding health reform and the likely impact on home health care. Heather Mizeur outlined the current status and here are the highlights:

• Some are speculating that the "real" deadline is mid-January, coinciding with the President's state of the union address; others, however, point to the intense pressure coming from the White House to get this done this year. Congressional leaders are stating a willingness to work seven days per week through the holidays in order to make this happen.
• Sticky items to watch are: the ability to opt out of the public option, the open funding questions, abortion and immigration issues
• Keep an eye on Maine's Olympia Snowe (she's not a fan of the public option); everyone is counting votes to see whether Democrats have the 60 votes necessary to break a filibuster
• Massachusetts Senator John Kerry is leading the charge to reduce the cuts to home health; he is working to gain bipartisan support
• The key issue relates to the offset provisions. Rules stipulate that to reduce cuts in one area, the proponent needs to come up with a plan to proportionately increase revenues or increase cuts elsewhere. This is going to be a tough proposition for Kerry.
• Look for a Senate version to emerge soon. Then the toughest work will begin - - melding the two bills together into something everyone will like.
• The likely Senate bill will contain fewer cuts to home health than the current House bill.

The VNAA is working to keep its members informed. And it looks as though perhaps not everyone will be enjoying the holidays this year.

"Never let a serious crisis go to waste"...

... so said White House Chief of Staff, Rahm Emanuel, recently. We were reminded of this at a breakfast panel discussion hosted by the firms of Solomon McCown and Goulston & Storrs this morning, entitled "Rising in a Down Economy". One after another, each panelest recounted experiences and advice gleaned from a variety of settings, including managing special projects for a large real estate development company, running a not-for-profit health related foundation, overseeing multimedia for a major media and publishing enterprise and working in the communications and public relations field. Diverse experiences and perspectives, but one common theme: times of crisis, panic, and challenge can be fertile territory for revitalization, renewal and creativity. My two favorite moments came when Bennie DiNardo, deputy managing editor for The Boston Globe (and point man for the successful offshoot, Boston.com), stated that ten years ago, the paper knew it had to move onto the internet. And so, it began to port content over from the paid subscription model to the free internet site. They had no idea how they could make any money doing that, but they knew they had to. So they jumped... and it seems that things have worked out for them. Ashley McCown, president of one of the breakfast's co-hosting firms, described the Chinese symbol for crisis. It is comprised of two brushstrokes, one representing danger, the other, opportunity.

Many of the posts here on this blog pertain to the current health reform debate. It strikes me that, ultimately, the likely impact on home health care will be painted with both of these broad brushstrokes.

The ergonomics of home care

Today, I had an opportunity to observe a few more home visits, this time in two inner city neighborhoods of Boston. Shawn, a physical therapist, and Nancy, a nurse, were my guides.

I remember a recent tour of a brand new state-of-the-art ambulatory care center. I was directed to the set-ups in the patient care rooms and asked to consider the ergonomics of each workstation. A consultant had been hired to design the area where the clinicians sit and interact with the patients... and the computer monitors and keyboards that serve as gateways into an also state-of-the-art electronic health record system. Painstaking attention was paid to the placement of the large robot-like arms that allowed for optimal positioning of the technologies so that inputs and outputs could proceed unhindered. The chairs looked like they would have been at home in the finest Wall Street boardrooms and the tan oak desk was smart and attractive. It was an ideal environment.

Shawn and Nancy don't work in places like that. Shawn helped a woman recovering from knee replacement surgery navigate through a cramped bathroom and up and down a narrow flight of stairs as she stretched and pushed herself toward recovery. Nancy led me up three winding flights of stairs into a pleasant home where a newborn and his newmom were contending with the normal stress of the occasion and the not so normal stress of serious medical problems. Both clinicians bent over undersized laptops and entered critical medical information; Shawn hunched over his computer as he sat at the end of his patient's bed while Nancy leaned over and tapped onto the screen leaning against a pillow, inches from the baby's head.

Shawn told me that he had worked in a hospital for many years as a PT and that he would accompany his patients over to a designated spot where they could walk up and down a few steps. But now, he sees the actual steps where his patients live and the help he provides is real and impactful and immediate. Nancy explained, holding the actual containers that the mother uses to prepare the critical formula for her child, the precise proportions of water and powder. This is no classroom, no state-of-the art laboratory.

It is real. It is the ergonomics of life. And that makes a huge difference.

When politics enter the exam room

In a Huffington Post piece first published a few months ago, but now being referred to in other places on-line, the concept of clinicians' views on health reform clashing with patients' views was discussed. The original article can be found by clicking here. Quoting directly from that content: Kelley McCahill took her 70-year-old mother to see a plastic surgeon about having a cancerous growth removed from her nose last Thursday. "If not the first sentence, the second sentence out of his mouth was, 'We can still get this done because Obamacare's not in place,'" McCahill told the Huffington Post. She said that the doctor, in a casual and jovial manner, repeatedly bashed President Obama's health care reform agenda during the 15-minute consultation.

This raises some interesting questions regarding the individual clinician's right and responsibility to address patient questions and concerns about the future of health care coverage. Though many of the concepts being bandied about on the nightly newscast may be complex or nebulous for some, the general public is increasingly coming to understand that the system, love it or hate it, could begin to change drastically, and soon.

One could conclude that there's no place for politics in the exam room (or at a hospital bedside or in a patient's home) and so that the health reform topic is best left alone. Alternatively, one might decide that the conversation should focus merely on facts. Or, some may feel that it's entirely appropriate to bring personal opinions (and concerns, fears, etc.) into a dialogue with patients.

What do you think? Feel free to comment on this post.

Helpful summary of reform bills

The "New York Times" published today a helpful, high level summary of the competing health reform proposals which Harry Reid and his colleagues are trying to meld into one bill for consideration by the Senate. Click here.

Looking through an Ansel Adams calendar today...

... reminded me of this place.

Could a procedural requirement derail reform?

"For years, we've been told that this couldn't be done," said a jubilant President Obama in the Rose Garden less than a day after the House narrowly voted yes on comprehensive health reform. And so, now all eyes turn to the Senate where Harry Reid will have his hands full. There are plenty of substantive issues that could grind this to a halt in the Senate, but could it all come down to a procedural one? Unlike the House, Reid can't bring a bill to a vote until the Congressinal Budget Office provides its comprehensive analysis of the financial impact of the legislation. If that doesn't happen soon, then the Senate may not have an opportunity to fully consider the matter until after Thanksgiving... typically the worst time to get anything done in Washington. Once the holiday break hits, then health reform becomes a 2010 (election year) issue, something the White House (and nervious legislators) have hoped to avoid. Harry Reid has stated that he won't be bound by any timelines and the President continues to state that this will happen "by the end of the year." Pay attention to the timing on the CBO report.

30 years later...

Some three decades ago, I wandered around this campus myself. Now, my second child is looking at applying to Holy Cross and the deju vu is considerable. At the luncheon, I saw a classmate I've not encountered since graduation day and the reminiscing made me feel... ah... seasoned. A few photos from the campus...

The Senate's Turn

According to Nancy Pelosi, "President Obama's leadership gives our nation hope. Today, with this legislation, we will give them health." It was a narrow victory for health reform advocates, but the House did their thing, and now it's up to the Senate. Just days ago, Harry Reid signaled that there would be no rush to get this done. There's no question that he and his colleagues will now face probably historic levels of pressure from the top of the government pyramid to make this a reality. And soon. This should be interesting.

White House working hard to regain momentum

After some signals coming from the House and Senate that health reform might not happen this year, it appears that the President is working overtime to regain the momentum he senses he may have lost. Time is of the essence and I expect the White House understands that pushing this into the election year could spell trouble. The President is tweeting updates and encouraging action from supporters. If you're a tweeter, click here to "tweet your rep".

I couldn't do this job... could you?

John Krasinski Turns Hideous

John Krasinski plays the affable, everyman Jim Halpert on the enormously successful show, "The Office". Halpert is funny, clever and engaging. John Krasinski is also the director of the David Foster Wallace adaptation of "Brief Interviews with Hideous Men", which opened at the Kendall Theatre in Cambridge last night. Krasinski popped in to say hello between evening shows and to discuss what it was like directing the film we were about to see. First, if you are an Office fan, you'll understand what I mean when I say that Krasinski is Halpert and vice versa. Krasinski energetically jogged onto the stage to the fond cheers of the sold out venue (we were told five times that it was a sell out, but why were there about 30 empty seats?) and immediately began to joke around. He led the audience on a Happy Birthday singalong for one of the audience members and thanked the crowd for the non-stop flashing pocket cameras that blinded him during his fifteen minute appearance. Krasinski too is funny, clever and engaging.

And then the movie. Scattershot scenes of brief interviews with various men set against a white cinderblock wall and in front of a large pitcher of water and a small silver tape recorder were spliced in with glimpses of the Julianne Nicholson character at gatherings and in and around a New Englandesque university. We learn that she is the interviewer, the main character, and Krasinski's (yes, he's in the film too) former lover. We hear a series of shallow, often self-absorbed men offer their own explanations in which Nicholson attempts to find meaning for her own lost love. There are moments that are truly funny, as when one of the men admits that he shouts, at the top of his lungs, "victory for the forces of democratic freedom!” right at... the most inopportune time. There is one long, but moving, sequence in which one character lovingly describes the humiliation of his father, a bathroom attendant to wealthy men of a bygone generation.

"Hideous" is a film adrift, looking to connect the pieces together into that one aha moment, which proves as elusive as Nicholson's attempt to understand why her boyfriend drifted away from her in the first place. Ultimately, it is a film that leaves you pessimistic and unsettled.

And it left me wishing the Office Krasinski had stuck around a little longer.

The Talent

In Hollywood, there's a saying that that town is full of the "suits" and the "talent". Today, I spent some time with the talent.

I worked out of our Southwest office in Braintree; this included a few business meetings, a lunch with the regional managers, and a nice informal get together with staff. The morning consisted of home visits and I was the guest of Ann Marie McGuire and Colin Highland. Ann Marie is a nurse and Colin is a physical therapist. We saw three patients

The first, a near 90 year old woman who lives with her sister, is experiencing CHF. She was gracious, vibrant and charming. Her sense of humor and spirit captivated me as I watched Ann Marie expertly enter information onto a laptop's touch screen, check vitals, and converse with her. The second patient, another near 90 year old resident of an assisted living facility, suffers from multiple physical conditions, requiring the expertise of both Ann Marie and Colin. I watched them interact with the patient and each other and was impressed with the hand-off of information between them. Colin and I stopped by the facility's nursing office and I heard from the staff nurse there that she appreciated the professionalism and exceptional communication she consistently receives from VNAB staff. She listened intently as Colin described what had happened with the patient and his recommendations regarding how he can continue to maintain his independence. The nurse told me that VNAB is distinguished from the other home health agencies by the comprehensiveness of its services and the quality of its clinical staff. Finally, Colin and I traveled to a senior residence and met a women recovering from hip replacement surgery. Colin walked with her to pick up her mail and spoke with her in a friendly and comfortable manner. It was obvious to me that this patient and Colin enjoy a trusting and warm relationship. When we departed, the patient thanked Colin and expressed her gratitude for the difference he and his PT assistant had made in her life. With the exception of having to contend with this patient's rambunctious Boston Terrier, it was an enjoyable visit.

I was not all that surprised to see the level of compassion and professionalism that Ann Marie and Colin brought to their jobs. Frankly, I expected that. What I was quite struck by, however, was how they were received by the patients. The three individuals we visited are vulnerable and overwhelmed by the complexity and burden of their ailments and treatment regimens. I saw that both Ann Marie and Colin had well established relationships with these patients and that their level of trust in their clinicians was extremely high. Ann Marie and Colin carefully explained what was happening and what was going to happen next. They described all of the positive observations as well as the concerns. They comforted and they lifted spirits. They offered hope and reassurance.

And I could see the effect of that in three glowing faces.

Macro Follow-Up

Recently, my brother and I conducted the second round of a "photo a day" exercise, designed to improve our creative eyes and photographic technique. The drill was that each of us had to take and post one photo each day to our respective photo websites. The only requirement was that the photo had to be "good". The hope (and outcome) was that by forcing this, you begin to look at the world around you differently. You notice colors, pattens, and the extraordinary in our ordinary midst. My gallery is here and Ed's is here. This point of this post is not that any of these photographs are actually any good... rather, that the exercise actually did what it was intended to do. When you carry a camera and the pressure of taking one decent shot around with you wherever you go, you begin to notice that we do live in an extraordinary world.

On some days, I set up shots, exercised great care and actually worked at it. Many days, however, I was flying around my normal day and just trying to grab a quick shot to check this off my to do list. The two pictures in the previous post are examples. Both were taken with an inexpensive point and shoot digital camera. Both were taken in the conference room near my former office. I set the camera to macro mode and in one photo, I pointed the camera up from the bottom of the vertical window blinds and fired away. The second, also on macro mode, was a close up of an ordinary office plant leaf. On my computer later, I jacked up the saturation, contrast and sharpening.

Macro Fun

How were these photos made? Expensive camera equipment? Studio lighting? Hardly. Check back tomorrow for the answer.

What about costs?

Why Health Reform? Extending insurance coverage to tens of millions of un/underinsured? Great. But what about the nagging issue of slowing the rise of health spending in the U.S.? Well, that's another thing altogether.

White House Budget Director, Peter Orszag, is arguing for a tax on employer sponsored health insurance as a critical lever for reducing costs. House Republicans are focusing on containing malpractice costs as a mechanism for constraining inflation. The present House and Senate bills contain a variety of provisions, including taxing high-end benefits, creating incentives for physicians to form integrated care groups (though there are pretty compelling incentives right now), rate setting panels (remember the Rate Setting Commission in Massachusetts?), and others.

Cost savings estimates are scarce and/or high level. Look for the public debate to turn to this issue as Health Reform proponents begin to fall back on their heels in the coming weeks.

Health Reform and the Back Burner

Senate Majority Leader Harry Reid said a mouthful. "We're not going to be bound by timelines", was his response when asked about the prospect of signing into law any form of significant health reform this year. This marks an important departure from what has been a consistent full court press by White House, Senate and House leaders. Health Reform and Now has been the theme... or better said, the key priority for the past six months. But last night's election results (New Jersey and Virginia) may be causing some to pause and take notice. Nancy Pelosi has said that she's willing to lose seats in order to pass Reform law, but now, given Reid's signal that this may not take place this year at all, thus moving the debate into a critical election year, the three top leaders may no longer be completely in step. Last night's gubernatorial results in NJ and VA should hardly impact the national reform debate... though some legislators, particularly those in the House, may have noticed that the President's political capital may have fallen as he was unable to save the Democratic candidates in those states. What does this mean? Perhaps that massive health reform may not fly. I believe the President knew what he was doing by pushing this agenda so fast and so hard and the fact that Reid is no longer, could (repeat could) signal the beginning of the end. The closer to the back burner this goes, the more likely it will come off the stove.