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.

Are the fines big enough?

The House bill stipulates up to a 2.5% of adjusted gross income tax penalty for individuals who choose to not purchase mandated insurance. The Senate package also contains fines, though they are far less stiff. The question is, will these penalties be sufficient enough to motivate big numbers of uninsured Americans toward purchasing coverage?

Here's the big problem. In the Senate bill, the fines are $200 in 2014, $400 in 2015 and $750 by 2017. When you compare these fines with the cost of coverage (i.e., the monthly premiums), it's almost a no-brainer: why buy the insurance? This is, in part, the logic behind the steeper fines in the House bill.

This will be one of the key issues debated in the coming days... expect fireworks.

Hospice Care... of the future...

Just had an interesting conversation with Diane Bergeron, Executive Director of VNA Hospice Care (affiliate of VNAB), about the care provided by hospice nurses. I mentioned that, in my own experience, not everyone has a good sense of what hospice care is all about until they go through it themselves with a loved one. Diane mentioned that our culture doesn't always handle the dying process of family members all that well and that, for some, the loss of control, the unpredictability, the isolation... can all be profoundly overwhelming. Diane described her vision of hospice care changing in the future much as the birthing process has evolved over the past half century. Diane said: "When you and I were born, mom was knocked out and they called dad, who was at work, when it was over. But the baby boom generation changed all that and I expect that our approach to dying will as well."

The worst bill ever? Just ask the WSJ...

Here's from an opinion posted by the Wall Street Journal: "Speaker Nancy Pelosi has reportedly told fellow Democrats that she's prepared to lose seats in 2010 if that's what it takes to pass ObamaCare, and little wonder. The health bill she unwrapped last Thursday, which President Obama hailed as a "critical milestone," may well be the worst piece of post-New Deal legislation ever introduced." Agree or disagree, this is a good read. See entire article by clicking here.

Health Reform... there's good news... and bad news

There are likely going to be millions of new patients with health insurance, benefitting the entire industry. And patients with insurance will gain access to routine and preventive care which will save the system money in the long term and improve the quality of life for many. All good. But... the unified House bill is also going to extract something too. The estimated 36m newly covered Americans will require new sources of funding, including a reduction in hospital reimbursement of over $400b in Medicare and Medicaid cuts. The Senate and House are also talking about cuts to physician reimbursement totalling some $200b over the next ten years. The pharmaceutical and device industries are also hit by the proposed law. Given all of the open funding issues, expect a great deal more debate before this is finalized.

Fall Stroll

Two pics from a late afternoon walk.