Berwick for CMS: the good… and bad news

(photo from The Boston Globe)

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

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

Why might his nomination be opposed?  A few reasons:

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

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

But not everyone thought that.

Cerberus

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

Interesting name for a company.

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

What were they thinking?

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

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

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

A follow-up from yesterday’s post

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

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

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

Less doctors... getting more done.

The Associated Press reported today:

WASHINGTON — Primary care physicians already are in short supply in parts of the country, and the landmark health care overhaul will bring them millions more newly insured patients in the next few years.

Recently published reports predict a shortfall of roughly 40,000 primary care doctors over the next decade, as physicians are increasingly drawn to the better pay, better hours, and higher profile of many other specialties.

Provisions in the new law are aimed at easing the strain, including bonus payments for certain physicians and expansion of community health centers, but a growing movement to change how primary care is delivered may do more to help with the influx, advocates say.

The “medical home’’ approach would enhance access to care, with a doctor-led team of nurses, physician assistants, and disease educators working together. Such teams could see more people while giving extra attention to those who need it most.

“A lot of things can be done in the team fashion where you don’t need the patient to see the physician every three months,’’ said Dr. Sam Jones of Fairfax Family Practice Centers, a large Virginia group of 10 primary care offices outside the nation’s capital that is morphing into this medical home model.

Only 30 percent of US doctors practice primary care. The government says 65 million people live in areas designated as having a shortage of primary care physicians, places already in need of more than 16,600 additional providers to fill the gaps. Among other steps, the new law provides a 10 percent bonus from Medicare for primary care doctors serving in those areas.

The Massachusetts Medical Society reported last fall that just over half of internists and 40 percent of family and general practitioners were not accepting new patients, an increase in recent years as the state implemented nearly universal coverage.

Nationally, the big surge for primary care will not start until 2014, when the bulk of the 32 million uninsured starts coming online.

The shortage of primary care physicians in this country has been long anticipated and the report above makes the point that millions of newly insureds will soon be gaining access to needed primary care (a good thing), thus stressing the already strained primary care system (not so good).

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

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

Health Reform: The Experts Speak

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

• Bill George "The bill addresses only one of the four essential elements of health care. Beyond insuring the uninsured,cost, quality, and lifestyles are not addressed. Unless we focus on all four, we will continue to have a dysfunctional system with unaffordable costs."

• Richard Bohmer "We need to make a distinction between debating how it will be paid for and what the 'it' is that is paid for." He argues we need more change around how health care can be delivered, citing experiments with disease management programs, substituting nurse practitioners for physicians in certain circumstances, in-store clinics to treat simple diseases, and "experiments with IT to enable precise electronic communication between patients and doctors so that real medical discussions can be had at a distance."
• Regina Herzlinger "The costs of this legislation, more than $900 billion, will put another nail in the coffin of the U.S. economy and open the door to a government-controlled health care system that gravely injures the sick and the entrepreneurs who could help them, along the way. The problem? The absence of a way to control the costs that already cripple U.S. global competitiveness."
• Robert Huckman "The good news is that the bill tackles many important issues related to insurance coverage. The more sobering news is that addressing coverage issues shines a bright light on the more fundamental reform that still needs to occur -- improving the process by which medical care is actually delivered to patients."

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

Becoming familiar

This kid rocks

Thanks for sending this, Jean.

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

Need a third word! Help...

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

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

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

What about: home health, images, kitchen sink?

Too goofy?

On the theme...

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

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

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

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

New look for VNA CEO

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

As always, comments welcome.

Thanks.

Moose Hill

Immediate... but unfamiliar.

Will iPad or won’t iPad?

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

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

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

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

Why did I flash the plastic?  Six reasons:

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

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