tag:blogger.com,1999:blog-66539407946937049412024-03-17T22:59:35.418-04:00Kent Bottles Private ViewsKent Bottles, MD ruminates on health, wellness, neuroscience, and lifeKent Bottleshttp://www.blogger.com/profile/12993140567796683570noreply@blogger.comBlogger95125tag:blogger.com,1999:blog-6653940794693704941.post-82115241905524057102013-12-02T19:03:00.003-05:002013-12-02T19:03:49.885-05:00Elan Gayle - Diane Thanksgiving Flight Twitter Feud<div style="line-height: 12.0pt; vertical-align: baseline;">
<br /></div>
<div style="line-height: 12.0pt; vertical-align: baseline;">
<span style="color: black; font-family: Helvetica; font-size: 12.0pt;">The 2013 Thanksgiving delayed flight
to Phoenix war between Elan Gayle and Diane in Seat 7A went viral because Gayle
live tweeted his aggressive disapproval of Diane’s self-centered attitude.<span style="mso-spacerun: yes;"> </span>According to Gayle, “She's telling the
flight attendants that it is Thanksgiving. She wants them to know she wants to
have dinner with her family. The male flight attendant said 'I understand
ma'am. I'm looking forward to seeing my family too.' She responded 'this isn't
about you.”<o:p></o:p></span></div>
<div style="line-height: 12.0pt; vertical-align: baseline;">
<br /></div>
<div class="e-entry-title" style="background: white; line-height: 24.0pt; margin-bottom: .0001pt; margin-bottom: 0in; margin-left: .5in; margin-right: 5.0pt; margin-top: 0in; vertical-align: baseline;">
<span style="color: #292f33; font-family: Helvetica; font-size: 12.0pt; mso-bidi-font-family: "Times New Roman"; mso-bidi-font-size: 18.0pt;">Our
flight is delayed. A woman on here is very upset because she has Thanksgiving
plans. She is the only one obviously. Praying for her<o:p></o:p></span></div>
<div class="MsoNormal" style="background: white; line-height: 16.0pt; text-indent: .5in;">
<a href="https://twitter.com/theyearofelan/statuses/406091489690001408"><span style="color: #707070; font-family: Helvetica;">11:05 AM - 28 Nov 2013</span></a><span style="color: #292f33; font-family: Helvetica;"><o:p></o:p></span></div>
<div class="MsoNormal" style="background: white; line-height: 16.0pt; text-indent: .5in;">
<br /></div>
<div class="MsoNormal">
<span style="color: #292f33; font-family: Helvetica;">When the
plane landed, Gayle waited for Diane to get off the plane so he could make sure
she knew he had broadcast their feud on twitter.<span style="mso-spacerun: yes;"> </span>Diane slapped him in the face.<span style="mso-spacerun: yes;"> </span>For a description of the lengthy and unfortunate encounter
during the flight including Gayle sending Diane unwanted vodka and wine and
vulgar notes, a representative news article can be found at the following
link:<span style="mso-spacerun: yes;"> </span></span><span style="font-family: Helvetica;"><a href="http://www.nydailynews.com/entertainment/gossip/bachelor-producer-ugly-note-battle-delayed-plane-article-1.1532660">http://www.nydailynews.com/entertainment/gossip/bachelor-producer-ugly-note-battle-delayed-plane-article-1.1532660</a><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">After Thanksgiving,
Gayle published a blog explaining that it was important for him to make the
point that one should not mistreat service workers.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“I
don’t care what’s going on with you:<span style="mso-spacerun: yes;">
</span>Don’t be rude to people who are doing their job…Don’t act like they are
less than you.<span style="mso-spacerun: yes;"> </span>Don’t abuse them
just because you’re the customer and ‘The Customer Is Always Right.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Gayle ends his blog
with: <span style="background: white; color: #222222;">“And it’s OUR job to tell
every Diane to shut up.” (</span></span><a href="http://theyearofelan.tumblr.com/"><span style="font-family: Helvetica;">http://theyearofelan.tumblr.com</span></a><span style="font-family: Helvetica;">)<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Another blog post
claiming to be written by Diane’s cousin surfaced with the revelation that
Diane has Stage IV small cell carcinoma of the lung:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">“Diane hasn’t been handling
her imminent death very well, but she really was looking forward to being with
us and the rest of her family – all of whom were flying in for one last
Thanksgiving with her.” (</span><a href="http://freethoughtblogs.com/butterfliesandwheels/2013/11/bullying-at-35-thousand-feet/"><span style="font-family: Helvetica;">http://freethoughtblogs.com/butterfliesandwheels/2013/11/bullying-at-35-thousand-feet/</span></a><span style="font-family: Helvetica;">)<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="background: white; color: #222222; font-family: Helvetica;">Response to the whole affair includes many applauding Gayle and others
bemoaning his shaming of Diane via social media tools.<span style="mso-spacerun: yes;"> </span>Some have even speculated that the
entire encounter is likely a hoax and never happened.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="background: white; color: #222222; font-family: Helvetica;">A column in Salon made what I think is the key observation:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica; mso-bidi-font-family: Times; mso-bidi-font-size: 16.0pt;">“Real or no, the
“Diane” story is designed to play on the very worst of human nature: the part
that knows that one’s own behavior is sacrosanct and it’s everyone <span style="mso-bidi-font-style: italic;">else </span>that’s the problem.”</span><span style="font-family: Helvetica;"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">(</span><a href="http://www.salon.com/2013/12/02/elan_gale_diane_and_the_age_of_public_twitter_shaming/"><span style="font-family: Helvetica;">http://www.salon.com/2013/12/02/elan_gale_diane_and_the_age_of_public_twitter_shaming/</span></a><span style="font-family: Helvetica;"> )<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">The Elan/Diane feud
would have been avoided if they had taken David Foster Wallace’s Kenyon College
commencement address advice:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“Here’s
one example of the utter wrongness of something I tend to be automatically sure
of:<span style="mso-spacerun: yes;"> </span>Everything in my own immediate
experience supports my deep belief that I am the absolute center of the
universe, the realest, most vivid and important person in existence.”<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">The commencement address
provides many stories and examples to bolster Wallace’s argument against all of
our self-centered “default-settings” that lead to behavior like that
experienced on the airplane flight to Phoenix.<span style="mso-spacerun: yes;"> </span>Wallace advises the graduates to embrace a special kind of
freedom to consciously choose to empathize with the people we encounter every
day.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“The
really important kind of freedom involves attention and awareness, and
discipline, and effort, and being able truly to care about other people and to
sacrifice for them, over and over, in myriad petty little unsexy ways, every
day.”<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Wallace’s suggestions
parallel the findings of social scientists who study meaning in human
lives.<span style="mso-spacerun: yes;"> </span>Investigators find that a
defining feature of meaning “is connection to something bigger than the self.”<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“People
who lead meaningful lives feel connected to others, to work, to a life purpose,
and to the world itself.<span style="mso-spacerun: yes;"> </span>Those who
reported having a meaningful life saw themselves as more other-oriented.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
(<a href="http://www.nytimes.com/2013/12/01/opinion/sunday/millennial-searchers.html?hpw&rref=opinion">http://www.nytimes.com/2013/12/01/opinion/sunday/millennial-searchers.html?hpw&rref=opinion</a>)</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Elan and Diane could
also have benefited from <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">John Dewey’s thoughts
about moral imagination, which includes “the capacity to concretely perceive
what is before us in light of what could be.”<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Barry Schwartz and
Kenneth Sharpe’s book Practical Wisdom describes how Luke, a janitor in a midwestern
hospital, approached a tense situation with the father of a man who was in a
coma.<span style="mso-spacerun: yes;"> </span>Upon meeting the father in
the hallway after cleaning the patient’s room, the father angrily accused Luke
of not doing his job.<span style="mso-spacerun: yes;"> </span>Luke had to
choose between supporting several different positive ideals, which in this
specific situation clashed.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: Helvetica;">Be
honest: I cleaned the room already<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: Helvetica;">Be
courageous:<span style="mso-spacerun: yes;"> </span>Stand up for one’s own
dignity<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: Helvetica;">Be
fair:<span style="mso-spacerun: yes;"> </span>Room has already been clean<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: Helvetica;">Be
kind:<span style="mso-spacerun: yes;"> </span>Clean the room again so
father could observe the activity<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Luke choose how to frame
the issue taking into account the job he had created for himself to support the
hospital as a place to be compassionate and kind and help healing.<span style="mso-spacerun: yes;"> </span>He did not frame his action in terms of
honesty, courage, justice or his personal rights. Luke decided to defuse the
situation and clean the hospital room for a second time so the father could
observe for himself that his comatose son’s room was clean.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">All of us encounter
situations like the Elan/Diane feud where we get on each other’s nerves.<span style="mso-spacerun: yes;"> </span>David Foster Wallace, John Dewey, Barry
Schwartz, and Kenneth Sharpe provide us with tools to make better choices than
our two now famous Thanksgiving travelers.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="background: white; line-height: 16.0pt;">
<br /></div>
<div class="MsoNormal" style="background: white; line-height: 16.0pt; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="background: white; line-height: 16.0pt; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="background: white; line-height: 16.0pt;">
<br /></div>
<div class="MsoNormal" style="background: white; line-height: 16.0pt;">
<br /></div>
<div style="line-height: 12.0pt; vertical-align: baseline;">
<br /></div>
<div style="line-height: 12.0pt; vertical-align: baseline;">
<br /></div>
<div class="MsoNormal" style="line-height: 12.0pt; vertical-align: baseline;">
<br /></div>
<h4 align="center" style="line-height: 11.0pt; text-align: center; vertical-align: baseline;">
<span style="color: #666666; font-family: Arial; font-size: 10.0pt; font-weight: normal; text-transform: uppercase;"><o:p> </o:p></span></h4>
<!--[if gte mso 9]><xml>
<o:OfficeDocumentSettings>
<o:AllowPNG/>
</o:OfficeDocumentSettings>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:WordDocument>
<w:Zoom>0</w:Zoom>
<w:TrackMoves>false</w:TrackMoves>
<w:TrackFormatting/>
<w:PunctuationKerning/>
<w:DrawingGridHorizontalSpacing>18 pt</w:DrawingGridHorizontalSpacing>
<w:DrawingGridVerticalSpacing>18 pt</w:DrawingGridVerticalSpacing>
<w:DisplayHorizontalDrawingGridEvery>0</w:DisplayHorizontalDrawingGridEvery>
<w:DisplayVerticalDrawingGridEvery>0</w:DisplayVerticalDrawingGridEvery>
<w:ValidateAgainstSchemas/>
<w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid>
<w:IgnoreMixedContent>false</w:IgnoreMixedContent>
<w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText>
<w:Compatibility>
<w:BreakWrappedTables/>
<w:DontGrowAutofit/>
<w:DontAutofitConstrainedTables/>
<w:DontVertAlignInTxbx/>
</w:Compatibility>
</w:WordDocument>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:LatentStyles DefLockedState="false" LatentStyleCount="276">
</w:LatentStyles>
</xml><![endif]-->
<!--[if gte mso 10]>
<style>
/* Style Definitions */
table.MsoNormalTable
{mso-style-name:"Table Normal";
mso-tstyle-rowband-size:0;
mso-tstyle-colband-size:0;
mso-style-noshow:yes;
mso-style-parent:"";
mso-padding-alt:0in 5.4pt 0in 5.4pt;
mso-para-margin:0in;
mso-para-margin-bottom:.0001pt;
mso-pagination:widow-orphan;
font-size:12.0pt;
font-family:"Times New Roman";
mso-ascii-font-family:Cambria;
mso-ascii-theme-font:minor-latin;
mso-fareast-font-family:"Times New Roman";
mso-fareast-theme-font:minor-fareast;
mso-hansi-font-family:Cambria;
mso-hansi-theme-font:minor-latin;}
</style>
<![endif]-->
<!--StartFragment-->
<!--EndFragment--><br />
<div class="MsoNormal">
<br /></div>
Kent Bottleshttp://www.blogger.com/profile/12993140567796683570noreply@blogger.com25tag:blogger.com,1999:blog-6653940794693704941.post-15041533154740548242013-06-11T13:18:00.001-04:002013-06-11T13:18:43.109-04:00Do All of Us Really Have to Change?
<!--[if gte mso 9]><xml>
<o:OfficeDocumentSettings>
<o:AllowPNG/>
</o:OfficeDocumentSettings>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:WordDocument>
<w:Zoom>0</w:Zoom>
<w:TrackMoves>false</w:TrackMoves>
<w:TrackFormatting/>
<w:PunctuationKerning/>
<w:DrawingGridHorizontalSpacing>18 pt</w:DrawingGridHorizontalSpacing>
<w:DrawingGridVerticalSpacing>18 pt</w:DrawingGridVerticalSpacing>
<w:DisplayHorizontalDrawingGridEvery>0</w:DisplayHorizontalDrawingGridEvery>
<w:DisplayVerticalDrawingGridEvery>0</w:DisplayVerticalDrawingGridEvery>
<w:ValidateAgainstSchemas/>
<w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid>
<w:IgnoreMixedContent>false</w:IgnoreMixedContent>
<w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText>
<w:Compatibility>
<w:BreakWrappedTables/>
<w:DontGrowAutofit/>
<w:DontAutofitConstrainedTables/>
<w:DontVertAlignInTxbx/>
</w:Compatibility>
</w:WordDocument>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:LatentStyles DefLockedState="false" LatentStyleCount="276">
</w:LatentStyles>
</xml><![endif]-->
<!--[if gte mso 10]>
<style>
/* Style Definitions */
table.MsoNormalTable
{mso-style-name:"Table Normal";
mso-tstyle-rowband-size:0;
mso-tstyle-colband-size:0;
mso-style-noshow:yes;
mso-style-parent:"";
mso-padding-alt:0in 5.4pt 0in 5.4pt;
mso-para-margin:0in;
mso-para-margin-bottom:.0001pt;
mso-pagination:widow-orphan;
font-size:12.0pt;
font-family:"Times New Roman";
mso-ascii-font-family:Cambria;
mso-ascii-theme-font:minor-latin;
mso-fareast-font-family:"Times New Roman";
mso-fareast-theme-font:minor-fareast;
mso-hansi-font-family:Cambria;
mso-hansi-theme-font:minor-latin;}
</style>
<![endif]-->
<!--StartFragment-->
<br />
<div class="MsoNormal">
As someone who professionally closely tracks the debate over
the transformation of the American health care clinical delivery system, I did
not learn much new from the June 2<sup>nd</sup> New York Times article titled
“The 2.7 Trillion Medical Bill.” I
did find the article’s approach useful in explaining how the wide variations in
price for procedures contribute to the unnecessary high cost of American health
care. (<a href="http://www.nytimes.com/2013/06/02/health/colonoscopies-explain-why-us-leads-the-world-in-health-expenditures.html?pagewanted=all">http://www.nytimes.com/2013/06/02/health/colonoscopies-explain-why-us-leads-the-world-in-health-expenditures.html?pagewanted=all</a>)
</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Although the article did document many procedures are more
expensive in the United States than in the rest of the world, it concentrated
on how colonoscopies average $1,185 in America and $655 in Switzerland. They could have just as easily focused
on MRIs where the American average cost is $1,121 vs. the Dutch average cost of
$319 or hip replacement surgery where it costs on average $40,363 in the United
States vs. $7,731 in Spain. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I did make several power point slides from the article for
future presentations, but then I did not think much about the impact of the
article until days later when I read the letters to the editor. The article and the response to
it provide fascinating and powerful insights into the whole health care debate.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
In typical guild based medicine fashion, there are letters
from the leaders of the American Society of Anesthesiologists, the American
College of Radiology, and the American College of Gastroenterology. John M. Zerwas, the President of the
American Society of Anesthesiologists, offers no evidence-based medical reason
for his carefully worded concluding sentence: “Whether a procedure takes place in an office, a surgical
center or a hospital, we believe that sedation is best delivered with physician
anesthesiologists involved.” Dr.
Zerwas does not answer the challenge of experts who in the article question the
need for physician anesthesiologists to monitor office-based sedatives that are
safely administered by a wide range of doctors and nurses in other
countries. Dr. Zerwas does not
explain why less expensive nurse anesthetists could not be used. Dr. Zerwas does not explain why the
charges for the sedation are so much more expensive than the charges for the
physician performing the colonoscopy.
Dr. Zerwas does not explain that one reason for his society’s rigid
stand is that it makes money for his members. (<a href="http://www.nytimes.com/2013/06/07/opinion/the-continuing-debate-over-health-costs.html">http://www.nytimes.com/2013/06/07/opinion/the-continuing-debate-over-health-costs.html</a>)
</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Judy Yee, the chairwoman of the Colorectal Cancer Committee
of the American College of Radiology, is quick to point out in her letter to
the editor that “Medicare coverage of virtual colonoscopy would make this less
expensive test more widely available, attract many more people to be screened
and ultimately save lives.” She
does not, of course, point out that this method has the downsides of missing
some small lesions and exposing the patient to radiation. She also does not comment on the
financial gains that would be made by her society’s members if virtual colonoscopy
replaced standard colonoscopy. (<a href="http://www.nytimes.com/2013/06/07/opinion/the-continuing-debate-over-health-costs.html">http://www.nytimes.com/2013/06/07/opinion/the-continuing-debate-over-health-costs.html</a>)
</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Ronald J. Vender, President of the American College of
Gastroenterology, “is disappointed that [the article] unfairly casts outsized
blame for high medical costs on colonoscopy and by extension on
gastroenterologists.” In the last
sentence of his letter he does provide a nod to shared decision making which
could lower costs and improve care: “It is correct that there are screening
strategies other than colonoscopy and likewise there are varied patient
preferences, so while colonoscopy is our preferred screening strategy, we agree
that the best test is one that actually gets taken.” Dr. Vender does not explain that some of the other screening
strategies are less expensive and that his members make a lot of money doing
colonoscopies. (<a href="http://www.nytimes.com/2013/06/04/opinion/why-health-care-costs-are-so-high.html?pagewanted=all">http://www.nytimes.com/2013/06/04/opinion/why-health-care-costs-are-so-high.html?pagewanted=all</a>)
</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Sara Hartley in her letter advocates for “Medicare for all,
a national health insurance that eliminates needless profiteering and stealth
subsidies” and addresses “another major reason for price inflation: cost shifting from the uninsured and
inadequately covered.” I think she
means cost shifting from the insured to the uninsured, but cost shifting
certainly does occur and it makes the whole issue hard to understand and
control. ( <a href="http://www.nytimes.com/2013/06/04/opinion/why-health-care-costs-are-so-high.html?pagewanted=all">http://www.nytimes.com/2013/06/04/opinion/why-health-care-costs-are-so-high.html?pagewanted=all</a>)
</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Dr. Kenneth Prager, a New Jersey surgeon, does write about
financial incentives in his letter to the editor in response to the original
article: </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
“I suspect that if physicians were
salaried there would be a substantial decrease in the number of medical
procedures performed, including colonoscopies. Money has an insidious way of
biasing medical judgment. When
physicians profit from every procedure, it is too easy for some to justify it
as in the patient’s best interest even when sound clinical judgment argues the
contrary.”( <a href="http://www.nytimes.com/2013/06/04/opinion/why-health-care-costs-are-so-high.html?pagewanted=all">http://www.nytimes.com/2013/06/04/opinion/why-health-care-costs-are-so-high.html?pagewanted=all</a>)
</div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal">
I imagine if Dr. Prager bumped into Dr. Scott Ingber, Chief
Medical Officer at Mount Sinai North Shore Medical Group, at a conference or
cocktail party a lively debate might ensue. Dr. Ingber, with presumably a straight face, states in his
letter that “portraying doctors as overly concerned with financial advancement
plants seeds of skepticism in patients when a successful physician-patient
relationship rests upon unwavering trust.” One can just hear Dr. Prager quoting Reagan “to trust, but
verify.” It does not take too much
imagination to conjure up that Dr. Prager will refer Dr. Ingber to the
ProPublica website that exposes pharmaceutical payments to physicians (<a href="http://www.propublica.org/series/dollars-for-docs">http://www.propublica.org/series/dollars-for-docs</a>)
or to articles about medical device companies paying orthopaedic surgeons to
use their implants even if the patient is unaware of the cozy financial
relationship. (<a href="http://www.drugwatch.com/2012/01/18/orthopedic-surgeons-and-medical-device-companies-cosey-bed-fellows/">http://www.drugwatch.com/2012/01/18/orthopedic-surgeons-and-medical-device-companies-cosey-bed-fellows/</a>) If Claire Burson of New Milford
Conneticiut happened to overhear the discussion, she might interrupt to point
out the quote from the patient in the article who says, “If a doctor says you
need it, you don’t ask.” Ms. Burson contends that:</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
“Attitudes like that need to
change. Of course you ask. You ask
why. You ask if there are other
options. You ask how the results
will affect your treatment. And
you should be able to ask what it will cost.” (<a href="http://www.nytimes.com/2013/06/04/opinion/why-health-care-costs-are-so-high.html?pagewanted=all">http://www.nytimes.com/2013/06/04/opinion/why-health-care-costs-are-so-high.html?pagewanted=all</a>)
</div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal">
You knew someone from an insurance company would write in to
defend that industry, and Sam Ho, Chief Medical Officer of UnitedHealthcare
does not disappoint us. He writes:</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
“Several health care organizations,
including UnitedHealthcare, have introduced online and mobile tools that put
relevant medical price information at people’s fingertips, enabling them to
comparison shop for health care as they would with other consumer products and services.”
((<a href="http://www.nytimes.com/2013/06/07/opinion/the-continuing-debate-over-health-costs.html">http://www.nytimes.com/2013/06/07/opinion/the-continuing-debate-over-health-costs.html</a>)</div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal">
Dr. Ho does not explain that health care is not like other
consumer products. I want to buy
an iPhone; I don’t want to see a doctor or go to the hospital. And it is hardly true that we have the
tools to comparison shop for medical care. Didn’t Dr. Ho read about the summer project by Jaime
Rosenthal? The Washington University student documented that only 10 percent of hospitals could quote a
complete price for hip replacement and the ones that did ranged in price from
$11,000 to $125,000? (<a href="http://www.washingtonpost.com/blogs/wonkblog/wp/2013/02/12/how-much-does-hip-surgery-cost-somewhere-between-10000-and-125000/">http://www.washingtonpost.com/blogs/wonkblog/wp/2013/02/12/how-much-does-hip-surgery-cost-somewhere-between-10000-and-125000/</a>)
</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Perhaps the last word should go to Lane Rosenthal of
Minneapolis:</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
“As your thoughtful case study
reported, we are all collectively at fault – from providers, hospitals,
pharmaceutical companies, device makers and insurers, to every one of us who
demands state-of-the-art technology for everything from a hangnail to a
headache, wants antibiotics for a cold, or threatens litigation. I don’t have the answer for how to
untangle the hydra-headed health care mess, but I do know it won’t be solved
until across the board we all stop finger-pointing and accept responsibility.” (<a href="http://www.nytimes.com/2013/06/07/opinion/the-continuing-debate-over-health-costs.html">http://www.nytimes.com/2013/06/07/opinion/the-continuing-debate-over-health-costs.html</a>)</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Alas, I guess we all have to change and accept
accountability. And humans are
good at neither change nor accountability. </div>
<div class="MsoNormal">
<br /></div>
<!--EndFragment-->Kent Bottleshttp://www.blogger.com/profile/12993140567796683570noreply@blogger.com4tag:blogger.com,1999:blog-6653940794693704941.post-39948252920974780122013-02-22T09:55:00.001-05:002013-02-22T09:55:54.088-05:00How To Practice Medicine in a World We Can Never Truly Understand
<!--[if gte mso 9]><xml>
<o:OfficeDocumentSettings>
<o:AllowPNG/>
</o:OfficeDocumentSettings>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:WordDocument>
<w:Zoom>0</w:Zoom>
<w:TrackMoves>false</w:TrackMoves>
<w:TrackFormatting/>
<w:PunctuationKerning/>
<w:DrawingGridHorizontalSpacing>18 pt</w:DrawingGridHorizontalSpacing>
<w:DrawingGridVerticalSpacing>18 pt</w:DrawingGridVerticalSpacing>
<w:DisplayHorizontalDrawingGridEvery>0</w:DisplayHorizontalDrawingGridEvery>
<w:DisplayVerticalDrawingGridEvery>0</w:DisplayVerticalDrawingGridEvery>
<w:ValidateAgainstSchemas/>
<w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid>
<w:IgnoreMixedContent>false</w:IgnoreMixedContent>
<w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText>
<w:Compatibility>
<w:BreakWrappedTables/>
<w:DontGrowAutofit/>
<w:DontAutofitConstrainedTables/>
<w:DontVertAlignInTxbx/>
</w:Compatibility>
</w:WordDocument>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:LatentStyles DefLockedState="false" LatentStyleCount="276">
</w:LatentStyles>
</xml><![endif]-->
<!--[if gte mso 10]>
<style>
/* Style Definitions */
table.MsoNormalTable
{mso-style-name:"Table Normal";
mso-tstyle-rowband-size:0;
mso-tstyle-colband-size:0;
mso-style-noshow:yes;
mso-style-parent:"";
mso-padding-alt:0in 5.4pt 0in 5.4pt;
mso-para-margin:0in;
mso-para-margin-bottom:.0001pt;
mso-pagination:widow-orphan;
font-size:10.0pt;
font-family:"Times New Roman";
mso-ascii-font-family:Cambria;
mso-ascii-theme-font:minor-latin;
mso-hansi-font-family:Cambria;
mso-hansi-theme-font:minor-latin;}
</style>
<![endif]-->
<!--StartFragment-->
<br />
<div class="MsoNormal">
<span style="font-family: Helvetica;">Central to the problem
of how best to live in a world that we cannot understand is how to regard:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“The
Extended Disorder Family (or Cluster): (i) uncertainty, (ii) variability, (iii)
imperfect, incomplete knowledge, (iv) chance, (v) chaos, (vi) volatility, (vii)
disorder, (viii) entropy, (ix) time, (x) the unknown, (xi) randomness, (xii)
turmoil, (xiii) stressor, (xiv) error, (xv) dispersion of outcomes, (xvi)
unknowledge. (Nassim Nicholas
Taleb, Antifragile, London: Allen Lane, 2012)<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">To this impressive list,
I would add seventeenth and eighteenth items: failure and death.
All of these characteristics scare and frighten most of us, and so we do
our best to avoid them. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Despite the popularity
of self-help books emphasizing the pursuit of happiness, a vocal minority has
advocated embracing all of the above negative items in order to live fully and
successfully.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Eric G. Wilson perhaps
provides the best overview of this minority report when he observes that<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“To
desire only happiness in a world undoubtedly tragic is to become inauthentic,
to settle for unrealistic abstractions that ignore concrete situations.” <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">And<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“Our
passion for felicity hints at an ominous hatred for all that grows and thrives
and then dies.” (Eric G. Wilson, Against Happiness, New York: Sarah Crichton Books, 2008)<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">To be alive and to
realize that you are going to die means being insecure and vulnerable. According to Martha Nussbaum one should
embrace this uncertainty.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“To
be a good human is to have a kind of openness to the world, an ability to trust
uncertain things beyond your own control, that can lead you to be shattered in
very extreme circumstances for which you were not to blame. That says something
very important about the ethical life:
that it is based on a trust in the uncertainty, and on a willingness to
be exposed. It’s based on being
more like a plant than a jewel: something rather fragile, but whose very
particular beauty is inseparable from that fragility.” (Oliver Burkeman, The
Antidote, New York: Faber and
Faber, Inc., 2012). <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">The Stoics may have been
the first to realize that embracing the negative can be a useful tool for human
beings attempting to lead a meaningful life. William Irving in <u>A Guide to
the Good Life: The Ancient Art of Stoic
Joy</u> describes their negative visualization as imagining that the worst
possible outcome may occur. And if
bad things do happen that is the way it is supposed to be. Marcus Aurelius advised us to
“constantly regard the universe as one living being, having one substance and
one soul. (</span><a href="http://classiclit.about.com/od/aureliusmarcus/a/aa_maurelius.htm"><span style="font-family: Helvetica;">http://classiclit.about.com/od/aureliusmarcus/a/aa_maurelius.htm</span></a><span style="font-family: Helvetica;">) </span><span style="font-family: Helvetica; mso-bidi-font-family: Helvetica; mso-bidi-font-size: 13.0pt; mso-bidi-font-weight: bold;">Whatever happens at all happens as it
should</span><span style="font-family: Helvetica; mso-bidi-font-family: Helvetica; mso-bidi-font-size: 13.0pt;">; you will find this true, if you watch
narrowly</span><span style="font-family: Helvetica;">.” (</span><a href="http://en.wikiquote.org/wiki/Marcus_Aurelius"><span style="font-family: Helvetica;">http://en.wikiquote.org/wiki/Marcus_Aurelius</span></a><span style="font-family: Helvetica;">) <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">By concentrating on this
glass half full philosophy, the Stoics solved two of the more vexing problems
that humans encounter when they pursue happiness. The hedonic treadmill effect where sources of pleasure last
only a short period of time is minimized when one meditates on the likely
negative outcome of everything in life.
Negative visualization also decreases the anxiety associated with the
irrational fears that our minds come up with when worrying about the unknown
future. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Oliver Burkeman in <u>The Antidote</u> describes how Albert Ellis, the
second most influential psychotherapist of the twentieth century, advocated a
similar negative approach to life.
He differentiated become a terrible outcome and a merely undesirable
outcome, and he argued that it could always be worse. In advising an anxious and ambivalent woman trying to decide
if she should move to be with her boyfriend, Ellis shouted:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“So
maybe he turns out to be a jerk, and you get divorced! That would be highly
disagreeable! You might feel sad! But it doesn’t have to be awful. It doesn’t have to be completely
terrible.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">One of the things that
troubles me most about the current American fascination with happiness is how
self-absorbed and superficial the entire enterprise can become. Those that are most concerned with
happiness often appear to be ignoring much of reality. Taleb in <u>Antifragile</u>
defines via negativa as focusing on what something is not and he recommends
using it as recipe for what to avoid, what not to do. He also observes that we know what is wrong with more
certainty than we know what is right.
Applying these concepts to happiness, he believes the subject is best
dealt with as a negative concept:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“Instead,
they should be lecturing us about unhappiness (I speculate that just as those
who lecture on happiness look unhappy, those who lecture on unhappiness would
look happy).” <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Which brings us to Alan
Watts who in <u>The Wisdom of Insecurity</u> makes
two very important points. The
first is that <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“There
is a contradiction in wanting to be perfectly secure in a universe whose very
nature is momentariness and fluidity.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">His second key
observation in this important book about our inability to control events in a
world that we truly do not understand is his fascination with the law of
reversed effort.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“When
you try to stay on the surface of the water, you sink; but when you try to
sink, you float…Insecurity is the result of trying to be secure…contrariwise,
salvation and sanity consist in the most radical recognition that we have no
way of saving ourselves.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">This realization that
the world we live in is essentially insecure and that denying this reality
makes us unhappy is the message of Pema Chodron. She writes, “Things are not permanent, they don’t last,
there is no final security.” <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">What does the
realization that we will never truly understand the world we live in mean for
those of us who are physicians?
Should the discussion above change the way we view medicine? David Agus in the <u>End of Illness </u>and Taleb in <u>Antifragile</u>
provide us with guidance about medicine in a complex emergent system world. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Having graduated from
Case Western Reserve School of Medicine in 1980 and having trained at UCSF as
an academic anatomic pathologist, I am steeped in the traditional approach to
health care where we assume we can understand the world of medicine. The biomedical model reduces every
illness to a biological mechanism of cause and effect, and physicians diagnose
diseases and then treat them.
Health is defined as absence of disease. The patient story and experience is subjective and
untrustworthy in comparison to the test results emanating from my pathology
laboratory, which are objective and true.
Generalists are replaced by specialists who regard cure as the only
important goal. And pathologists
are the most important of the specialists because treatment selection and
administration has to await the diagnosis rendered in the pathology
laboratory. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Agus labels the
traditional approach “the germ theory of disease, which dominated, and in many
ways defined, medicine in the twentieth century.” “The treatment only cared about the invading organism…it
didn’t care to define or understand the host (the human being).”<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Agus, an academic
oncologist and founder of both a proteomics and a genomics biotech start up
company, replaces the medical status quo with a system biology approach. “It is
important to approach your health in general from a lack of understanding. Honor the body and its relationship to
disease as a complex emergent system that you many never fully comprehend.” His conclusion that one does not need
to understand cancer to treat it is controversial. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Taleb’s <u>Antifragile </u>provides an approach to living in
a world we do not understand by applying his study of the statistics of random
events and his experience as an options trader. Taleb compares and contrasts a fragile and antifragile
approach to everything from science, business, errors, systems, and Greek
mythology. In science for example,
the fragilista who thinks he understands everything causes fragility by depriving
variability loving systems of variability and error loving systems of errors;
he favors directed research and grand theories. The opposite scientist is a practitioner who tries to
understand how things react to volatility and errors, and he favors stochastic
tinkering or bricolage to grand overarching theories. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">The French biologist
Francois Jacob used the term bricolage to describe the trial and error way that
nature exploits optionality. Jacob
gives the example of how half of all embryos undergo spontaneous abortion in
the uterus, which is easier than designing the perfect baby by blueprint. Another example of bricolage would be
the way that genes that work in simple animals are retained and utilized for
similar functions in higher animals.
This concept of “trying to make do with what you’ve got by recycling
pieces that would be otherwise wasted” illustrates how nature substitutes
optionality for intelligence. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Saras Sarasvathy’s study
of 45 successful entrepreneurs shows how the bricolage approach can be applied
to start-up companies. In Sarasvathy’s
effectuation system causally minded people (fragilistas in Taleb’s book) favor
a directed plan to achieve their goal.
Effectually minded people, on the other hand, take a trial and error
approach to see what they can make out of the means and materials that are on
hand. Applying the bird in the
hand principle and the principle of affordable loss, effectually minded people
forge ahead to see what happens.
Sarasvathy found that most successful entrepreneurs were effectually
minded. (</span><a href="http://www.effectuation.org/"><span style="font-family: Helvetica;">www.effectuation.org</span></a><span style="font-family: Helvetica;">)
A conclusion that would
please Taleb. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">When Taleb focuses on
medicine, he concentrates on the problems of iatrogenics and the agency
problem. Iatrogenics literally
means caused by the healer as iatros means healer in Greek. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“Every
time you visit a doctor and get a treatment, you incur risks of such medical
harm, which should be analyzed the way we analyze other trade-offs: probabilistic benefits minus
probabilistic costs.”<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">The agency problem is
when the agent has personal interests that are different from those of the
principal who uses the agent’s services<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“An
agency problem, for instance, is present with the stockbroker and the medical
doctor, whose ultimate interest is their own checking account, not your
financial and medical health, respectively, and who give you advice that is
geared to benefit themselves.”<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Taleb notes that
Montaigne recognized the agency problem when he wrote, “No doctor derives
pleasure from the health of his friends, wrote the Greek satirist, no soldier
from the peace of his city.” <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Taleb develops simple
decision rules for dealing with health and wellness. Using his concept of via negativa that we encountered above
when we discussed happiness, his first rule is “only resort to medical
techniques when the health payoff is very large (say, saving a life) and
visibly exceeds its potential harm, such as incontrovertibly needed surgery or
lifesaving medicine (penicillin). <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Taleb believes “we do
not need evidence of harm to claim that a drug or an unnatural via positiva
procedure is dangerous.” To
emphasize that harm can be difficult to appreciate, he notes that harm often
occurs in the future and that the past does not tell one much about rare random
events. The Turkey Problem makes
this point.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“The
turkey is fed by the butcher for a thousand days, and every day the turkey
pronounces with increased statistical confidence that the butcher ‘will never
hurt it’ – until Thanksgiving, which brings a Black Swan revision of belief for
the turkey.”<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Following Taleb’s advice
would have avoided the harm caused by Thalidomide (birth defects) and
Diethylstilbestrol (delayed cancer in daughters).<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“Iatrogenics,
being a cost-benefit situation, usually results from the treacherous conditions
in which the benefits are small, and visible – and the costs very large,
delayed, and hidden. And of
course, the potential costs are much worse than the cumulative gains.”<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Another Taleb rule is
“we should not take risks with near-healthy people; but we should take a lot, a
lot more risks with those deemed in danger” because iatrogenics has a
nonlinearity response. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“This
means that we need to focus on high-symptom conditions and ignore, I mean
really ignore, other situations in which the patient is not very ill.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Taleb also recognizes
that the paucity of medical articles reporting negative results has contributed
to the problem of overtreatment with sometimes disastrous results. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“What
made medicine mislead people for so long is that is successes were prominently
displayed, and its mistakes literally buried -- just like so many other interesting stories in the
cemetery of history.”<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Ben Goldacre in the <u>New York Times</u> recently discussed this point
when he wrote about the recall of a Johnson and Johnson artificial hip that
experienced a 40% failure rate:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“</span><span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 15.0pt;">The best evidence shows that half of all the clinical trials ever
conducted and completed on the treatments in use today have never been
published in academic journals. Trials with positive or flattering results,
unsurprisingly, are about twice as likely to be published — and this is true
for both academic research and industry studies.” (</span><a href="http://www.nytimes.com/2013/02/02/opinion/health-cares-trick-coin.html"><span style="font-family: Helvetica;">http://www.nytimes.com/2013/02/02/opinion/health-cares-trick-coin.html</span></a><span style="font-family: Helvetica;">)<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Perhaps the best way to
end this discussion of how to live wisely in a world that we can never truly
understand is to give Taleb the final word:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“If
there is something in nature you don’t understand, odds are it makes sense in a
deeper way that is beyond your understanding. So there is a logic to natural things that is much superior
to our own. Just as there is a
dichotomy in law: innocent until
proven guilty as opposed to guilty until proven innocent, let me express my
rule as follows; what Mother Nature does is rigorous until proven otherwise;
what humans and science do is flawed until proven otherwise.”<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 15.0pt; margin-left: .5in; margin-right: 0in; margin-top: 0in; mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 1.0pt; mso-layout-grid-align: none; mso-pagination: none; tab-stops: 47.0pt 1.0in; text-autospace: none;">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<!--EndFragment-->Kent Bottleshttp://www.blogger.com/profile/12993140567796683570noreply@blogger.com7tag:blogger.com,1999:blog-6653940794693704941.post-79503791035285565502013-02-06T18:18:00.001-05:002013-02-06T18:18:56.735-05:00Ohio vs. Pennsylvania: Which State Got Medicaid Expansion Right?
<!--[if gte mso 9]><xml>
<o:OfficeDocumentSettings>
<o:AllowPNG/>
</o:OfficeDocumentSettings>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:WordDocument>
<w:Zoom>0</w:Zoom>
<w:TrackMoves>false</w:TrackMoves>
<w:TrackFormatting/>
<w:PunctuationKerning/>
<w:DrawingGridHorizontalSpacing>18 pt</w:DrawingGridHorizontalSpacing>
<w:DrawingGridVerticalSpacing>18 pt</w:DrawingGridVerticalSpacing>
<w:DisplayHorizontalDrawingGridEvery>0</w:DisplayHorizontalDrawingGridEvery>
<w:DisplayVerticalDrawingGridEvery>0</w:DisplayVerticalDrawingGridEvery>
<w:ValidateAgainstSchemas/>
<w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid>
<w:IgnoreMixedContent>false</w:IgnoreMixedContent>
<w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText>
<w:Compatibility>
<w:BreakWrappedTables/>
<w:DontGrowAutofit/>
<w:DontAutofitConstrainedTables/>
<w:DontVertAlignInTxbx/>
</w:Compatibility>
</w:WordDocument>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:LatentStyles DefLockedState="false" LatentStyleCount="276">
</w:LatentStyles>
</xml><![endif]-->
<!--[if gte mso 10]>
<style>
/* Style Definitions */
table.MsoNormalTable
{mso-style-name:"Table Normal";
mso-tstyle-rowband-size:0;
mso-tstyle-colband-size:0;
mso-style-noshow:yes;
mso-style-parent:"";
mso-padding-alt:0in 5.4pt 0in 5.4pt;
mso-para-margin:0in;
mso-para-margin-bottom:.0001pt;
mso-pagination:widow-orphan;
font-size:12.0pt;
font-family:"Times New Roman";
mso-ascii-font-family:Cambria;
mso-ascii-theme-font:minor-latin;
mso-fareast-font-family:"Times New Roman";
mso-fareast-theme-font:minor-fareast;
mso-hansi-font-family:Cambria;
mso-hansi-theme-font:minor-latin;}
</style>
<![endif]-->
<!--StartFragment-->
<br />
<div class="MsoNormal">
<span style="font-family: Helvetica;">Reading the
announcements that Governor Corbett (PA) rejects the ACA Medicaid expansion on
the same day that Governors Snyder (MI) and Kasich (OH) decide to expand
Medicaid, I thought today was as good a time as any to take another look at
this controversial issue. On July
7, 2012 I wrote a long blog post that predicted many Republican governors would
eventually agree to the expansion.
My reading of the tealeaves was that it was just too good a deal to pass
up. (</span><a href="http://kentbottles.blogspot.com/2012/07/scotus-ppaca-medicaid-expansion.html"><span style="font-family: Helvetica;">http://kentbottles.blogspot.com/2012/07/scotus-ppaca-medicaid-expansion.html</span></a><span style="font-family: Helvetica;">) <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">When Governor Corbett
said in his budget speech that he would not add 500,000 Pennsylvania residents
to Medicaid “simultaneous boos and cheers broke out among legislators.” (</span><a href="http://www.philly.com/philly/news/politics/state/20130206_Corbett_rejects_expansion_of_Medicaid.html"><span style="font-family: Helvetica;">http://www.philly.com/philly/news/politics/state/20130206_Corbett_rejects_expansion_of_Medicaid.html</span></a><span style="font-family: Helvetica;">) The boos came from those who believed the Henry J.
Kaiser Family Foundation prediction that by 2022 such an expansion would cost
the state $2.8 billion while bringing in $37.8 billion in federal dollars. (</span><a href="http://www.kff.org/medicaid/8384.cfm"><span style="font-family: Helvetica;">http://www.kff.org/medicaid/8384.cfm</span></a><span style="font-family: Helvetica;">) The cheers came from Republicans who were afraid that
the state would have to raise taxes when federal subsidies declined in the
future. In my opinion, Governor
Corbett is making a mistake. I am
not alone in that assessment; I found a comment on a blog dated February 5,
2013 where SteveH wrote:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“I
heard Gail Wilensky speak yesterday and she thinks most GOP governors will end
up taking the expansion. It should
be a no-brainer but some GOP governors probably meet that criteria and will
turn it down.” (</span><a href="http://theincidentaleconomist.com/wordpress/the-medicaid-expansion-is-a-really-great-deal/"><span style="font-family: Helvetica;">http://theincidentaleconomist.com/wordpress/the-medicaid-expansion-is-a-really-great-deal/</span></a><span style="font-family: Helvetica;">)<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Governor Kasich’s
support of Medicaid expansion in Ohio brings to six the number of GOP governors
who have signed onto the program.
Because of his background as a guest host for Bill O’Reilly, an
investment banker, Chairman of the House Budget Committee, and a well-respected
deficit hawk, Kasich’s decision is important. Opponents of state Medicaid expansion certainly were
stunned and attacked him:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“Whatever
justification Kasich may give, the actual explanation for his embrace of the
Medicaid expansion is political cowardice. Chastened by his failed attempt at
public sector union reform and Obama’s victory in the state, Kasich is up for
reelection next year. And he’s
afraid to stand up to the inevitable onslaught of attacks from Democrats who
would charge that he was refusing to accept free money to bring health care to
poor Ohioans.” (</span><a href="http://washingtonexaminer.com/kasichs-cave-on-obamacare-shows-how-hard-it-is-to-beat-big-government/article/2520529?custom_click=rss"><span style="font-family: Helvetica;">http://washingtonexaminer.com/kasichs-cave-on-obamacare-shows-how-hard-it-is-to-beat-big-government/article/2520529?custom_click=rss</span></a><span style="font-family: Helvetica;">)<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Many observers believe
that Kasich’s defection from the opponents of expansion will make it harder for
other GOP governors to maintain this conservative position:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="color: #1a1a1a; font-family: Helvetica; mso-bidi-font-family: Times; mso-bidi-font-size: 14.0pt;">“Anti-ObamaCare
groups have lost the argument with a few other red-state governors, but Kasich
isn't just any red-state governor. He's been known as the most aggressive
spending hawk this side of Scott Walker and Mitch Daniels, and the winner of
the ‘Legislative Entrepreneur Award’ from the tea-party-affiliated
FreedomWorks.” (</span><a href="http://www.politico.com/story/2013/02/john-kasich-obamacares-biggest-red-state-catch-87143_Page2.html"><span style="font-family: Helvetica; mso-bidi-font-family: Times; mso-bidi-font-size: 14.0pt;">http://www.politico.com/story/2013/02/john-kasich-obamacares-biggest-red-state-catch-87143_Page2.html</span></a><span style="color: #1a1a1a; font-family: Helvetica; mso-bidi-font-family: Times; mso-bidi-font-size: 14.0pt;">) </span><span style="font-family: Helvetica;"> <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Democratic analysts
certainly think that the Kasich move is a game changer:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="color: #1a1a1a; font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 13.0pt;">“Thus
Kasich brings us closer to the day when those opposing the Medicaid expansion
in their own states—notably southern governors like Perry and Jindal and Bryant
and Bentley and Deal and Haley who are deliberately creating </span><a href="http://www.washingtonmonthly.com/political-animal-a/2013_01/unlucky_duckies042739.php"><span style="color: #133781; font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 13.0pt; text-decoration: none; text-underline: none;">huge arbitrary
gaps</span></a><span style="color: #1a1a1a; font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 13.0pt;"> in health care coverage—are forced
to stop hiding behind fiscal myths and just come out and admit they don’t want
their citizens to benefit from Obamacare, full stop.” (</span><a href="http://www.washingtonmonthly.com/political-animal-a/2013_02/kasich_gives_away_the_game042802.php"><span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 13.0pt;">http://www.washingtonmonthly.com/political-animal-a/2013_02/kasich_gives_away_the_game042802.php</span></a><span style="color: #1a1a1a; font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 13.0pt;">) <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="color: #1a1a1a; font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 13.0pt;">Kasich came out in favor of
expansion only after he assembled a coalition of Obamacare supporters and
opponents who all agreed that it represented sound economic policy. An Ohio
Health Policy Institute study extending to 2022 concluded that covering 684,000
citizens would require $609 million in state dollars and bring in $5 billion in
federal funds. As I predicted in
my July 2012 blog post, hospitals and physicians wanted the Medicaid
expansion. The Ohio Hospital
Association estimates that hospitals spend $2.5 billion a year on uncompensated
care. The strategy was to have the
coalition concentrate on educating the business community and state legislators
that the expansion made sense economically and was too good to pass up. (</span><a href="http://www.washingtonpost.com/blogs/wonkblog/wp/2013/02/06/exclusive-how-ohios-republican-governor-sold-the-state-on-expanding-medicaid/"><span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 13.0pt;">http://www.washingtonpost.com/blogs/wonkblog/wp/2013/02/06/exclusive-how-ohios-republican-governor-sold-the-state-on-expanding-medicaid/</span></a><span style="color: #1a1a1a; font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 13.0pt;">) <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="color: #1a1a1a; font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 13.0pt;">The best short article on the pro
side is titled “Why Opposition to
Medicaid Expansion is Nuts.” (</span><a href="http://www.bloomberg.com/news/2013-02-05/why-opposition-to-medicaid-expansion-is-nuts.html"><span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 13.0pt;">http://www.bloomberg.com/news/2013-02-05/why-opposition-to-medicaid-expansion-is-nuts.html</span></a><span style="color: #1a1a1a; font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 13.0pt;">) The best
long winded academic argument for expansion can be found here. (</span><a href="http://jhppl.dukejournals.org/content/early/2012/10/09/03616878-1898839.full.pdf"><span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 13.0pt;">http://jhppl.dukejournals.org/content/early/2012/10/09/03616878-1898839.full.pdf</span></a><span style="color: #1a1a1a; font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 13.0pt;">) The best
long argument against expansion, which did not convince me, is here (</span><a href="http://jhppl.dukejournals.org/content/early/2012/10/09/03616878-1898848.full.pdf"><span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 13.0pt;">http://jhppl.dukejournals.org/content/early/2012/10/09/03616878-1898848.full.pdf</span></a><span style="color: #1a1a1a; font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 13.0pt;">) <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="color: #1a1a1a; font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 13.0pt;">Upon rereading my July 2012 blog, I
am glad that I got most of it right immediately after the surprise Supreme
Court decision that created the controversy in the first place. </span><span style="font-family: Helvetica;"><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<!--EndFragment-->Kent Bottleshttp://www.blogger.com/profile/12993140567796683570noreply@blogger.com0tag:blogger.com,1999:blog-6653940794693704941.post-15964264971427819812013-01-31T15:06:00.002-05:002013-01-31T15:06:24.307-05:00Should your review of doctors be taken seriously?
<!--[if gte mso 9]><xml>
<o:OfficeDocumentSettings>
<o:AllowPNG/>
</o:OfficeDocumentSettings>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:WordDocument>
<w:Zoom>0</w:Zoom>
<w:TrackMoves>false</w:TrackMoves>
<w:TrackFormatting/>
<w:PunctuationKerning/>
<w:DrawingGridHorizontalSpacing>18 pt</w:DrawingGridHorizontalSpacing>
<w:DrawingGridVerticalSpacing>18 pt</w:DrawingGridVerticalSpacing>
<w:DisplayHorizontalDrawingGridEvery>0</w:DisplayHorizontalDrawingGridEvery>
<w:DisplayVerticalDrawingGridEvery>0</w:DisplayVerticalDrawingGridEvery>
<w:ValidateAgainstSchemas/>
<w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid>
<w:IgnoreMixedContent>false</w:IgnoreMixedContent>
<w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText>
<w:Compatibility>
<w:BreakWrappedTables/>
<w:DontGrowAutofit/>
<w:DontAutofitConstrainedTables/>
<w:DontVertAlignInTxbx/>
</w:Compatibility>
</w:WordDocument>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:LatentStyles DefLockedState="false" LatentStyleCount="276">
</w:LatentStyles>
</xml><![endif]-->
<!--[if gte mso 10]>
<style>
/* Style Definitions */
table.MsoNormalTable
{mso-style-name:"Table Normal";
mso-tstyle-rowband-size:0;
mso-tstyle-colband-size:0;
mso-style-noshow:yes;
mso-style-parent:"";
mso-padding-alt:0in 5.4pt 0in 5.4pt;
mso-para-margin:0in;
mso-para-margin-bottom:.0001pt;
mso-pagination:widow-orphan;
font-size:12.0pt;
font-family:"Times New Roman";
mso-ascii-font-family:Cambria;
mso-ascii-theme-font:minor-latin;
mso-fareast-font-family:"Times New Roman";
mso-fareast-theme-font:minor-fareast;
mso-hansi-font-family:Cambria;
mso-hansi-theme-font:minor-latin;}
</style>
<![endif]-->
<!--StartFragment-->
<br />
<div class="MsoNormal" style="margin-bottom: 12.0pt; mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<span style="color: #262626; font-family: Helvetica; mso-bidi-font-family: Verdana;">Recent articles highlight challenges with holding
providers accountable for the care they deliver. One of the major thrusts of
efforts to transform the American healthcare delivery system has been to become
more patient-centered and to allow patients to provide feedback that matters.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 12.0pt; mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<span style="color: #262626; font-family: Helvetica; mso-bidi-font-family: Verdana;">Emblematic of this is the emphasis on patient
involvement in the final rules for the Shared Savings Program accountable care
organizations (ACO).<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="color: #262626; font-family: Helvetica; mso-bidi-font-family: Verdana;">Echoing former Centers for Medicare & Medicaid
Services Director Don Berwick's plea on the behalf of patients ("Nothing
about us without us"), the ACO final rules emphasize patient engagement in
governance, quality improvement and the individual doctor/patient interaction.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="color: #262626; font-family: Helvetica; mso-bidi-font-family: Verdana;">Follow the link for the rest of this blog</span><span style="font-family: Helvetica;"><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">http://www.hospitalimpact.org/index.php/2013/01/30/is_patient_empowerment_the_next_step_for#disqus_thread<o:p></o:p></span></div>
<!--EndFragment-->Kent Bottleshttp://www.blogger.com/profile/12993140567796683570noreply@blogger.com0tag:blogger.com,1999:blog-6653940794693704941.post-36737407072614665422013-01-16T15:30:00.000-05:002013-01-16T15:30:13.836-05:00The Humanities vs. Science Question Revisited
<!--[if gte mso 9]><xml>
<o:OfficeDocumentSettings>
<o:AllowPNG/>
</o:OfficeDocumentSettings>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:WordDocument>
<w:Zoom>0</w:Zoom>
<w:TrackMoves>false</w:TrackMoves>
<w:TrackFormatting/>
<w:PunctuationKerning/>
<w:DrawingGridHorizontalSpacing>18 pt</w:DrawingGridHorizontalSpacing>
<w:DrawingGridVerticalSpacing>18 pt</w:DrawingGridVerticalSpacing>
<w:DisplayHorizontalDrawingGridEvery>0</w:DisplayHorizontalDrawingGridEvery>
<w:DisplayVerticalDrawingGridEvery>0</w:DisplayVerticalDrawingGridEvery>
<w:ValidateAgainstSchemas/>
<w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid>
<w:IgnoreMixedContent>false</w:IgnoreMixedContent>
<w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText>
<w:Compatibility>
<w:BreakWrappedTables/>
<w:DontGrowAutofit/>
<w:DontAutofitConstrainedTables/>
<w:DontVertAlignInTxbx/>
</w:Compatibility>
</w:WordDocument>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:LatentStyles DefLockedState="false" LatentStyleCount="276">
</w:LatentStyles>
</xml><![endif]-->
<!--[if gte mso 10]>
<style>
/* Style Definitions */
table.MsoNormalTable
{mso-style-name:"Table Normal";
mso-tstyle-rowband-size:0;
mso-tstyle-colband-size:0;
mso-style-noshow:yes;
mso-style-parent:"";
mso-padding-alt:0in 5.4pt 0in 5.4pt;
mso-para-margin:0in;
mso-para-margin-bottom:.0001pt;
mso-pagination:widow-orphan;
font-size:12.0pt;
font-family:"Times New Roman";
mso-ascii-font-family:Cambria;
mso-ascii-theme-font:minor-latin;
mso-fareast-font-family:"Times New Roman";
mso-fareast-theme-font:minor-fareast;
mso-hansi-font-family:Cambria;
mso-hansi-theme-font:minor-latin;}
</style>
<![endif]-->
<!--StartFragment-->
<br />
<div class="MsoBodyText">
<span style="font-family: Helvetica;">Two of my favorite
quotations are the 19</span><sup><span style="font-family: Helvetica; mso-bidi-font-size: 11.0pt;">th</span></sup><span style="font-family: Helvetica;">
century neurologist Jean Martin Charcot’s “Theory is good, but it doesn’t
prevent things from existing” and Albert Einstein’s <span style="color: #101010;">“In
theory, theory and practice are the same. In practice, they are not.” <o:p></o:p></span></span></div>
<div class="MsoBodyText">
<span style="font-family: Helvetica;"><span style="color: #101010;"><br /></span></span></div>
<div class="MsoBodyText">
<span style="font-family: Helvetica;">These two statements
summarize the tension between a medical science that thinks it can explain
everything and my own experience that an alternative theory of the mind is
needed. I explore these issues in great detail in a five part essay
titled Human Understanding, Randomness, Free Will, and Delusions found here <a href="http://www.thedoctorweighsin.com/human-understanding-randomness-free-will-and-delusion-part-i/"><span style="color: #3675a7; text-decoration: none; text-underline: none;">http://www.thedoctorweighsin.com/human-understanding-randomness-free-will-and-delusion-part-i/</span></a>,
<a href="http://www.thedoctorweighsin.com/human-understanding-randomness-free-will-and-delusion-part-ii/"><span style="color: #3675a7; text-decoration: none; text-underline: none;">http://www.thedoctorweighsin.com/human-understanding-randomness-free-will-and-delusion-part-ii/</span></a>,
<a href="http://www.thedoctorweighsin.com/human-understanding-randomness-free-will-and-delusion-part-iii/"><span style="color: #3675a7; text-decoration: none; text-underline: none;">http://www.thedoctorweighsin.com/human-understanding-randomness-free-will-and-delusion-part-iii/</span></a>,
<a href="http://www.thedoctorweighsin.com/human-understanding-randomness-free-will-and-delusion-part-iv/"><span style="color: #3675a7; text-decoration: none; text-underline: none;">http://www.thedoctorweighsin.com/human-understanding-randomness-free-will-and-delusion-part-iv/</span></a>,
<a href="http://www.thedoctorweighsin.com/human-understanding-randomness-free-will-and-delusion-part-v/"><span style="color: #3675a7; text-decoration: none; text-underline: none;">http://www.thedoctorweighsin.com/human-understanding-randomness-free-will-and-delusion-part-v/</span></a>
and in a two part essay titled The Humanities vs. Science linked here <a href="http://www.thedoctorweighsin.com/the-humanities-vs-science-part-i/"><span style="color: #3675a7; text-decoration: none; text-underline: none;">http://www.thedoctorweighsin.com/the-humanities-vs-science-part-i/</span></a>
and <span style="color: #3675a7; text-decoration: none; text-underline: none;"><a href="http://www.thedoctorweighsin.com/the-humanities-vs-science-part-ii/">http://www.thedoctorweighsin.com/the-humanities-vs-science-part-ii/</a></span><o:p></o:p></span></div>
<div class="MsoBodyText">
<span style="font-family: Helvetica;"><br /></span></div>
<div style="background: white; line-height: 22.0pt;">
<span style="font-family: Helvetica; font-size: 12.0pt; mso-bidi-font-size: 10.0pt;">I first started worrying about
this controversy when I read</span><span style="color: #111111; font-family: Helvetica; font-size: 12.0pt; mso-bidi-font-size: 14.0pt;"> </span><span style="font-family: Helvetica; font-size: 12.0pt; mso-bidi-font-size: 10.0pt;"><a href="http://www.thedoctorweighsin.com/the-humanities-vs-science-part-ii/(http://ow.ly/bNVE5)"><span style="color: windowtext; text-decoration: none; text-underline: none;">Francis Crick</span></a></span><span style="color: #111111; font-family: Helvetica; font-size: 12.0pt; mso-bidi-font-size: 14.0pt;">’s Astonishing Hypothesis:<o:p></o:p></span></div>
<div class="MsoBodyTextIndent">
<span style="font-family: Helvetica;">“You, your joys
and sorrows, your memories and your ambitions, your sense of personal identity
and free will, are in fact no more than the behavior of a vast assembly of
nerve cells and their associated molecules.” <o:p></o:p></span></div>
<div class="MsoBodyTextIndent">
<span style="font-family: Helvetica;"><br /></span></div>
<div class="MsoBodyText">
<span style="font-family: Helvetica;">This subject of
humanities vs. the sciences was not on my mind last night when I settled in by
the fire to read “Escape From Spiderhead,” the fourth short story in George
Saunders’ new collection Tenth of December. By the time I had finished this 37-page short story, I
understood that Saunders had captured the essence of what is wrong with
Nobelist Crick’s theory.<o:p></o:p></span></div>
<div class="MsoBodyText">
<span style="font-family: Helvetica;"><br /></span></div>
<div class="MsoBodyText">
<span style="font-family: Helvetica;">The main character
Jeff is subjected to scientific experiments as part of his punishment for a
violent crime; the investigators inject VerbaluceTM, VeriTalk TM, ChatEaseTM
and ED556 in Jeff’s MobiPakTM and observe the results. A few pages into the story, I realized
we are in the future and the scientists are testing Crick’s Astonishing Hypothesis. By manipulating Jeff’s “nerve cells and
their associated molecules,” the investigators make Jeff fall passionately and
physically in love with two other subjects, Heather and Rachel. By changing the chemicals in the
MobiPakTM they can make all of the subjects feel nothing for their former lover. <o:p></o:p></span></div>
<div class="MsoBodyText">
<span style="font-family: Helvetica;"><br /></span></div>
<div class="MsoBodyText">
<span style="font-family: Helvetica;">In follow-up
experiments, Jeff is devastated when Heather dies after Jeff is told to give
her DarkenfloxxTM. The head
scientist tells Jeff:<o:p></o:p></span></div>
<div class="MsoBodyText">
<span style="font-family: Helvetica;"><br /></span></div>
<div class="MsoBodyTextIndent">
<span style="font-family: Helvetica;">“In science, we
explore the unknown. It was
unknown what five minutes on DarkenfloxxTM would do to Heather. Now we
know. The other thing we know…is
that you really, for sure, do not harbor any residual romantic feelings for
Heather. That’s a big deal, Jeff.
A beacon of hope at a sad time for all… My guess is, ProtComm’s going to be
like: ‘Wow, Utica’s really leading
the pack in terms of providing mind-blowing new data on ED289/290.’”<o:p></o:p></span></div>
<div class="MsoBodyTextIndent">
<span style="font-family: Helvetica;"><br /></span></div>
<div class="MsoBodyText">
<span style="font-family: Helvetica;">In a twist at the end,
Jeff validating his humanity finds an unexpected way to refuse to participate
in such experiments on human beings.<o:p></o:p></span></div>
<div class="MsoBodyText">
<span style="font-family: Helvetica;"><br /></span></div>
<div class="MsoBodyText">
<span style="font-family: Helvetica;">Saunders’ story gives
me more reason to reject Crick and embrace <a href="http://ow.ly/bNPbC"><span style="color: windowtext; text-decoration: none; text-underline: none;">Marilynne
Robinso</span><span style="color: #2361a1; text-decoration: none; text-underline: none;">n</span></a>’s conclusion in her <span style="background: white;">Dwight
Harrington Terry Foundation Lectures on Religion in the Light of Science and
Philosophy at Yale. She believes</span></span><span style="font-family: Helvetica; mso-bidi-font-size: 10.0pt;"> </span><span style="font-family: Helvetica;">that there is a mind separate from the brain,
there are things unknowable in this world, and that the humanities can still
teach me things that science cannot explain:</span><span style="font-family: Helvetica; mso-bidi-font-size: 10.0pt;"><o:p></o:p></span></div>
<div class="MsoBodyText">
<span style="font-family: Helvetica;"><br /></span></div>
<div class="MsoBodyText" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“As
proof of the existence of mind we have only history and civilization, art, science,
and philosophy. And at the same time, of course, that extraordinary individuation.”</span><span style="font-family: Helvetica; mso-bidi-font-size: 14.0pt;"><o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;"><a href="http://www.share-widget.com/myshare.php5"><span style="background: white; color: #0098cc; mso-bidi-font-size: 11.0pt;"><br />
</span></a></span><span style="font-family: Helvetica; mso-bidi-font-size: 10.0pt;"><o:p></o:p></span></div>
<div class="MsoNormal" style="background: white; line-height: 22.0pt;">
<br /></div>
<div class="MsoNormal" style="background: white; line-height: 22.0pt;">
<br /></div>
<div class="MsoNormal" style="background: white; line-height: 22.0pt;">
<br /></div>
<div class="MsoNormal" style="background: white; line-height: 22.0pt;">
<span style="font-family: Helvetica;"> <o:p></o:p></span></div>
<div class="MsoNormal" style="background: white; line-height: 22.0pt;">
<br /></div>
<div class="MsoNormal" style="background: white; line-height: 22.0pt;">
<br /></div>
<div class="MsoNormal">
<br /></div>
<!--EndFragment-->Kent Bottleshttp://www.blogger.com/profile/12993140567796683570noreply@blogger.com1tag:blogger.com,1999:blog-6653940794693704941.post-6782187651290027192013-01-08T18:12:00.003-05:002013-01-08T18:12:41.641-05:00The Downsides of Setting Professional & Personal Goalshttp://www.hospitalimpact.org/index.php/2013/01/07/title_85Kent Bottleshttp://www.blogger.com/profile/12993140567796683570noreply@blogger.com1tag:blogger.com,1999:blog-6653940794693704941.post-75124019282353969012012-12-31T11:26:00.001-05:002012-12-31T11:26:47.539-05:00An Information Flaneur's Best Blog Posts of 2012
<!--[if gte mso 9]><xml>
<o:OfficeDocumentSettings>
<o:AllowPNG/>
</o:OfficeDocumentSettings>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:WordDocument>
<w:Zoom>0</w:Zoom>
<w:TrackMoves>false</w:TrackMoves>
<w:TrackFormatting/>
<w:PunctuationKerning/>
<w:DrawingGridHorizontalSpacing>18 pt</w:DrawingGridHorizontalSpacing>
<w:DrawingGridVerticalSpacing>18 pt</w:DrawingGridVerticalSpacing>
<w:DisplayHorizontalDrawingGridEvery>0</w:DisplayHorizontalDrawingGridEvery>
<w:DisplayVerticalDrawingGridEvery>0</w:DisplayVerticalDrawingGridEvery>
<w:ValidateAgainstSchemas/>
<w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid>
<w:IgnoreMixedContent>false</w:IgnoreMixedContent>
<w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText>
<w:Compatibility>
<w:BreakWrappedTables/>
<w:DontGrowAutofit/>
<w:DontAutofitConstrainedTables/>
<w:DontVertAlignInTxbx/>
</w:Compatibility>
</w:WordDocument>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:LatentStyles DefLockedState="false" LatentStyleCount="276">
</w:LatentStyles>
</xml><![endif]-->
<!--[if gte mso 10]>
<style>
/* Style Definitions */
table.MsoNormalTable
{mso-style-name:"Table Normal";
mso-tstyle-rowband-size:0;
mso-tstyle-colband-size:0;
mso-style-noshow:yes;
mso-style-parent:"";
mso-padding-alt:0in 5.4pt 0in 5.4pt;
mso-para-margin:0in;
mso-para-margin-bottom:.0001pt;
mso-pagination:widow-orphan;
font-size:10.0pt;
font-family:"Times New Roman";
mso-ascii-font-family:Cambria;
mso-ascii-theme-font:minor-latin;
mso-hansi-font-family:Cambria;
mso-hansi-theme-font:minor-latin;}
</style>
<![endif]-->
<!--StartFragment-->
<br />
<div class="MsoNormal">
<span style="font-family: Helvetica;">As a self described
Information Flaneur who wanders aimlessly around the Internet and my world
searching for what I don’t know that I don’t know, I did not expect to find any
rhyme or reason to my 2012 blog posts.
And yet when I read them today on New Year’s Eve to select the Best of 2012,
I surprised myself by finding six coherent and recurring overarching themes:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoListParagraphCxSpFirst" style="mso-list: l0 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><span style="font-family: Helvetica;">American
physicians have lost their way and need to undergo intense self-scrutiny<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><span style="font-family: Helvetica;">American
health plans need to reinvent themselves or disappear<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><span style="font-family: Helvetica;">The digital
future of medicine is fascinating and largely unknowable<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><span style="font-family: Helvetica;">There is an
urgent need to bridge the gap between the humanities and the sciences<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><span style="font-family: Helvetica;">The American
preoccupation with Happiness is wrongheaded but extremely important<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpLast" style="mso-list: l0 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><span style="font-family: Helvetica;">Understanding
and explaining the Affordable Act takes a lot of time and energy, but it is
worth it <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoListParagraphCxSpFirst">
<b><span style="font-family: Helvetica;">American physicians have lost their way and need
to undergo intense self-scrutiny<o:p></o:p></span></b></div>
<div class="MsoListParagraphCxSpLast">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Some of my closest
colleagues found it amusing that I of all people wrote passionately about the
need for physicians to embrace humility and win the battle for the soul of American
Medicine. </span><span style="background: white; color: #111111; font-family: Helvetica; mso-bidi-font-size: 9.5pt;">“Early in life I had to choose between honest
arrogance and hypocritical humility. I chose the former and have seen no reason
to change” is a Frank Lloyd Wright quotation that I used ironically at the
start of one of my diatribes calling for physicians to undergo intense self-scrutiny,
and my closest friend said he thought Wright could be speaking for me.</span><span style="font-family: Helvetica; mso-bidi-font-size: 10.0pt;"><o:p></o:p></span></div>
<div class="MsoListParagraph">
<a href="http://www.thedoctorweighsin.com/physicians-humility-and-the-transformation-of-american-healthcare-2/"><span style="font-family: Helvetica;">http://www.thedoctorweighsin.com/physicians-humility-and-the-transformation-of-american-healthcare-2/</span></a><span style="font-family: Helvetica;"> <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Nevertheless, there is a
battle for the soul of American Medicine; I pontificated about it here </span><a href="http://thehealthcareblog.com/blog/2012/12/20/the-battle-for-the-souls-of-american-doctors/"><span style="font-family: Helvetica;">http://thehealthcareblog.com/blog/2012/12/20/the-battle-for-the-souls-of-american-doctors/</span></a><span style="font-family: Helvetica;"> and
in a three part essay inspired by the English Olympics Opening Ceremony, which
celebrated the National Health Service </span><a href="http://www.thedoctorweighsin.com/the-olympics-doctors-nhs-transformation-and-heroes-why-the-difference-between-usa-and-uk/"><span style="font-family: Helvetica;">http://www.thedoctorweighsin.com/the-olympics-doctors-nhs-transformation-and-heroes-why-the-difference-between-usa-and-uk/</span></a><span style="font-family: Helvetica;">, </span><a href="http://www.thedoctorweighsin.com/the-olympics-doctors-the-nhs-transformation-and-heroes-why-the-difference-between-the-usa-and-uk-part-ii/"><span style="font-family: Helvetica;">http://www.thedoctorweighsin.com/the-olympics-doctors-the-nhs-transformation-and-heroes-why-the-difference-between-the-usa-and-uk-part-ii/</span></a><span style="font-family: Helvetica;">, </span><a href="http://www.thedoctorweighsin.com/the-olympics-doctors-the-nhs-transformation-and-heroes-why-the-difference-between-the-usa-and-uk-part-iii/"><span style="font-family: Helvetica;">http://www.thedoctorweighsin.com/the-olympics-doctors-the-nhs-transformation-and-heroes-why-the-difference-between-the-usa-and-uk-part-iii/</span></a><span style="font-family: Helvetica;">
These blogs drew the wrath of many practicing physicians, as did my blog
post that attributed much of any personal or professional success to luck </span><a href="http://www.thedoctorweighsin.com/does-luck-contribute-to-personal-success-2/"><span style="font-family: Helvetica;">http://www.thedoctorweighsin.com/does-luck-contribute-to-personal-success-2/</span></a><span style="font-family: Helvetica;">.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoListParagraph">
<b><span style="font-family: Helvetica;">American health plans need to reinvent themselves
or disappear<o:p></o:p></span></b></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">The survival of Obama’s
Affordable Care Act has demolished the traditional business model of the
American health insurance company, and it has been fascinating to watch them
scramble to reinvent themselves.
Some are buying bankrupt delivery systems and others are investing in
providers and smartphone applications, but none of these tactics will work
unless they can transform their corporate cultures. Read about the challenges here </span><a href="http://thehealthcareblog.com/blog/2012/07/22/health-insurers-the-affordable-care-act-extinction-or-reinvention/"><span style="font-family: Helvetica;">http://thehealthcareblog.com/blog/2012/07/22/health-insurers-the-affordable-care-act-extinction-or-reinvention/</span></a><span style="font-family: Helvetica;">, here </span><a href="http://www.thedoctorweighsin.com/health-plans-continue-to-struggle-to-reinvent-themselves/"><span style="font-family: Helvetica;">http://www.thedoctorweighsin.com/health-plans-continue-to-struggle-to-reinvent-themselves/</span></a><span style="font-family: Helvetica;">, and here </span><a href="http://kentbottles.blogspot.com/2012/03/technology-aetna-itriage-and-future-of.html"><span style="font-family: Helvetica;">http://kentbottles.blogspot.com/2012/03/technology-aetna-itriage-and-future-of.html</span></a><span style="font-family: Helvetica;">. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><span style="font-family: Helvetica;">The digital future of medicine is fascinating and
largely unknowable<o:p></o:p></span></b></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Like everyone else I
read Eric Topol’s book and tried to keep track on Twitter of how digitizing a
human being will revolutionize medicine.
I reviewed two books on digital medicine </span><a href="http://www.thedoctorweighsin.com/the-future-of-medicine-as-envisioned-by-topol-and-agus/"><span style="font-family: Helvetica;">http://www.thedoctorweighsin.com/the-future-of-medicine-as-envisioned-by-topol-and-agus/</span></a><span style="font-family: Helvetica;">, advised hospital executives to get with it </span><a href="http://www.hospitalimpact.org/index.php/2012/03/06/p4009#more4009"><span style="font-family: Helvetica;">http://www.hospitalimpact.org/index.php/2012/03/06/p4009#more4009</span></a><span style="font-family: Helvetica;">, and wrote a summary of an iMedicine conference
organized by medical students </span><a href="http://kentbottles.blogspot.com/2012/04/imedicine-influence-of-social-media-on.html"><span style="font-family: Helvetica;">http://kentbottles.blogspot.com/2012/04/imedicine-influence-of-social-media-on.html</span></a><span style="font-family: Helvetica;">. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoListParagraphCxSpFirst">
<b><span style="font-family: Helvetica;">There is an urgent need to bridge the gap between
the humanities and science<o:p></o:p></span></b></div>
<div class="MsoListParagraphCxSpLast">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Two of my favorite
quotations are the 19<sup>th</sup> century neurologist Jean Martin Charcot’s
“Theory is good, but it doesn’t prevent things from existing” and Albert
Einstein’s </span><span style="color: #131313; font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 14.0pt;">“In theory, theory and practice are
the same. In practice, they are not.”
These two statements summarize the tension between a medical science
that thinks it can explain everything and my own experience that an alternative
theory of the mind is needed. I
explore these issues in great detail in a five part essay titled Human Understanding,
Randomness, Free Will, and Delusions found here </span><a href="http://www.thedoctorweighsin.com/human-understanding-randomness-free-will-and-delusion-part-i/"><span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 14.0pt;">http://www.thedoctorweighsin.com/human-understanding-randomness-free-will-and-delusion-part-i/</span></a><span style="color: #131313; font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 14.0pt;">, </span><a href="http://www.thedoctorweighsin.com/human-understanding-randomness-free-will-and-delusion-part-ii/"><span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 14.0pt;">http://www.thedoctorweighsin.com/human-understanding-randomness-free-will-and-delusion-part-ii/</span></a><span style="color: #131313; font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 14.0pt;">, </span><a href="http://www.thedoctorweighsin.com/human-understanding-randomness-free-will-and-delusion-part-iii/"><span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 14.0pt;">http://www.thedoctorweighsin.com/human-understanding-randomness-free-will-and-delusion-part-iii/</span></a><span style="color: #131313; font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 14.0pt;">, </span><a href="http://www.thedoctorweighsin.com/human-understanding-randomness-free-will-and-delusion-part-iv/"><span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 14.0pt;">http://www.thedoctorweighsin.com/human-understanding-randomness-free-will-and-delusion-part-iv/</span></a><span style="color: #131313; font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 14.0pt;">, </span><a href="http://www.thedoctorweighsin.com/human-understanding-randomness-free-will-and-delusion-part-v/"><span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 14.0pt;">http://www.thedoctorweighsin.com/human-understanding-randomness-free-will-and-delusion-part-v/</span></a><span style="color: #131313; font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 14.0pt;"> and in a two part essay titled The Humanities vs.
Science linked here </span><a href="http://www.thedoctorweighsin.com/the-humanities-vs-science-part-i/"><span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 14.0pt;">http://www.thedoctorweighsin.com/the-humanities-vs-science-part-i/</span></a><span style="color: #131313; font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 14.0pt;"> and </span><a href="http://www.thedoctorweighsin.com/the-humanities-vs-science-part-ii/"><span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 14.0pt;">http://www.thedoctorweighsin.com/the-humanities-vs-science-part-ii/</span></a><span style="color: #131313; font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 14.0pt;"> <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="color: #131313; font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 14.0pt;">Siri Hustvedt’s elegant book review
of Oliver Sacks’ new book <u>Hallucinations </u>convinces
me I need to read more of Sacks and re-read some of Hustvedt’s novels to make
better sense of this complex subject. (http://www.nytimes.com/2012/12/30/books/review/hallucinations-by-oliver-sacks.html)<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoListParagraphCxSpFirst">
<b><span style="font-family: Helvetica;">The American preoccupation with Happiness is
wrongheaded but extremely important<o:p></o:p></span></b></div>
<div class="MsoListParagraphCxSpLast">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Even though I have read
at last count 19 books on happiness, I am always a little bit skeptical about
the whole enterprise. I do find it
fascinating that bronze medal winners are happier than silver medal winners and
that winning the lottery often results in misery, but there is something
wrongheaded about pursuing happiness as a goal. Viewing Stefan Sagmeister’s The Happy Show at an art museum
at the University of Pennsylvania inspired me to write a four part blog post on
happiness: </span><a href="http://www.thedoctorweighsin.com/musings-on-stefan-sagmeisters-the-happy-show/"><span style="font-family: Helvetica;">http://www.thedoctorweighsin.com/musings-on-stefan-sagmeisters-the-happy-show/</span></a><span style="font-family: Helvetica;">, </span><a href="http://www.thedoctorweighsin.com/musings-on-stefan-sagmeister-the-happy-show-part-ii/"><span style="font-family: Helvetica;">http://www.thedoctorweighsin.com/musings-on-stefan-sagmeister-the-happy-show-part-ii/</span></a><span style="font-family: Helvetica;">, </span><a href="http://www.thedoctorweighsin.com/musings-on-stefan-sagmeister-the-happy-show-part-iii/"><span style="font-family: Helvetica;">http://www.thedoctorweighsin.com/musings-on-stefan-sagmeister-the-happy-show-part-iii/</span></a><span style="font-family: Helvetica;">, </span><a href="http://kentbottles.blogspot.com/2012/05/musings-on-stefan-sagmeister-happy-show_21.html"><span style="font-family: Helvetica;">http://kentbottles.blogspot.com/2012/05/musings-on-stefan-sagmeister-happy-show_21.html</span></a><span style="font-family: Helvetica;">. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">My skepticism about the
whole subject made me write The Downsides of Trying Too Hard to Be Happy, which
can be found here </span><a href="http://www.thedoctorweighsin.com/the-downsides-of-trying-too-hard-to-be-happy-part-i/"><span style="font-family: Helvetica;">http://www.thedoctorweighsin.com/the-downsides-of-trying-too-hard-to-be-happy-part-i/</span></a><span style="font-family: Helvetica;"> and </span><a href="http://www.thedoctorweighsin.com/the-downsides-of-trying-too-hard-to-be-happy-part-ii/"><span style="font-family: Helvetica;">http://www.thedoctorweighsin.com/the-downsides-of-trying-too-hard-to-be-happy-part-ii/</span></a><span style="font-family: Helvetica;">. I just finished reading a new book by Oliver Burkeman
titled <u>The Antidote: Happiness for People Who Can’t Stand Positive Thinking</u>,
which has reinforced and brought focus to my skepticism. I recommend it highly.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><span style="font-family: Helvetica;">Understanding and explaining the Affordable Act
takes a lot of time and energy, but it is worth<o:p></o:p></span></b></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">I spent much of 2012
running around the country giving keynotes, retreats, and seminars on the
Affordable Care Act. I also
enjoyed teaching another graduate class at the Thomas Jefferson School of
Population Health on health policy and the structure of the American delivery
system. My best blogs on this
subject were on the demise of fee for service payments </span><a href="http://healthworkscollective.com/kent-bottles/70536/fee-service-really-dead"><span style="font-family: Helvetica;">http://healthworkscollective.com/kent-bottles/70536/fee-service-really-dead</span></a><span style="font-family: Helvetica;">, the Supreme Court decision upholding the
individual mandate </span><a href="http://kentbottles.blogspot.com/2012/06/why-did-chief-justice-roberts-do-it.html"><span style="font-family: Helvetica;">http://kentbottles.blogspot.com/2012/06/why-did-chief-justice-roberts-do-it.html</span></a><span style="font-family: Helvetica;">, and the Medicaid expansion controversy </span><a href="http://www.thedoctorweighsin.com/the-scotus-the-ppaca-the-medicaid-expansion-decision/"><span style="font-family: Helvetica;">http://www.thedoctorweighsin.com/the-scotus-the-ppaca-the-medicaid-expansion-decision/</span></a><span style="font-family: Helvetica;">. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">At the end of 2012 I was
asked to predict what health care journalists should cover in 2013. My essay can be read here <a href="http://www.reportingonhealth.org/2012/11/15/kent-bottles-new-ideas-covering-health-care-2013">http://www.reportingonhealth.org/2012/11/15/kent-bottles-new-ideas-covering-health-care-2013</a>.
However, I must warn you that a
far better way to understand health care in 2013 is to wander around twitter,
read books and newspapers, and go to conferences in fields other than medicine. Join me in becoming an information
flaneur. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoListParagraph">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<!--EndFragment-->Kent Bottleshttp://www.blogger.com/profile/12993140567796683570noreply@blogger.com1tag:blogger.com,1999:blog-6653940794693704941.post-61379637223057479972012-12-19T15:26:00.001-05:002012-12-19T15:26:11.167-05:00The Battle for the Souls of American Doctors
<!--[if gte mso 9]><xml>
<o:OfficeDocumentSettings>
<o:AllowPNG/>
</o:OfficeDocumentSettings>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:WordDocument>
<w:Zoom>0</w:Zoom>
<w:TrackMoves>false</w:TrackMoves>
<w:TrackFormatting/>
<w:PunctuationKerning/>
<w:DrawingGridHorizontalSpacing>18 pt</w:DrawingGridHorizontalSpacing>
<w:DrawingGridVerticalSpacing>18 pt</w:DrawingGridVerticalSpacing>
<w:DisplayHorizontalDrawingGridEvery>0</w:DisplayHorizontalDrawingGridEvery>
<w:DisplayVerticalDrawingGridEvery>0</w:DisplayVerticalDrawingGridEvery>
<w:ValidateAgainstSchemas/>
<w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid>
<w:IgnoreMixedContent>false</w:IgnoreMixedContent>
<w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText>
<w:Compatibility>
<w:BreakWrappedTables/>
<w:DontGrowAutofit/>
<w:DontAutofitConstrainedTables/>
<w:DontVertAlignInTxbx/>
</w:Compatibility>
</w:WordDocument>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:LatentStyles DefLockedState="false" LatentStyleCount="276">
</w:LatentStyles>
</xml><![endif]-->
<!--[if gte mso 10]>
<style>
/* Style Definitions */
table.MsoNormalTable
{mso-style-name:"Table Normal";
mso-tstyle-rowband-size:0;
mso-tstyle-colband-size:0;
mso-style-noshow:yes;
mso-style-parent:"";
mso-padding-alt:0in 5.4pt 0in 5.4pt;
mso-para-margin:0in;
mso-para-margin-bottom:.0001pt;
mso-pagination:widow-orphan;
font-size:12.0pt;
font-family:"Times New Roman";
mso-ascii-font-family:Cambria;
mso-ascii-theme-font:minor-latin;
mso-fareast-font-family:"Times New Roman";
mso-fareast-theme-font:minor-fareast;
mso-hansi-font-family:Cambria;
mso-hansi-theme-font:minor-latin;}
</style>
<![endif]-->
<!--StartFragment-->
<br />
<div class="MsoNormal">
<span style="font-family: Helvetica;">We physicians like to
think that we are really different from other workers. We physicians, perhaps thinking back to
that medical school application essay we all wrote, really believe that we went
into this career to simply help others.
We physicians truly believe that we always put our patients first. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Because we sincerely
believe all of the above, we are shocked when someone like Uwe Reinhardt points
out that collectively we act just like any other worker in the economy. The classic 1986 letters between the
Princeton professor Reinhardt and former New England Journal of Medicine editor
Arnold Relman highlight the tension between how we think of ourselves and how
we act. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="color: #1a1a1a; font-family: Helvetica; mso-bidi-font-family: Helvetica; mso-bidi-font-size: 13.0pt;">Relman thinks physicians are
special and he asks Reinhardt the following question:</span><span style="color: #1a1a1a; font-family: Helvetica; mso-bidi-font-family: Arial; mso-bidi-font-size: 13.0pt;"><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="color: #1a1a1a; font-family: Helvetica; mso-bidi-font-family: Helvetica; mso-bidi-font-size: 13.0pt;">“Do you really see no difference
between physicians and hospitals on the one hand, and ‘purveyors of other goods
and services,’ on the other?”</span><span style="color: #1a1a1a; font-family: Helvetica; mso-bidi-font-family: Arial; mso-bidi-font-size: 13.0pt;"><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="color: #1a1a1a; font-family: Helvetica; mso-bidi-font-family: Helvetica; mso-bidi-font-size: 13.0pt;">Reinhardt is ready with a long
answer that should be read in its entirety. The short answer is that
doctors act like any other human beings. A portion of his answer
includes the following:</span><span style="color: #1a1a1a; font-family: Helvetica; mso-bidi-font-family: Arial; mso-bidi-font-size: 13.0pt;"><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="color: #1a1a1a; font-family: Helvetica; mso-bidi-font-family: Helvetica; mso-bidi-font-size: 13.0pt;">“Surely you will agree that it
has been one of American medicine’s more hallowed tenets that piece-rate
compensation is the sine qua non of high quality medical care. Think
about this tenet, We have here a profession that openly professes that its
members are unlikely to do their best unless they are rewarded in cold cash for
every little ministration rendered their patients. If an economist made
that assertion, one might write it off as one more of that profession’s kooky
beliefs. But physicians are saying it.” (</span><a href="http://content.healthaffairs.org/content/5/2/5.full.pdf+html"><span style="color: #3675a7; font-family: Helvetica; mso-bidi-font-family: Helvetica; mso-bidi-font-size: 13.0pt; text-decoration: none; text-underline: none;">http://content.healthaffairs.org/content/5/2/5.full.pdf+html</span></a><span style="color: #1a1a1a; font-family: Helvetica; mso-bidi-font-family: Helvetica; mso-bidi-font-size: 13.0pt;">)</span><span style="font-family: Helvetica;"> <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">I have recently written
about the inevitable transition from fee for service payment to global,
value-based payment systems, and I was surprised when a primary care physician
whom I admire tweeted that he thought the end of fee for service would be the
end of primary care. (</span><a href="http://thehealthcareblog.com/blog/2012/12/12/is-fee-for-service-really-dead-really/"><span style="font-family: Helvetica;">http://thehealthcareblog.com/blog/2012/12/12/is-fee-for-service-really-dead-really/</span></a><span style="font-family: Helvetica;">) <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">This tension between the
ideal of medicine and the economic reality of how medicine is practiced in the
United States is perhaps best summarized by Atul Gawande in his famous New
Yorker article about McAllen, Texas:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="color: #262626; font-family: Helvetica; mso-bidi-font-family: "Lucida Grande"; mso-bidi-font-size: 13.0pt;">“Here,
along the banks of the Rio Grande, in the Square Dance Capital of the World, a
medical community has come to treat patients the way subprime-mortgage lenders
treated home buyers:<b> </b>as profit centers." (</span><a href="http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande"><span style="font-family: Helvetica; mso-bidi-font-family: "Lucida Grande"; mso-bidi-font-size: 13.0pt;">http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande</span></a><span style="font-family: Helvetica;">)</span><span style="color: #262626; font-family: Helvetica; mso-bidi-font-family: "Lucida Grande"; mso-bidi-font-size: 13.0pt;"><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">This morning I was
reminded of this battle for the soul of American medicine when I read two
articles in the New York Times.
On the front page an article titled “Quiet Doctor, Lavish Insider: A Parallel Life” describes how a
well-respected neurologist at the University of Michigan capped off his
successful academic career by cooperating with federal prosecutors to avoid
charges in a Wall Street insider stock trading scandal. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“The
riddle for Dr. Gilman’s longtime friends and colleagues is why a nationally
respected neurologist was pulled into the high-rolling life of a consultant to
financiers and how he, by his own admission, crossed the line into criminal
behavior.” (</span><a href="http://www.nytimes.com/2012/12/16/business/sidney-gilmans-shift-led-to-insider-trading-case.html?ref=health"><span style="font-family: Helvetica;">http://www.nytimes.com/2012/12/16/business/sidney-gilmans-shift-led-to-insider-trading-case.html?ref=health</span></a><span style="font-family: Helvetica;">) <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">The other article in the
Times published on the same day was the obituary of Dr. William F. House who
invented the cochlear implant. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“Neither
the institute nor Dr. House made any money on the implant. He never sought a
patent on any of his inventions, he said, because he did not want to restrict
other researchers. A nephew, Dr. John House, the current president of the House
institute, said his uncle had made the deal to license it to the 3M Company not
for profit but simply to get it built by a reputable manufacturer.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">Reflecting
on his business decisions in his memoir, Dr. House acknowledged, ‘I might be a
little richer today.’” (</span><a href="http://www.nytimes.com/2012/12/16/health/dr-william-f-house-inventor-of-cochlear-implant-dies.html?_r=0"><span style="font-family: Helvetica;">http://www.nytimes.com/2012/12/16/health/dr-william-f-house-inventor-of-cochlear-implant-dies.html?_r=0</span></a><span style="font-family: Helvetica;">) <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">A major challenge for 21<sup>st</sup>
century American medicine is to cultivate the culture epitomized by Dr. House
and avoid the mistakes of Dr. Gilman.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<!--EndFragment-->Kent Bottleshttp://www.blogger.com/profile/12993140567796683570noreply@blogger.com3tag:blogger.com,1999:blog-6653940794693704941.post-33669816439194798672012-12-11T13:47:00.002-05:002012-12-11T13:47:48.855-05:00Is Fee-For-Service Really Dead?
<!--[if gte mso 9]><xml>
<o:OfficeDocumentSettings>
<o:AllowPNG/>
</o:OfficeDocumentSettings>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:WordDocument>
<w:Zoom>0</w:Zoom>
<w:TrackMoves>false</w:TrackMoves>
<w:TrackFormatting/>
<w:PunctuationKerning/>
<w:DrawingGridHorizontalSpacing>18 pt</w:DrawingGridHorizontalSpacing>
<w:DrawingGridVerticalSpacing>18 pt</w:DrawingGridVerticalSpacing>
<w:DisplayHorizontalDrawingGridEvery>0</w:DisplayHorizontalDrawingGridEvery>
<w:DisplayVerticalDrawingGridEvery>0</w:DisplayVerticalDrawingGridEvery>
<w:ValidateAgainstSchemas/>
<w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid>
<w:IgnoreMixedContent>false</w:IgnoreMixedContent>
<w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText>
<w:Compatibility>
<w:BreakWrappedTables/>
<w:DontGrowAutofit/>
<w:DontAutofitConstrainedTables/>
<w:DontVertAlignInTxbx/>
</w:Compatibility>
</w:WordDocument>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:LatentStyles DefLockedState="false" LatentStyleCount="276">
</w:LatentStyles>
</xml><![endif]-->
<!--[if gte mso 10]>
<style>
/* Style Definitions */
table.MsoNormalTable
{mso-style-name:"Table Normal";
mso-tstyle-rowband-size:0;
mso-tstyle-colband-size:0;
mso-style-noshow:yes;
mso-style-parent:"";
mso-padding-alt:0in 5.4pt 0in 5.4pt;
mso-para-margin:0in;
mso-para-margin-bottom:.0001pt;
mso-pagination:widow-orphan;
font-size:10.0pt;
font-family:"Times New Roman";
mso-ascii-font-family:Cambria;
mso-ascii-theme-font:minor-latin;
mso-hansi-font-family:Cambria;
mso-hansi-theme-font:minor-latin;}
</style>
<![endif]-->
<!--StartFragment-->
<br />
<div class="MsoNormal">
<span style="font-family: Helvetica;">The 21<sup>st</sup>
century challenge for the American health care delivery system is to deliver
higher quality care for less money.
Republican and Democratic experts agree that payment reform involving
transitioning from fee-for-service to global, value-based systems is necessary
for us to achieve that goal.
Accountable care organizations (ACOs) are the new entities that will
receive the new global payments and distribute them to the doctors, allied
health professionals, hospitals, and post-acute care facilities that care for
the patients; Medicare ACOs are being piloted under provisions in the
Affordable Care Act (ACA) and Commercial ACOs are being developed by private
insurance companies, hospitals, and physician groups. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">The ideal payment system
would support the ideal value-driven health care delivery system. Distinguished expert panels convened by
the Commonwealth Fund and the Institute of Medicine have described the
attributes of a system that would be far superior to our current delivery
system:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoListParagraphCxSpFirst" style="margin-left: 1.0in; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><span style="font-family: Helvetica;">Care would
be patient-centered<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 1.0in; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><span style="font-family: Helvetica;">Care would
be safe and effective<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 1.0in; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><span style="font-family: Helvetica;">Care would
be timely and accessible<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 1.0in; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><span style="font-family: Helvetica;">Care would
be efficient with little waste<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 1.0in; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><span style="font-family: Helvetica;">Care would
be coordinated among providers and across facilities<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 1.0in; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><span style="font-family: Helvetica;">Continuity
of care and care relationships would be facilitated<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 1.0in; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><span style="font-family: Helvetica;">Collaboration
among providers would deliver high quality, low cost care<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 1.0in; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><span style="font-family: Helvetica;">Patients’
clinical information would be efficiently exchanged<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 1.0in; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><span style="font-family: Helvetica;">Caregivers
would engage patients in ways that would maximize health<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 1.0in; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><span style="font-family: Helvetica;">Accountability
for each aspect and for total care would be clear<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpLast" style="margin-left: 1.0in; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><span style="font-family: Helvetica;">Continuous
innovation, learning, and improvement would occur<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">
(<a href="http://www.minnesotamedicine.com/tabid/3679/Default.aspx">http://www.minnesotamedicine.com/tabid/3679/Default.aspx</a>)<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Although fee-for-service
does not have all of the above ideal attributes, it does have a long history of
paying for medical care. Atul
Gawande’s fascinating description of how he negotiated for his first salary as
an attending surgeon at Harvard includes a brief history of fee-for-service
medicine. He starts with
eighteenth century BC Babylon where surgeons got ten shekels for lifesaving
operations on citizens and two shekels for the same operation on slaves and
ends up with the standardized fee schedule that was developed in the 1980s to
replace the “usual, customary, and reasonable fees” that insurance companies
did not always find reasonable.
Gawande’s article is a good place to start understanding the strengths
and weaknesses of this a la carte approach to paying doctors with its 600 page
master fee schedule that lists what 24 different insurers pay for different
services that Harvard physicians bill (<a href="http://www.newyorker.com/archive/2005/04/04/050404fa_fact">http://www.newyorker.com/archive/2005/04/04/050404fa_fact</a>).
<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Fee-for-service has
lasted so long because it does have some advantages. Conceptually, it is easy to understand because each
procedure, service, intervention, or medical device is billed and paid for
separately. Fee-for-service
encourages the delivery of care, is flexible enough to work with different
sizes and types of physician practices, different types of care such as office
visit, operation, procedure, or therapy session, and different sites of care
such as office, skilled nursing facility, nursing home, hospital, or
out-patient surgery center.
Fee-for-service supports accountability for each separate portion of
care, but it falls down in supporting accountability for total clinical care
provided by many different providers. (<a href="http://www.minnesotamedicine.com/tabid/3679/Default.aspx">http://www.minnesotamedicine.com/tabid/3679/Default.aspx</a>)<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">While the concept of
fee-for-service is relatively straightforward, the reality can be quite
confusing for both patients and providers. Fee-for-service payments are constrained by CPT and ICD-9
rules that establish what can and cannot be billed for. Unlike normal consumer markets, the
list price for a service is hard to pin down because the amount paid is
negotiated between different insurers and providers. When a health reporter was told by her physician to obtain
an expensive MRI to work up her migraine headaches, she experienced frustration
trying to establish just how much the test would cost (<a href="http://www.kaiserhealthnews.org/Stories/2012/December/09/mri-cost-price-comparison-health-insurance.aspx">http://www.kaiserhealthnews.org/Stories/2012/December/09/mri-cost-price-comparison-health-insurance.aspx</a>). Her local hospital could not tell her
how much it would cost; an academic medical center quoted her a price of $5,315
for an uninsured patient, but could not tell her what the price would be to her
insurance company; an independent imaging center told her that the price would
be $2,000 to $3,600 for an uninsured patient and about $600 to $1,200 for an
insured patient. She finally got
the scan at her local hospital and was surprised to get a bill for $7,468. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Fee-for-service also
makes coordination of care across multiple providers and different settings
difficult. Since the payments are
limited to one provider performing one service, this arrangement leads to hospitalized
patients receiving different bills from the surgeon, the anesthesiologist, the
pathologist, the infectious disease consultant, the radiologist, and the
respiratory therapist.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">The biggest problem with
fee-for-service payments is that it results in overutilization and unnecessary
care. Dr. Gawande’s <u>New Yorker</u> article about McAllen, Texas
explained the problem of medical overuse so clearly that President Obama had
members of the Senate and the House of Representatives read it during the
debate over the Affordable Care Act.
One cardiac surgeon in McAllen said, “Medicine has become a pig trough
here. We took a wrong turn when
doctors stopped being doctors and became businessmen.”<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“Compared
with patients in El Paso and nationwide, patients in McAllen got more of pretty
much everything – more diagnostic testing, more hospital treatment, more
surgery, more homecare.” (<a href="http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?currentPage=all">http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?currentPage=all</a>)
<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Health care policy
experts on both the left and the right agree that ending the fee-for-service
payment system will be necessary to control health care costs. <u>The New
England Journal of Medicine</u> recently published back-to-back articles with
how the two approaches would bend the health care cost curve. The Republicans responded with the
following proposals:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">•Medicare
premium support replaces defined benefit to be used to purchase insurance<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">•Convert
tax subsidy for employer insurance to predetermined refundable credit<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: Helvetica;">•Transition
from fee for service to bundled payments<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: Helvetica;">•High
option plan for Medicare<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: Helvetica;">•Regional
Medicare plans to encourage greater entrepreneurship <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">•Health
insurance exchanges without “heavy regulation imposed by ACA” (<a href="http://www.nejm.org/doi/full/10.1056/NEJMsb1207996">http://www.nejm.org/doi/full/10.1056/NEJMsb1207996</a>)
<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Not surprisingly, the
Democratic health policy wonks came up with a slightly different list of
solutions:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">•Model
of state self-regulation with spending targets where public & private
payers negotiate payment rates with providers<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: Helvetica;">•Replace
fee-for-service with bundled and global payments<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: Helvetica;">•Medicare
competitive bidding for medical devices, lab tests, X-rays, etc<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">•Insurers
should offer tiered plans with lower copays if patient chooses high value
providers<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: Helvetica;">•Payers
& providers electronically exchange eligibility, claims, etc<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: Helvetica;">•Single-standardized
physician credentialing <o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: Helvetica;">•Price
transparency<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: Helvetica;">•Non
physician providers should practice to full extent of their training <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">•Stark
Law extended to prohibit physician self referrals for services paid by private
payers<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: Helvetica;">•FEHBP
transition to new payment models<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: Helvetica;">•Safe
harbor against malpractice if physician uses HIT & EBM guidelines<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">•Shifting
costs to patients & cuts to provider payments are not good ways to cut
costs (<a href="http://www.nejm.org/doi/full/10.1056/NEJMsb1205901">http://www.nejm.org/doi/full/10.1056/NEJMsb1205901</a>)
<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Replacing
fee-for-service payments with global, value-based payment methods is the one
proposed solution that both liberal and conservative health policy experts
agree on. Ken Kizer, MD spoke for
most health care policy experts when he stated at a recent American Society of
Clinical Oncology meeting, “Payment reform is inevitable. Fee for service is dead.” (<a href="http://thehealthcareblog.com/blog/2012/12/10/acos-we're-not-there-y/#more-55492">http://thehealthcareblog.com/blog/2012/12/10/acos-we’re-not-there-y/#more-55492</a>)
Health care experts are attracted
to payment reform because of the estimated $200 to $600 billion savings over
ten years (<a href="http://capsules.kaiserhealthnews.org/index.php/2012/12/report-payment-reform-leaves-docs-uneasy/">http://capsules.kaiserhealthnews.org/index.php/2012/12/report-payment-reform-leaves-docs-uneasy/</a>).
<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Practicing physicians
have not shown the same level of enthusiasm for the elimination of
fee-for-service.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“A </span><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; font-family: Helvetica;">survey of doctors by Harris Interactive
finds that 59 percent of physicians believe that the fee-for-service system
encourages them to provide ‘an appropriate level of care.’ Only 15 percent
disagreed. Although 37 percent of doctors thought such a system encourages the
use of more care or expensive care, 38 percent also said that a fee-for-service
system encourages coordination of care. Not surprisingly, the 400 U.S.-based
primary care physicians and 600 U.S.-based specialists surveyed, did not favor
the idea of a global capitation payment—or a fixed payment per month for all
medical services. Nearly 60 percent of the doctors surveyed said that
capitation put too much risk on the provider.”</span><span style="font-family: Helvetica; mso-bidi-font-size: 10.0pt;"><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">(<a href="http://capsules.kaiserhealthnews.org/index.php/2012/12/report-payment-reform-leaves-docs-uneasy/">http://capsules.kaiserhealthnews.org/index.php/2012/12/report-payment-reform-leaves-docs-uneasy/</a>)
<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Another problem for
health care leaders is managing the transition from fee-for-service to global,
value-based payment systems. Dr.
Don Berwick, former head of CMS, describes the transition problem facing leaders
who are still paid mostly by fee-for-service arrangements:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="background: white; font-family: Helvetica; mso-bidi-font-size: 8.0pt;">They've got one foot on the dock
and one foot on the boat and they're drifting apart. One foot is
fee-for-service, revenue-driven, grow the volume, do more and more, which is
the dock, and the boat is, let's focus on what patients really need and
decrease unnecessary care and the liability or harmable (sic) unnecessary care.<span style="color: #4a4840;"> (</span></span><span style="font-family: Helvetica;"><a href="http://www.healthleadersmedia.com/content/QUA-287211/QA-Don-Berwick-Reflects-on-Healthcare-Reform-Part-I">http://www.healthleadersmedia.com/content/QUA-287211/QA-Don-Berwick-Reflects-on-Healthcare-Reform-Part-I</a>
) <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="background: white; color: #4a4840; font-family: Helvetica; mso-bidi-font-size: 8.0pt;">Steve Blumberg has described four types of
health care leaders when it comes to dealing with the transition away from
fee-for-service:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoListParagraphCxSpFirst" style="margin-left: 1.0in; mso-add-space: auto; mso-list: l0 level1 lfo2; text-indent: -.25in;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><span style="font-family: Helvetica;">Leaders who
are acquiring the necessary tools and shifting the culture to deal with new
payment systems.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 1.0in; mso-add-space: auto; mso-list: l0 level1 lfo2; text-indent: -.25in;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><span style="font-family: Helvetica;">Leaders who
understand the problem intellectually but have not embraced any solution.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 1.0in; mso-add-space: auto; mso-list: l0 level1 lfo2; text-indent: -.25in;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><span style="font-family: Helvetica;">Leaders who
are just waiting and hoping the problem goes away.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 1.0in; mso-add-space: auto; mso-list: l0 level1 lfo2; text-indent: -.25in;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><span style="font-family: Helvetica;">Leaders who
are trying to get their organizations acquired by others so they don’t have to
deal with the problem.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpLast" style="margin-left: 1.0in; mso-add-space: auto;">
<br /></div>
<div class="MsoNormal" style="margin-left: .75in;">
<span style="font-family: Helvetica;">(<a href="http://thehealthcareblog.com/blog/2012/12/10/acos-we're-not-there-y/#more-55492">http://thehealthcareblog.com/blog/2012/12/10/acos-we’re-not-there-y/#more-55492</a>)<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Blumberg’s observations
are spot on and match my impressions from talking with health care leaders from
all over the country. I have met
executives who belong in each of the four groups, and the smallest number in my
experience resides in the proactive first category. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">I recently read with
interest two reports out of California, which support the uneven preparation of
health care to get ready for accountable care organizations that are not paid
by fee-for-service. In San
Francisco providers appear to fall into all four categories (<a href="http://www.chcf.org/publications/2012/12/regional-market-san-francisco">http://www.chcf.org/publications/2012/12/regional-market-san-francisco</a>).
In Fresno, California physicians appear content to remain in fee-for-service
arrangements and appear to land squarely in the third category of waiting and
not preparing to respond to federal health care reform. (<a href="http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/A/PDF%20AlmanacRegMktBriefFresno12.pdf">http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/A/PDF%20AlmanacRegMktBriefFresno12.pdf</a>) <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">This gap between the
health policy experts and practicing physicians and local health care leaders
is worrisome. Even if Accountable
Care Organizations paid by global, value-based payments are inevitable and the
best possible solution to the unsustainable cost of American medicine, the
reform enterprise will fail or flounder without an enormous cultural change by
all the participants in this complicated and important endeavor. </span><span style="font-family: Helvetica; mso-bidi-font-size: 10.0pt;"><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoListParagraph" style="margin-left: 1.0in; mso-add-space: auto;">
<br /></div>
<!--EndFragment-->Kent Bottleshttp://www.blogger.com/profile/12993140567796683570noreply@blogger.com0tag:blogger.com,1999:blog-6653940794693704941.post-29470025518857840272012-10-04T13:20:00.000-04:002012-10-04T13:20:06.575-04:00Health Insurance Reinvention: The Florida Blue Example
<!--[if gte mso 9]><xml>
<o:OfficeDocumentSettings>
<o:AllowPNG/>
</o:OfficeDocumentSettings>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:WordDocument>
<w:Zoom>0</w:Zoom>
<w:TrackMoves>false</w:TrackMoves>
<w:TrackFormatting/>
<w:PunctuationKerning/>
<w:DrawingGridHorizontalSpacing>18 pt</w:DrawingGridHorizontalSpacing>
<w:DrawingGridVerticalSpacing>18 pt</w:DrawingGridVerticalSpacing>
<w:DisplayHorizontalDrawingGridEvery>0</w:DisplayHorizontalDrawingGridEvery>
<w:DisplayVerticalDrawingGridEvery>0</w:DisplayVerticalDrawingGridEvery>
<w:ValidateAgainstSchemas/>
<w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid>
<w:IgnoreMixedContent>false</w:IgnoreMixedContent>
<w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText>
<w:Compatibility>
<w:BreakWrappedTables/>
<w:DontGrowAutofit/>
<w:DontAutofitConstrainedTables/>
<w:DontVertAlignInTxbx/>
</w:Compatibility>
</w:WordDocument>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:LatentStyles DefLockedState="false" LatentStyleCount="276">
</w:LatentStyles>
</xml><![endif]-->
<!--[if gte mso 10]>
<style>
/* Style Definitions */
table.MsoNormalTable
{mso-style-name:"Table Normal";
mso-tstyle-rowband-size:0;
mso-tstyle-colband-size:0;
mso-style-noshow:yes;
mso-style-parent:"";
mso-padding-alt:0in 5.4pt 0in 5.4pt;
mso-para-margin:0in;
mso-para-margin-bottom:.0001pt;
mso-pagination:widow-orphan;
font-size:10.0pt;
font-family:"Times New Roman";
mso-ascii-font-family:Cambria;
mso-ascii-theme-font:minor-latin;
mso-hansi-font-family:Cambria;
mso-hansi-theme-font:minor-latin;}
</style>
<![endif]-->
<!--StartFragment-->
<br />
<div class="MsoNormal">
<span style="font-family: Helvetica;">One of the perks of
giving keynotes all over the country is being able to hear what other health
care leaders are saying without having to pay the conference fees. One of my major keynote themes is that
everyone (patients, doctors, hospitals, employers, and health plans) will have
to change in order to thrive during the current health care delivery system
transformation. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Recently in Delray
Beach, I stayed after my keynote to hear Florida Blue CEO Patrick Geraghty
describe his first year of trying to change the Blue Cross/Blue Shield
franchise to respond to health care reform. I have written elsewhere about the health plan response to
the changing environment (</span><a href="http://thehealthcareblog.com/blog/2012/07/22/health-insurers-the-affordable-care-act-extinction-or-reinvention/"><span style="font-family: Helvetica;">http://thehealthcareblog.com/blog/2012/07/22/health-insurers-the-affordable-care-act-extinction-or-reinvention/</span></a><span style="font-family: Helvetica;">), but Geraghty’s speech highlighted how urgent
and how difficult change can be when an industry business model is disrupted by
federal legislation and market forces.
<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Geraghty has led the
Blues effort in Florida to update their name, mission, vision, and values. Focus groups revealed that the new name
Florida Blue was easier to say and communicated a less corporate, more friendly
image than the old name Blue Cross Blue Shield which brought to mind adjectives
such as corporate, distant, and expensive. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">A four paragraph mission
statement was replaced by a single sentence: “To help people and communities
achieve better health.” The
vision statement was rewritten to now describe the company as “a leading
innovator enabling healthy communities.” The five corporate values now include the familiar
“respect,” “integrity,” and “excellence,” and the more unusual “courage” and
“imagination.” <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">What I found most
intriguing and revealing was how these new efforts are being translated into
concrete tactics such as opening retail centers and partnering with Disney on a
new innovation institute. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Florida Blue recognizes
they must engage consumers in the new world of Affordable Care Act Insurance
Exchanges, and they have opened retail stores so that there is a center within
25 minutes of 80% of their membership. These stores do more than just sell insurance and
resolve claims problems. They
also:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoListParagraphCxSpFirst" style="mso-list: l0 level1 lfo1; text-indent: -.25in;">
</div>
<ul>
<li><span style="font-family: Symbol; text-indent: -0.25in;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;"> <b> </b></span></span><span style="font-family: Helvetica; text-indent: -0.25in;"><b>Teach people to use online tools such as iPads and smartphone health apps</b></span></li>
<li><b style="text-indent: -0.25in;"><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span><span style="font-family: Helvetica;">Provide
health and wellness services such as health risk assessments</span></b></li>
<li><b style="text-indent: -0.25in;"><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span><span style="font-family: Helvetica;">Engage and
educate legislators at the store in the state capital</span></b></li>
<li><b style="text-indent: -0.25in;"><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span><span style="font-family: Helvetica;">Host
programs where book donations for school kids are tied to the number of points scored by the Miami Heat and the Orlando Magic</span></b></li>
<li><b style="text-indent: -0.25in;"><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span></b><span style="font-family: Helvetica; text-indent: -0.25in;"><b>Act as
starting and finishing points for fitness runs</b></span></li>
</ul>
<!--[if !supportLists]--><br />
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Partnerships with Disney
include both a kids’ center at the Disney World’s Epcot and a new health care innovation
institute. Geraghty said that the kids’
center will feature health and wellness games and exhibits and that 500,000
visits a year can be anticipated.
He was also happy that Disney chose Florida Blue to join GE, Johnson
& Johnson, and Cisco as partners in the state of the art innovation center.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Geraghty described how
his Accountable Care Organization (ACO) experiment with Baptist Health South
Florida differed from the federal Medicare Shared Savings Program. By reducing the 64 quality metrics in
the federal program to 15, he believes they have created a more flexible and
workable model.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Florida Blue’s ACO
elements of success include:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoListParagraphCxSpFirst" style="mso-list: l1 level1 lfo2; text-indent: -.25in;">
</div>
<ul>
<li><span style="font-family: Symbol; text-indent: -0.25in;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span><span style="font-family: Helvetica; text-indent: -0.25in;"><b>Trust
between all the parties involved</b></span></li>
<li><b style="text-indent: -0.25in;"><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span><span style="font-family: Helvetica;">Data
transparency</span></b></li>
<li><b style="text-indent: -0.25in;"><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span><span style="font-family: Helvetica;">Meaningful
quality measures</span></b></li>
<li><b style="text-indent: -0.25in;"><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span><span style="font-family: Helvetica;">All parties
having vested interest in success of program</span></b></li>
<li><b style="text-indent: -0.25in;"><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span></b><span style="font-family: Helvetica; text-indent: -0.25in;"><b>Shared
savings aligns with best interests of the patient</b></span></li>
</ul>
<!--[if !supportLists]--><br />
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">It is still an open
question whether health plans can evolve fast enough to be successful in the
newly emerging health care world. At least one question to Geraghty in the
question and answer session reflected skepticism on the part of hospital
leadership to be able to truly trust a health plan. “They are among the most disliked industries in the United
States” according to Harvard professor Regina Herzlinger. </span><span style="color: #1a1a1a; font-family: Helvetica; mso-bidi-font-family: Helvetica;">Another
expert, Fred Karutz of Silverlink Communications, thinks that health care
insurance companies have a long way to go because they are new to the retail
environment. “As people become consumers, they seek out value. In the group
space, health plans could never hear the consumer scream, but in the retail
space everybody can hear the consumer scream.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="color: #1a1a1a; font-family: Helvetica; mso-bidi-font-family: Helvetica;"> (</span><a href="http://www.nytimes.com/2012/06/22/us/politics/insurance-companies-are-trying-to-soften-their-image.html?pagewanted=all"><span style="color: #315482; font-family: Helvetica; mso-bidi-font-family: Helvetica; text-decoration: none; text-underline: none;">http://www.nytimes.com/2012/06/22/us/politics/insurance-companies-are-trying-to-soften-their-image.html?pagewanted=all</span></a><span style="color: #1a1a1a; font-family: Helvetica; mso-bidi-font-family: Helvetica;">)<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="color: #1a1a1a; font-family: Helvetica; mso-bidi-font-family: Helvetica;">Florida Blue seems to be responding to this new retail
challenge with imagination and focus. Time will tell if they are successful in
becoming an effective and trusted partner to patients and providers in a
transformed clinical delivery system. </span><span style="font-family: Helvetica;"><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<!--EndFragment-->Kent Bottleshttp://www.blogger.com/profile/12993140567796683570noreply@blogger.com2tag:blogger.com,1999:blog-6653940794693704941.post-79041206684938413272012-09-29T16:59:00.001-04:002012-09-29T16:59:09.718-04:00Health Plans Continue to Struggle to Reinvent Themselves
<!--[if gte mso 9]><xml>
<o:OfficeDocumentSettings>
<o:AllowPNG/>
</o:OfficeDocumentSettings>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:WordDocument>
<w:Zoom>0</w:Zoom>
<w:TrackMoves>false</w:TrackMoves>
<w:TrackFormatting/>
<w:PunctuationKerning/>
<w:DrawingGridHorizontalSpacing>18 pt</w:DrawingGridHorizontalSpacing>
<w:DrawingGridVerticalSpacing>18 pt</w:DrawingGridVerticalSpacing>
<w:DisplayHorizontalDrawingGridEvery>0</w:DisplayHorizontalDrawingGridEvery>
<w:DisplayVerticalDrawingGridEvery>0</w:DisplayVerticalDrawingGridEvery>
<w:ValidateAgainstSchemas/>
<w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid>
<w:IgnoreMixedContent>false</w:IgnoreMixedContent>
<w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText>
<w:Compatibility>
<w:BreakWrappedTables/>
<w:DontGrowAutofit/>
<w:DontAutofitConstrainedTables/>
<w:DontVertAlignInTxbx/>
</w:Compatibility>
</w:WordDocument>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:LatentStyles DefLockedState="false" LatentStyleCount="276">
</w:LatentStyles>
</xml><![endif]-->
<!--[if gte mso 10]>
<style>
/* Style Definitions */
table.MsoNormalTable
{mso-style-name:"Table Normal";
mso-tstyle-rowband-size:0;
mso-tstyle-colband-size:0;
mso-style-noshow:yes;
mso-style-parent:"";
mso-padding-alt:0in 5.4pt 0in 5.4pt;
mso-para-margin:0in;
mso-para-margin-bottom:.0001pt;
mso-pagination:widow-orphan;
font-size:12.0pt;
font-family:"Times New Roman";
mso-ascii-font-family:Cambria;
mso-ascii-theme-font:minor-latin;
mso-fareast-font-family:"Times New Roman";
mso-fareast-theme-font:minor-fareast;
mso-hansi-font-family:Cambria;
mso-hansi-theme-font:minor-latin;}
</style>
<![endif]-->
<!--StartFragment-->
<br />
<div class="MsoNormal">
<span style="font-family: Helvetica;">American health care
insurers continue to scramble to try to reinvent themselves and discover a new
business model that will be successful during a time of transformation and
payment reform. In previous blogs I
have described several different approaches, some of which leave me skeptical. (<a href="http://www.thedoctorweighsin.com/health-insurers-the-ppaca-extinction-or-reinvention-part-i/">http://www.thedoctorweighsin.com/health-insurers-the-ppaca-extinction-or-reinvention-part-i/</a>
)<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">One of the most
interesting and controversial attempts to reinvent a health insurance franchise
appears to becoming unraveled. I
wondered in print if new Highmark CEO William Winkenwereder would continue to
try to implement fired Highmark CEOKenneth Melani’s aggressive merger with the
failing West Penn Allegheny Health System. The new CEO did not have Melani’s historical loyalty to West
Penn Allegheny, and many questioned the wisdom of the merger from the start. (<a href="http://www.thedoctorweighsin.com/health-insurers-the-ppaca-extinction-or-reinvention-part-ii/">http://www.thedoctorweighsin.com/health-insurers-the-ppaca-extinction-or-reinvention-part-ii/</a>)
<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Late last week, the West
Penn Allegheny board called off the merger because Highmark wanted the health
system to declare bankruptcy to get out from under nearly $1billion in
debt. Highmark had already
acquired Jefferson Regional Health System, Premier Medical Associates (the
largest independent multispecialty physician group), and planned medical malls
to supplement West Penn Allegheny in a new integrated delivery system. (<a href="http://old.post-gazette.com/pg/12273/1265542-28.stm">http://old.post-gazette.com/pg/12273/1265542-28.stm</a>)
Highmark also tried to acquire
Excela Health, partner in its medical mall and gain majority ownership in the
Westmoreland county provider network.
When Excela declined the offer, Highmark threatened Excela according to
the Excela board chair: “The threat was clear – if Excela did not enter into an
acquisition or affiliation with it, Highmark would use its monopoly position to
destroy Excela,” said James Breisinger.
(<a href="http://www.fiercehealthpayer.com/story/highmark-trying-destroy-health-system-after-failed-alignment/2012-08-02">http://www.fiercehealthpayer.com/story/highmark-trying-destroy-health-system-after-failed-alignment/2012-08-02</a>)
<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Reaction to the failure
of the merger included Jan Jennings,
President of American Healthcare Solutions, who said, “It is the
dumbest, most recless abandonment of fiduciary responsibility I have ever seen.
I don’t think anybody from out of town sees West Penn Allegheny as some kind of
crown jewel. I just think it is a
big mistake.” (<a href="http://triblive.com/business/2687181-74/penn-west-highmark-allegheny-system-health-agreement-board-officials-community#axzz27sxdlxu9">http://triblive.com/business/2687181-74/penn-west-highmark-allegheny-system-health-agreement-board-officials-community#axzz27sxdlxu9</a>)
<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Highmark is not the only
insurance company that is finding out that reinvention can be difficult. When Patrick Geraghty left Minnesota
Blue Cross and Blue Shield to run the Florida Blues, the Minnesota Board hired
Kenneth Burdick largely because he had experience with the highly successful
for profit UnitedHealth Group.
After six months on the job Burdick was fired due to “examples of
leadership that weren’t optimal.”
Board chairman Vance Opperman was quoted as saying, “’What you have is a
difference in culture. The
difference between for-profit and not-for-profit is pretty big…After looking at
this for many hours and many meetings, we came to the unfortunate and unhappy
realization that Ken couldn’t make the transition and couldn’t bring the
leadership team with him.’” (<a href="http://www.startribune.com/business/163068436.html?refer=y">http://www.startribune.com/business/163068436.html?refer=y</a>)
<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Another health care
organization struggling to cope with the new health care environment is Seattle’s Group Health Cooperative which
recently decided to cut $250 million over the next 16 months to better position
the organization in the new world. Group Health has already assembled the
combination of hospitals, physicians, and health insurance plan that Highmark
was trying to emulate in Pittsburgh.
However, CEO Scott Armstrong is facing three years of sharp declines in
revenues, and he has arranged for Richard Magnuson, executive vice president
and chief financial and administrative officer to leave the $3.5 billion health
system. (<a href="http://seattletimes.com/html/localnews/2019204930_grouphealthxml.html">http://seattletimes.com/html/localnews/2019204930_grouphealthxml.html</a>)
<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">HealthPartners of
Minneapolis is a fourth health plan recently announcing a new direction by merging
with Park Nicollet to respond to federal health care reform measures. If approved by regulators, the new
system will become the second largest in Minnesota with 1,500 physicians and
two hospitals Regions in St. Paul and Methodist in St. Louis Park. HealthPartners insurance plan covers
1.4 million people. Keith
Halleland, a health care attorney, states that the merger is part of a national
trend to “’provide total cost of care for a variety of populations’” and to
create “’one organization that can do everything for basically anyone in the
health care environment.’” (<a href="http://www.startribune.com/business/168058306.html?refer=y">http://www.startribune.com/business/168058306.html?refer=y</a>)
<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">These four examples of
health plans trying to create new business models for the 21<sup>st</sup> century
offer a window into the complicated and evolving health care environment that
is creating anxiety and opportunity for everyone involved in the industry. <o:p></o:p></span></div>
<!--EndFragment-->Kent Bottleshttp://www.blogger.com/profile/12993140567796683570noreply@blogger.com9tag:blogger.com,1999:blog-6653940794693704941.post-50099329017812919242012-09-27T07:17:00.001-04:002012-09-27T07:17:19.261-04:00Sticking to Health & Wellness Goals: These Websites Made Me Do It
<!--[if gte mso 9]><xml>
<o:OfficeDocumentSettings>
<o:AllowPNG/>
</o:OfficeDocumentSettings>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:WordDocument>
<w:Zoom>0</w:Zoom>
<w:TrackMoves>false</w:TrackMoves>
<w:TrackFormatting/>
<w:PunctuationKerning/>
<w:DrawingGridHorizontalSpacing>18 pt</w:DrawingGridHorizontalSpacing>
<w:DrawingGridVerticalSpacing>18 pt</w:DrawingGridVerticalSpacing>
<w:DisplayHorizontalDrawingGridEvery>0</w:DisplayHorizontalDrawingGridEvery>
<w:DisplayVerticalDrawingGridEvery>0</w:DisplayVerticalDrawingGridEvery>
<w:ValidateAgainstSchemas/>
<w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid>
<w:IgnoreMixedContent>false</w:IgnoreMixedContent>
<w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText>
<w:Compatibility>
<w:BreakWrappedTables/>
<w:DontGrowAutofit/>
<w:DontAutofitConstrainedTables/>
<w:DontVertAlignInTxbx/>
</w:Compatibility>
</w:WordDocument>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:LatentStyles DefLockedState="false" LatentStyleCount="276">
</w:LatentStyles>
</xml><![endif]-->
<!--[if gte mso 10]>
<style>
/* Style Definitions */
table.MsoNormalTable
{mso-style-name:"Table Normal";
mso-tstyle-rowband-size:0;
mso-tstyle-colband-size:0;
mso-style-noshow:yes;
mso-style-parent:"";
mso-padding-alt:0in 5.4pt 0in 5.4pt;
mso-para-margin:0in;
mso-para-margin-bottom:.0001pt;
mso-pagination:widow-orphan;
font-size:12.0pt;
font-family:"Times New Roman";
mso-ascii-font-family:Cambria;
mso-ascii-theme-font:minor-latin;
mso-fareast-font-family:"Times New Roman";
mso-fareast-theme-font:minor-fareast;
mso-hansi-font-family:Cambria;
mso-hansi-theme-font:minor-latin;}
</style>
<![endif]-->
<!--StartFragment-->
<br />
<div class="MsoNormal">
<span style="font-family: Helvetica;">My regular readers know
how important I think behavioral economics will become in the field of health
care. (<a href="http://www.hospitalimpact.org/index.php/2012/05/16/understanding_barriers_to_shared_decisio">http://www.hospitalimpact.org/index.php/2012/05/16/understanding_barriers_to_shared_decisio</a>) The best place to start thinking about
applications of behavioral economics principles to wellness is Nobel Prize
Winner Daniel Kahneman’s book Thinking, Fast and Slow <a href="http://kentbottles.blogspot.com/2012/09/8-things-medical-school-failed-to-teach.html">http://kentbottles.blogspot.com/2012/09/8-things-medical-school-failed-to-teach.html</a>
<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Several start-up
companies have created ways for people to apply behavioral economics heuristics
to their own individual fitness and wellness programs. Jordan Goldberg was so intrigued by
these possibilities he encountered in undergraduate classes at Yale that he
started a company, Stickk, with his professors Dean Karlan and Ian Ayres. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">As Goldberg related in an
e-Patients Connections 2012 talk in Philadelphia recently, people say they want
to do healthy things, but then life happens, and they don’t follow through on
their stated intentions. Stickk
creates clever ways to take advantage of nudges and libertarian paternalism to
frame choices so people do what they really want to achieve.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">My favorite example of
this concept is their anti-charity
option where Stickk takes money away from you to give to a charity you hate if
you do not achieve your goal. If
your stated goal is to walk 10,000 steps every day and you slack off, the
despised charity you choose gets an automatic contribution. According to Goldberg the George W. Bush
Library is a favorite charity in this program. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">By applying the
behavioral economics principles of hyperbolic discounts, real time loss
aversion, carrot vs. stick, reference points, and power of defaults, Stickk has created both public and
commercial websites that may really get people to stick to their stated health
and wellness goals. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Aherk! is another
website designing tools for people having difficulty sticking to their weight
loss regimen. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“The
user also emails Aherk! An embarrassing photo – referred to as ‘the bomb’ on
the site. When the deadline hits,
Facebook friends vote on whether the goal was achieved. If not, up goes that incriminating pic
at the expense of some social media status.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">(<a href="http://articles.philly.com/2012-09-26/news/34103610_1_facebook-timeline-website-posts-social-media">http://articles.philly.com/2012-09-26/news/34103610_1_facebook-timeline-website-posts-social-media</a>)
<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Other start-ups applying
behavioral economic heuristics to healthcare include GymPact where smartphones
track missed exercise workouts and automatically fine the participant and
MetaReal’s Virtual Fridge Lock with its refrigerator device that posts a
Facebook notice when one raids the refrigerator when one is not supposed to. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">One can find psychology
professors who think the above tactics are laudable and those who object to
these approaches:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“I
would rather see a website that allows a person to define a goal and state a
reward the person will give him or herself if the goal is met.” Erin Way<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“Committing
to anything in public, something that has been known for a long time in
psychology, is a good way to get people to stick to their guns…People don’t
like to feel like a fool.” Andrew Ward (<a href="http://articles.philly.com/2012-09-26/news/34103610_1_facebook-timeline-website-posts-social-media">http://articles.philly.com/2012-09-26/news/34103610_1_facebook-timeline-website-posts-social-media</a>)
<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<!--EndFragment-->Kent Bottleshttp://www.blogger.com/profile/12993140567796683570noreply@blogger.com3tag:blogger.com,1999:blog-6653940794693704941.post-20799647037015031422012-09-26T12:00:00.002-04:002012-09-26T12:00:40.757-04:008 Things Medical School Failed to Teach Me About Being a Physician Executive
<!--[if gte mso 9]><xml>
<o:OfficeDocumentSettings>
<o:AllowPNG/>
</o:OfficeDocumentSettings>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:WordDocument>
<w:Zoom>0</w:Zoom>
<w:TrackMoves>false</w:TrackMoves>
<w:TrackFormatting/>
<w:PunctuationKerning/>
<w:DrawingGridHorizontalSpacing>18 pt</w:DrawingGridHorizontalSpacing>
<w:DrawingGridVerticalSpacing>18 pt</w:DrawingGridVerticalSpacing>
<w:DisplayHorizontalDrawingGridEvery>0</w:DisplayHorizontalDrawingGridEvery>
<w:DisplayVerticalDrawingGridEvery>0</w:DisplayVerticalDrawingGridEvery>
<w:ValidateAgainstSchemas/>
<w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid>
<w:IgnoreMixedContent>false</w:IgnoreMixedContent>
<w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText>
<w:Compatibility>
<w:BreakWrappedTables/>
<w:DontGrowAutofit/>
<w:DontAutofitConstrainedTables/>
<w:DontVertAlignInTxbx/>
</w:Compatibility>
</w:WordDocument>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:LatentStyles DefLockedState="false" LatentStyleCount="276">
</w:LatentStyles>
</xml><![endif]-->
<!--[if gte mso 10]>
<style>
/* Style Definitions */
table.MsoNormalTable
{mso-style-name:"Table Normal";
mso-tstyle-rowband-size:0;
mso-tstyle-colband-size:0;
mso-style-noshow:yes;
mso-style-parent:"";
mso-padding-alt:0in 5.4pt 0in 5.4pt;
mso-para-margin:0in;
mso-para-margin-bottom:.0001pt;
mso-pagination:widow-orphan;
font-size:12.0pt;
font-family:"Times New Roman";
mso-ascii-font-family:Cambria;
mso-ascii-theme-font:minor-latin;
mso-fareast-font-family:"Times New Roman";
mso-fareast-theme-font:minor-fareast;
mso-hansi-font-family:Cambria;
mso-hansi-theme-font:minor-latin;}
</style>
<![endif]-->
<!--StartFragment-->
<br />
<div class="MsoNormal">
<span style="font-family: Helvetica;">You Will Have to Move a
Lot<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">I went to medical school
in Cleveland and did myj pathology residency in San Francisco at UCSF. I was on the medical school faculty at
UCSF, Iowa, Allegheny University of the Health Sciences, and Michigan
State. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Since leaving academic
medicine, I have worked at a bio-tech start up in Cambridge, an educational and
research institute in Grand Rapids, a $2 billion integrated delivery system in
Iowa, and an evidence-based medicine consortium in Minneapolis.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">In my experience
physician executive positions do not always last a long time because the
environment changes, my career aspirations changed, and getting the job done
sometimes means alienating enough people to get in the way of long job tenure. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">You Will Have to
Reinvent Yourself Over and Over Again<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">My main professional
roles have included: medical school pathology course master, surgical
pathologist, division head, vice chair of academic department, chair of
academic department, medical director of managed care, corporate operations
officer of ambulatory care, special assistant to the president of a big ten
university for managed care, search consultant, chief knowledge officer of a
genomics bio-tech start up, president and ceo of an educational consortium,
chief medical officer of a delivery system, president and ceo of an evidence
based medicine institute, and health policy professor at a school of population
health.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">My only educational
credentials are a bachelor’s degree in history and a MD degree. Although I have taught in MBA programs,
I do not have a MBA degree.
Although I headed up a genomics repository of DNA, I had to teach myself
genomics and proteomics on my own.
Although I teach health policy and population health, I did formally study
these subjects. I have discovered
that if I read a lot, go to conferences in different fields, and talk to smart
people, I can pick up what I need to know without going on to obtain lots of
graduate degrees.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Everything is in the New
York Times and The Wall Street Journal
<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">I am amazed at how much
I am able to keep up with payment reform, federal health care reform, and major
trends just by reading these two newspapers every day. It is also good to see how liberals and
conservatives interpret the same story, often with dramatically different
conclusions.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">The Killer App in Social
Media is Community<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Twitter has become the
most important technology in my career as a physician executive. I follow about 2000 key opinion leaders
in health care, and about 7000 people follow me.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">I use twitter to
crowdsoure subjects that I need to master in order to give keynotes or consult
with health care systems. For
example, Einstein Medical School asked me to come give a presentation on social
media and undergraduate medical school education. In order to prepare for a subject that I had not thought
about much, I tweeted the following: “Help; need best practices of social
medical and medical school education.” <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">I received responses
from all over the world that formed the basis for my all day seminar that was
well received and consisted of concrete examples of medical educators from the
Cleveland Clinic to the UK using twitter and facebook in ways I had never
imagined.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">An important point here
is that it is now my obligation to my social media community of practice to
provide knowledge to others when they are reaching out for assistance.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">If I can’t understand
it, I don’t believe it<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">When I started out in
leadership roles, I did not always trust my own judgment. I sometimes thought I was not smart
enough to grasp situations that made no sense to me.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">When I was Interim Head
of pathology at Iowa, I thought my lack of training in clinical pathology was
the reason I could not understand the classification of all the technologists
in the hospital labs. It took a
while to grasp that job classifications and titles had multiplied and
proliferated in a way that did not serve us well in a changing health care
environment. It was only when I
truly understood that the system did not make sense that I could lead a
simplification of job titles that made more sense in that time of managed
care. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">I will never forget
going to a meeting in Palm Springs of venture capitalists. What made them different from others I
had encountered was their skepticism and insistence that they understand how
start-up companies would make money.
If they could not understand the business plan, they did not
invest. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">You Will Fail; Do it
Quickly and Cheaply<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">A successful
entrepreneur in Iowa taught me that failure is inevitable. The trick is to recognize when you have
failed, learn from it, and move on as quickly and cheaply as possible. When I was helping to raise $36 million
dollars for a genomics company, I was amazed to learn from venture capitalists that
they do not try to predict winners and losers. They do not think it is possible. When they invest in 20 companies, they are hoping that one
of them will be a Google or apple.
They fully expect the others to fail. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">I have noticed that
health care organizations have a hard time killing programs that are simply not
working. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">You Must Become a Life
Long Learner<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">When I graduated from
Case Western Reserve School of Medicine in 1980, there was no Internet, no Google,
no disease called AIDS, and no smartphones. You must continue to learn about the world you live in, and
the world will continue to change in amazing and confusing ways.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Master the Gartner Hype
Cycle and Learn Behavioral Economics<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Do yourself a favor. Master the Gartner Hype Cycle to
understand why all those revolutionary disruptive technologies fail and those
startup stocks go down (<a href="http://www.gartner.com/it/products/research/media_products/book/index.jsp">http://www.gartner.com/it/products/research/media_products/book/index.jsp</a>)
<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<span style="font-family: Helvetica; font-size: 12.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman"; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Cambria; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">Read Nobel Prize winner Daniel Kahneman’s book Thinking, Fast and Slow;
you will understand why you and those you work with are often irrational and annoying.</span><!--EndFragment-->Kent Bottleshttp://www.blogger.com/profile/12993140567796683570noreply@blogger.com26tag:blogger.com,1999:blog-6653940794693704941.post-42746207338426200912012-09-22T10:14:00.001-04:002012-09-22T10:14:47.690-04:00Why Do Academic Medical Centers Do Poorly on Quality Report Cards?<!--[if gte mso 9]><xml>
<o:OfficeDocumentSettings>
<o:AllowPNG/>
</o:OfficeDocumentSettings>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:WordDocument>
<w:Zoom>0</w:Zoom>
<w:TrackMoves>false</w:TrackMoves>
<w:TrackFormatting/>
<w:PunctuationKerning/>
<w:DrawingGridHorizontalSpacing>18 pt</w:DrawingGridHorizontalSpacing>
<w:DrawingGridVerticalSpacing>18 pt</w:DrawingGridVerticalSpacing>
<w:DisplayHorizontalDrawingGridEvery>0</w:DisplayHorizontalDrawingGridEvery>
<w:DisplayVerticalDrawingGridEvery>0</w:DisplayVerticalDrawingGridEvery>
<w:ValidateAgainstSchemas/>
<w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid>
<w:IgnoreMixedContent>false</w:IgnoreMixedContent>
<w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText>
<w:Compatibility>
<w:BreakWrappedTables/>
<w:DontGrowAutofit/>
<w:DontAutofitConstrainedTables/>
<w:DontVertAlignInTxbx/>
</w:Compatibility>
</w:WordDocument>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:LatentStyles DefLockedState="false" LatentStyleCount="276">
</w:LatentStyles>
</xml><![endif]-->
<!--[if gte mso 10]>
<style>
/* Style Definitions */
table.MsoNormalTable
{mso-style-name:"Table Normal";
mso-tstyle-rowband-size:0;
mso-tstyle-colband-size:0;
mso-style-noshow:yes;
mso-style-parent:"";
mso-padding-alt:0in 5.4pt 0in 5.4pt;
mso-para-margin:0in;
mso-para-margin-bottom:.0001pt;
mso-pagination:widow-orphan;
font-size:12.0pt;
font-family:"Times New Roman";
mso-ascii-font-family:Cambria;
mso-ascii-theme-font:minor-latin;
mso-fareast-font-family:"Times New Roman";
mso-fareast-theme-font:minor-fareast;
mso-hansi-font-family:Cambria;
mso-hansi-theme-font:minor-latin;}
</style>
<![endif]-->
<!--StartFragment-->
<br />
<div class="MsoNormal">
<span style="font-family: Helvetica;">In September 2012, the
Joint Commission recognized 620 hospitals (about 18% of the total number of
accredited American hospitals) as “top performers,” but many were surprised when
some of the biggest names in academic medical centers failed to make the
cut. Johns Hopkins, Massachusetts
General Hospital, and the Cleveland Clinic (perennial winners in the US News
& World Report best hospital competition) did not qualify when the Joint
Commission based their ranking not on reputation but on specific actions that “add
up to millions of opportunities ‘to provide the right care to the patients at
American hospitals.’” (<a href="http://www.washingtonpost.com/national/health-science/holy-cross-2-other-area-hospitals-make-top-performer-list/2012/09/20/5cf2bba2-0334-11e2-9b24-ff730c7f6312_story.html">http://www.washingtonpost.com/national/health-science/holy-cross-2-other-area-hospitals-make-top-performer-list/2012/09/20/5cf2bba2-0334-11e2-9b24-ff730c7f6312_story.html</a>
)<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">The gap between the
perceived reputation of America’s “best” hospitals and medical schools and
their performance on an evidence-based medicine report card provides an
interesting lens through which to understand the role and performance of
America’s academic medical centers in the 21<sup>st</sup> century. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">The most pressing
challenge for American medicine has been summarized in the triple aim: how to cut the per-capita cost of
healthcare, how to increase the quality and experience of the care for the
patient, and how to improve the health and wellness of specific populations. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Can we expect academic
medical centers to lead the country in meeting the challenge? If history is any guide, the answer may
be no. In a 2001 article titled “Improving
the Quality of Health Care: Who
Will Lead?” the authors state<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“We
see few signs that academic medical leaders are prepared to expend much effect
on health care issues outside the realms of biomedical research and medical
education. They exerted little
leadership in what may arguably be characterized as the most important health
policy debates of the past thirty years:
tobacco control, health care cost containment, and universal access.” <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">(<a href="http://content.healthaffairs.org/content/20/5/164.abstract">http://content.healthaffairs.org/content/20/5/164.abstract</a>)
<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Having been a professor
at several medical schools (UCSF, University of Iowa, Allegheny University of
the Health Sciences, and Michigan State), I learned early on that the key to
academic advancement was NIH funded basic science research. While lip service was paid to the ideal
triple threat professor (great clinician, superb teacher, and peer reviewed
published investigator), the results of the tenure process clearly resulted in
a culture where funded research counted far more than teaching and clinical
care delivery. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">This gap between what
the country needs and what medical schools traditionally emphasize was
demonstrated when researchers studied more than 60,000 medical school graduates
from 1999 to 2001. As Pauline W.
Chen, MD wrote in the New York Times:<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“Putting
the issues of primary care shortage, underserved communities and workforce
diversity under the banner of ‘social mission,’ the researchers found that many
of the schools that were traditionally ranked highly were also among those
least focused and least successful in addressing the most pressing issues
facing the country right now.” <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">A recent report from the
Lucien Institute at the National Patient Safety Foundation describes the kind
of culture required to achieve the goals of the triple aim.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;"> “Achieving
safety in the work environment requires much more than <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">implementing
new rules and procedures. It requires developing and sustaining cultures of
safety that engender trust and embrace reporting, transparency, and disciplined
practices. It also requires an
atmosphere of respect among the health care disciplines and a fundamental
ability of all practitioners to work together in teams.” (<a href="http://thehealthcareblog.com/blog/2010/03/20/a-culture-of-fear-and-intimidation-reforming-medical-education/">http://thehealthcareblog.com/blog/2010/03/20/a-culture-of-fear-and-intimidation-reforming-medical-education/</a>)
<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">The Association of
American Medical Colleges survey on medical school culture reveals a culture
that does little to encourage trust and transparency. From 2004 to 2008, 12.7%
to 16.7% of students reported being publicly belittled or humiliated. The best program for implementing a
culture of safety I have seen did not originate in an academic medical center;
it was developed and implemented at the Sentara Healthcare System in Virginia.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Academic medical center
hospitals often save the lives of patients with complicated conditions who
benefit from cutting edge treatments supported by basic science research. However, it is revealing that the
community Holy Cross Hospital in Silver Spring, Maryland made the Joint
Commission’s list of “top
performers” and the famed Johns Hopkins did not do as well on the quality
scoring report card. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">The Holy Cross vice
president of quality and care management cites three factors for the hospital’s
excellent quality results: intensive review of patients’ charts, the electronic
medical record system, and the leadership focus on quality. (<a href="http://www.washingtonpost.com/national/health-science/holy-cross-2-other-area-hospitals-make-top-performer-list/2012/09/20/5cf2bba2-0334-11e2-9b24-ff730c7f6312_story.html">http://www.washingtonpost.com/national/health-science/holy-cross-2-other-area-hospitals-make-top-performer-list/2012/09/20/5cf2bba2-0334-11e2-9b24-ff730c7f6312_story.html</a>
) <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">When it comes to
choosing a hospital, patients should take into account quality report cards as
well as reputation. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<!--EndFragment-->Kent Bottleshttp://www.blogger.com/profile/12993140567796683570noreply@blogger.com7tag:blogger.com,1999:blog-6653940794693704941.post-76335947090821000542012-08-15T18:39:00.001-04:002012-08-15T18:39:45.332-04:00Physicians, Humility and the Transformation of American Healthcare
<br />
<div class="MsoNormal">
<span style="font-family: Helvetica;">“A disease and its
treatment can be a series of humiliations, a chisel for humility” <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;"> Laurel
Lee<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: 5.0in;">
<span style="font-family: Helvetica;"> </span></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">“Fullness of knowledge
always means some understanding of the depths of our ignorance, and that is always
conducive to humility and reverence.” Robert Millikan<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">“Humility is nothing
less but a right judgment of ourselves.”
William
Law<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">“Early in life I had to
choose between honest arrogance and hypocritical humility. I chose the former and have seen no
reason to change.” Frank
Lloyd Wright<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">“Humility is the
foundation of all the other virtues hence, in the soul in which this virtue
does not exist there cannot be any other virtue except in mere appearance. Saint Augustine<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;"> <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Three physicians got me
thinking about humility. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">At the health care
innovations summit in Washington, DC earlier this year, I heard Atul Gawande,
MD call for medical schools to do a better job at training physicians in
humility, discipline, and teamwork (</span><a href="http://careandcost.com/2012/02/03/notes-on-the-care-innovation-summit/"><span style="font-family: Helvetica;">http://careandcost.com/2012/02/03/notes-on-the-care-innovation-summit/</span></a><span style="font-family: Helvetica;">).
In a 2010 Stanford School of Medicine Commencement speech, Dr. Gawande
stated:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“And
when you are a doctor or a medical scientist this is the work you want to do.
It is work with a different set of values from the ones that medicine
traditionally has had: values of
teamwork instead of individual autonomy, ambition for the right process rather
than the right technology, and perhaps above all, humility – for we need
humility to recognize that, under conditions of complexity, no technology will
be infallible. No individual will
be, either.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">(</span><a href="http://www.newyorker.com/online/blogs/newsdesk/2010/06/gawande-stanford-speech.html"><span style="font-family: Helvetica;">http://www.newyorker.com/online/blogs/newsdesk/2010/06/gawande-stanford-speech.html</span></a><span style="font-family: Helvetica;">) <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Eric Van De Graaff, MD
wrote a blog titled “Why Are So Many Doctors Complete Jerks?” Dr. Van De Graaff
was chagrined when his own mother was disappointed when he became a physician;
she “had a deep-seated disdain for doctors.” Dr. Van De Graaff answered his own question with two
theories. His first theory was that some physicians “let the glory of their
careers go to their heads and begin to treat patients and underlings like
chewing gum on a movie theater floor.”
His second theory was that physicians act like jerks when emergencies
occur and they feel overwhelmed and frightened. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Dr. Van De Graaff offers
two simple rules, which he admits he sometimes does not follow:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“Rule
#1: It is simply not allowable to
be impolite, mean, nasty, or snippy with staff or patients even when you are in
a stressful situation.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">Rule
#2: Whatever is stressing you is
probably stressing those around you as much or more. Under those circumstances
you have to go out of your way to be kinder and more understanding. As a doctor, you control the mood in
the clinic and operating room even if you can’t control the situation.” (</span><a href="http://www.kevinmd.com/blog/2012/08/doctors-complete-jerks.html"><span style="font-family: Helvetica;">http://www.kevinmd.com/blog/2012/08/doctors-complete-jerks.html</span></a><span style="font-family: Helvetica;">) <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">A physician left the
following comment on the above Van De Graaff blog post:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“Frustrations
and stress mount, yes. I think in medicine we should be aware that continuing
bad behavior is partially the responsibility of us all. We have social
standards and maybe should ask ourselves how much have we allowed these actions
to continue? None of us function in a vacuum. We all have the ability to affect change and reward positive
communication.”<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">How do we as a community
of physicians respond to these three physicians who are clearly calling for
physicians to exhibit more humility in our practice of medicine? Do we know how to affect this change in
behavior in our colleagues and ourselves? T. S. Eliot once wrote, “Humility is the most difficult of
all virtues; nothing dies harder than the desire to think well of oneself.” (</span><span style="color: #262626; font-family: Helvetica; mso-bidi-font-family: Arial; mso-bidi-font-size: 23.0pt; mso-bidi-font-weight: bold;">Shakespeare and the Stoicism of
Seneca. </span><span style="color: #262626; font-family: Helvetica; mso-bidi-font-family: Arial; mso-bidi-font-size: 16.0pt;">An address read before the
Shakespeare Association 18th March, 1927)</span><span style="font-family: Helvetica;"><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">The English words
humility and humble are derived from the Latin noun humilitas and the adjective
humilis which can be defined as grounded, from the earth, respectful,
unassuming, modest, and low.
Humility is often contrasted with the terms pride, haughtiness, and
arrogance (See the Frank Lloyd Wright quotation at the beginning of this post). Humility has been held up as a virtue in
both religious and ethical writings.
<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Pride and arrogance are
commonplace among physicians and provide the punch line for the famous New
Yorker cartoon where a physician goes to the front of the line in heaven
“because he thinks he is God.” In the Christian tradition, part of humility is self-knowledge
about the limits of one’s own skills, knowledge, and authority. (</span><a href="http://www.wikihow.com/Be-Humble"><span style="font-family: Helvetica;">http://www.wikihow.com/Be-Humble</span></a><span style="font-family: Helvetica;">)
When a professional like a physician or a teacher does have superior
content knowledge when compared to the patient or the student, arrogance is an
all too common attitude. Bertrand
Russell was talking about teaching, but his lesson applies to physicians as
well:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“In
the presence of a child [the teacher] feels an unaccountable humility – a
humility not easily defensible on any rational ground, and yet somehow nearer
to wisdom than the easy self-confidence of many parents and teachers.” (</span><a href="http://www.williamhare.org/assets/hare_humilityasvirtue.pdf"><span style="font-family: Helvetica;">http://www.williamhare.org/assets/hare_humilityasvirtue.pdf</span></a><span style="font-family: Helvetica;">) <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">The Harvard psychiatrist
Robert Coles thought the greatest achievement of his mentor physician/poet
William Carlos Williams “was to teach doctors honest self-scrutiny, to show how
‘we become full of ourselves, self-preoccupied, so caught up in either our
importance or our own affairs that we can’t listen and pay attention to other
people, even our patients at times.’”
(Carlin Romano. America the Philosophical, New York: Knopf, 2012).<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Honest self-scrutiny of
physician limitations is particularly relevant now that medical group
practices, hospitals, and integrated delivery systems are undergoing process
work redesign in order to respond to federal health care and payment reform. Socrates criticized craftsmen and poets
for assuming that the knowledge and expertise they acquired in one area meant
that they were experts in any area under discussion. (</span><a href="http://www.williamhare.org/assets/hare_humilityasvirtue.pdf"><span style="font-family: Helvetica;">http://www.williamhare.org/assets/hare_humilityasvirtue.pdf</span></a><span style="font-family: Helvetica;">) Having sat in on many lean workgroups, there is a tendency
for physicians to pontificate on subjects about which they know little. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Another component of
humility in Christian teachings is the recognition of the contributions and
skills of others (</span><a href="http://www.wikihow.com/Be-Humble"><span style="font-family: Helvetica;">http://www.wikihow.com/Be-Humble</span></a><span style="font-family: Helvetica;">). Dr. Gawande has spoken eloquently about how
traditionally medicine has emphasized independence and autonomy (acting like cowboys) and
how the complexity and need to decrease per-capita costs now require physicians
to work effectively in interdisciplinary teams, even when they are not the
designated leaders (acting like pit crews) (</span><a href="http://page2anesthesiology.org/2011/teamwork-humility-and-generosity-opening-session-with-atul-gawande-m-d/"><span style="font-family: Helvetica;">http://page2anesthesiology.org/2011/teamwork-humility-and-generosity-opening-session-with-atul-gawande-m-d/</span></a><span style="font-family: Helvetica;">) In my experience consulting with physician
groups, I have noticed that doctors are much more willing to listen to another
physician, rather than a non-physician advisor who may have more content
expertise relevant to the problem under discussion. Developing more skill in this component of humility would
help develop effective and efficient teams. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">If the physician does
not maintain the correct balance between authority and humility, difficulties
can arise in taking the patient’ s story and wishes seriously or in not
critically assessing the patient’s wishes that may be unknowingly harmful to
his health. Dennis Gunning
discusses this ideal balance in teaching history:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“It
is hard for a teacher not to feel uneasy when faced with a fourteen-year-old
giving an unorthodox interpretation of a piece of source material. We really have to school ourselves not
to ‘put him right’, not to sweep his interpretation aside (or, equally bad,
apparently accept it, but in such a way that everybody knows that we are just
humouring the student.)” (</span><a href="http://www.williamhare.org/assets/hare_humilityasvirtue.pdf"><span style="font-family: Helvetica;">http://www.williamhare.org/assets/hare_humilityasvirtue.pdf</span></a><span style="font-family: Helvetica;">) <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">One does not have to
recall that the first definition of doctor in the Oxford English Dictionary is
“teacher, instructor; one who gives instruction in some branch of knowledge” to
see how Gunning’s advice might apply to the physician/patient
relationship. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">How difficult and
important this balancing act can be for physicians is highlighted by our need
to continuously improve the care we give our patients. Henry Sidgwick in 1874 commented on how
strange it is for those who are experts to embrace a humility that requires a
low opinion of one’s self. Would it make more sense to try for an accurate
appraisal of one’s abilities? “Sidgwick suggested that the value of humility
lay in its ability to temper the emotion of self-admiration, and to prevent
appropriate self-esteem…from turning into self complacency.” (</span><a href="http://www.williamhare.org/assets/hare_humilityasvirtue.pdf"><span style="font-family: Helvetica;">http://www.williamhare.org/assets/hare_humilityasvirtue.pdf</span></a><span style="font-family: Helvetica;">) Sidgwick believes that those who lack humility
will exhibit self-satisfaction and complacency that will prevent the
recognition of the need for continuous improvement. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">When organizations need to
change behavior, they rarely consult philosophers and theologians about
humility; they usually look to rules with some sort of policing mechanism and
incentives. And we now have
hospitals and payers instituting rules governing physician conduct, pay for
performance incentives, and patient satisfaction surveys to encourage us to
improve. I have described
elsewhere why physician report cards are fraught with difficulties (</span><a href="http://thehealthcareblog.com/blog/2010/08/21/trust-me-im-a-doctor-vs-physician-quality-report-cards/"><span style="font-family: Helvetica;">http://thehealthcareblog.com/blog/2010/08/21/trust-me-im-a-doctor-vs-physician-quality-report-cards/</span></a><span style="font-family: Helvetica;"> and </span><a href="http://kentbottles.blogspot.com/2010/08/physician-quality-report-cards-part-ii.html"><span style="font-family: Helvetica;">http://kentbottles.blogspot.com/2010/08/physician-quality-report-cards-part-ii.html</span></a><span style="font-family: Helvetica;">) and why pay for performance programs often fail
(</span><a href="http://www.kentbottles.com/pdfs/Pay-for-Performance-Why-It-Will-Not-Work.pdf"><span style="font-family: Helvetica;">http://www.kentbottles.com/pdfs/Pay-for-Performance-Why-It-Will-Not-Work.pdf</span></a><span style="font-family: Helvetica;">). <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Barry Schwartz and
Kenneth Sharpe in <u>Practical Wisdom: The Right
Way to Do the Right Thing</u> (New York:
Riverhead Books, 2010) make a convincing argument that hospitals and
medical groups should add training in practical wisdom in addition to their
rules and incentives. Drawing upon
Aristotle’s Nicomachean Ethics, they think physicians need to be able, with
humility, to choose between “right things that clash, or between better and best,
or sometimes between bad and worse.”<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“Rules
can’t tell experienced practitioners how to do the constant interpretation and
balancing that is part of their everyday work. Consider the doctor who has been
well educated in the rules of how to practice medicine, but is constantly
called on to make more complicated decisions. How should such a doctor balance respect for the autonomy of
her patients when it comes to making decisions with the knowledge that
sometimes the patient is not the best judge of what is needed? How should the
doctor balance empathetic involvement with each patient with the detachment
needed to make sound judgments?... How should the doctor balance the desire to
tell patients the truth, no matter how difficult, with the desire to be kind?”<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Schwartz and Sharpe
teach us that practical wisdom “depended on our ability to perceive the
situation, to have the appropriate feelings or desires about it, to deliberate
about what was appropriate in these circumstances, and to act.”<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">My favorite example of
practical wisdom is their discussion of a hospital janitor who cleans the room
of a comatose young man and then later is confronted by the patient’s father
who claims the room has not been cleaned.
The janitor exhibits practical wisdom by remembering that his goal is to
care and comfort patients and their families, and so he cleans the room again
so the father can see him do it.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“And
when the angry father confronted him, Luke also had to sort out conflicting
aims. There were other legitimate
things he might have chosen to do.
Be honest: tell the father
he had cleaned the room already.
Be courageous: stand up to
the father’s anger and refuse the unfair demand to clean the room again. But Luke had to determine how to
balance these competing aims in this circumstance.”<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">It seems to me that a
better and deeper understanding of humility by the physician community of the
United States would serve all of us well in this time of rapid change and
health care reform. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
Kent Bottleshttp://www.blogger.com/profile/12993140567796683570noreply@blogger.com9tag:blogger.com,1999:blog-6653940794693704941.post-43085673838499946862012-08-09T08:13:00.001-04:002012-08-09T08:13:36.962-04:00Does Luck Contribute to Personal Success?<br />
<div class="MsoNormal">
<span style="font-family: Helvetica;">Romney pouncing on
Obama’s statement “you didn’t build that” got me thinking about success and
luck and community. Romney took
Obama’s words out of context and contends that the President is hostile to
successful small businesses and always looks to government for the
answers. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">When the entire
quotation is examined, it is clear that Obama is saying that successful people
are helped “by personal mentors and government policies that support
infrastructure and technology.”
Here is what the President said in Roanoke, Virginia on July 13, 2012:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“If
you were successful, somebody along the line gave you some help. There was a
great teacher somewhere in your life.
Somebody helped to create this unbelievable system that we have that
allowed you to thrive. Somebody
invested in roads and bridges. If
you’ve got a business, you didn’t build that. Somebody else made that happen.”
(</span><a href="http://www.washingtonpost.com/politics/as-romney-obama-spar-over-you-didnt-build-that-small-businesses-add-context/2012/07/25/gJQA6IN79W_story.html"><span style="font-family: Helvetica;">http://www.washingtonpost.com/politics/as-romney-obama-spar-over-you-didnt-build-that-small-businesses-add-context/2012/07/25/gJQA6IN79W_story.html</span></a><span style="font-family: Helvetica;">) <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">What interests me here
is not the election speeches and ads; what interests me is the expression of
two different views of American culture.
<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“One
narrative puts the big gamble at the center of American life: from the earliest English settlements
at Jamestown and Massachusetts Bay, risky ventures in real estate (and other
less palpable commodities) power the progress of a fluid, mobile democracy….
The other narrative exalts a different sort of hero – a disciplined self-made
man, whose success comes through careful cultivation of (implicitly Protestant)
virtues in cooperation with a Providential plan.” (Jackson Lears, Something for
Nothing. New York: Penguin Group, 2003)<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">In the first narrative,
luck contributes to success or failure and net worth may not correlate with
moral worth. In the second, luck
does not play a role in success and net worth in this world does reflect moral
worth. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Conservatives regard
success in the marketplace as due to the individual’s hard work and skill. Liberals believe that hardworking folks
can fail because of bad luck and events beyond their control. No wonder Romney and Obama are arguing
over what causes success or failure. (</span><a href="http://www.nytimes.com/2012/08/05/business/of-luck-and-success-economic-view.html"><span style="font-family: Helvetica;">http://www.nytimes.com/2012/08/05/business/of-luck-and-success-economic-view.html</span></a><span style="font-family: Helvetica;">) <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">When I read Daniel
Kahneman’s superb summary of behavioral economics, <u>Thinking, Fast and Slow, </u>(New York: Farrar, Straus & Giroux,
2011)<u> </u>I was surprised to find two formulas
dealing with success. Kahneman
describes these two formulas as his favorites: “Success = luck + talent; Great success = a little more
talent + a lot of luck.” He also
states, “Luck plays a large role in every story of success; it is almost always
easy to identify a small change in the story that would have turned a remarkable
achievement into a mediocre outcome.”<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Recent research on
online markets concludes that the link between quality and success is
uncertain. The best products
sometimes fail, and the worst products sometimes succeed. Success in the marketplace for products
that are not the best or the worst is mostly due to luck. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">In the research, a
control group listened to music by obscure bands and rated them without knowing
what others thought of the songs.
The researchers then compared the results of the control group with
results from eight other versions of the study where participants could see how
many times each song had been downloaded and its average rating. The researchers concluded that if a few
early listeners disliked the song it would fail. If a few early listeners liked the same song it could go on
to be a winner in the contest.
“The song ‘Lockdown,’ by the band 52 Metro, is a case in point. Ranked
26<sup>th</sup> out of 48 in the objective ratings, it finished at No. 1 in one
of the eight groups, but at No. 40 in another.” (</span><a href="http://www.nytimes.com/2012/08/05/business/of-luck-and-success-economic-view.html"><span style="font-family: Helvetica;">http://www.nytimes.com/2012/08/05/business/of-luck-and-success-economic-view.html</span></a><span style="font-family: Helvetica;">)<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Michael Lewis, the
enormously successful writer of books like <u>Liar’s
Poker</u> and <u>Moneyball, </u>gave the 2012
commencement speech at his alma mater, Princeton. He described how an art history major ended up at 28 years
old the author of a best selling business book with a little fame, a small
fortune, and new life narrative. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“Even
I could see there was another, truer narrative, with luck as its theme. What were the odds of being seated at
that dinner next to that Salomon Brothers lady? Of landing inside the best Wall
Street firm from which to write the story of an age? Of landing in the seat
with the best view of the business? Of having parents who didn’t disinherit me
but instead sighed and said, ‘do it if you must?’ Of having had that sense of
must kindled inside me by a professor of art history at Princeton? Of having been let into Princeton in
the first place?”<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Later in the speech, he
observes that the true narrative of his successful career makes many in America
uncomfortable.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“People
really don’t like to hear success explained away as luck – especially
successful people. As they age, and succeed, people feel their success was
somehow inevitable. They don’t
want to acknowledge the role played by accident in their lives. There is a reason for this: the world does not want to acknowledge
it either.” (</span><a href="http://blogs.ajc.com/get-schooled-blog/2012/06/09/author-michael-lewis-commencement-speech-lucky-you/"><span style="font-family: Helvetica;">http://blogs.ajc.com/get-schooled-blog/2012/06/09/author-michael-lewis-commencement-speech-lucky-you/</span></a><span style="font-family: Helvetica;">) <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">It is hard to imagine
Mitt Romney giving a similar commencement speech. It is easy to identify Romney
with the narrative that has no place for luck in the story of his personal
success. Romney clearly believes in the dominant culture of control where
everything from universities to medicine is valued by the marketplace.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“The
new rhetoricians of progress believed that their success was the product of a
meritocratic process, that they were the type who took chances successfully,
that their superior skill and drive allowed them to make their own luck – and
that history was on their side.
This is a fair summary of the dominant mood within managerial
professional elites, amid the triumphalist atmosphere of the American fin de
siècle. (Jackson Lears, Something
for Nothing. New York: Penguin
Group, 2003)<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Contrast that point of
view with Tim Berners-Lee who invented the world wide web without cashing in to
become a millionaire.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="color: #0e0e0e; font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 14.0pt;">“People
have sometimes asked me whether I am upset that I have not made a lot of money
from the Web. In fact, I made some quite conscious decisions about which
way to take my life. These I would not change…. What does distress me, though,
is how important a question it seems to be maddening is the terrible notion that
a person’s value depends on how important and financially successful they are,
and that that is measured in terms of money. That suggests disrespect for
the researchers across the globe developing ideas for the next leaps in science
and technology. Core in my upbringing was a value system that put
monetary gain well in its place, behind things like doing what I really want to
do. To use net worth as a criterion by which to judge people is to set
our children’s sights on cash rather than on things that will actually make
them happy.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="color: #0e0e0e; font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 14.0pt;">(Tim
Berners-Lee, Weaving the Web: The
Original Design and Ultimate Destiny of the World Wide Web by Its Inventor. San
Francisco: Harper, 1999)<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal">
<span style="color: #0e0e0e; font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 14.0pt;">In the afterword to the 25<sup>th</sup>
Anniversary Edition of <u>The Gift: Creativity and the Artist in the Modern
World </u>(New York: Vintage, 2007), Lewis Hyde describes why he wrote his book
about the parts of the world that do not work well under the marketplace
theory:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="color: #0e0e0e; font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 14.0pt;">“The
first is simply that there are categories of human enterprise that are not well
organized or supported by market forces.
Family life, religious life, public service, pure science, and of course
much artistic practice: none of
these operates very well when framed simply in terms of exchange value. The second assumption follows: any community that values these things
will find nonmarket ways to organize them. It will develop gift-exchange institutions dedicated to
their support.”<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<u><span style="color: #0e0e0e; font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 14.0pt;">The
Gift </span></u><span style="color: #0e0e0e; font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 14.0pt;">is a great place to start thinking
about the tension between the two narratives described in the beginning of this
blog post. The current tension in
the medical scientific community between knowledge being a gift or a commodity
is nicely summarized in this quotation by MIT Geneticist Jonathan Kind:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="color: #0e0e0e; font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 14.0pt;"> “’In
the past one of the strengths of American bio-medical science was the <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="color: #0e0e0e; font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 14.0pt;">free
exchange of materials, strains of organisms and information…But now, if you
sanction and institutionalize private gain and parenting of microorganisms,
then you don’t send out your strains because you don’t want them in the public
sector. That’s already happening
now. People are no longer sharing their strains of bacteria and their results
as freely as they did in the past.’”<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="color: #0e0e0e; font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 14.0pt;">Those of us who have won Warren
Buffett’s “ovarian lottery” and have experienced a modicum of worldly success
might living in the United States of America should constantly remind ourselves
that we are indeed lucky. We
should heed the conclusion of Lewis’ commencement speech:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="color: #0e0e0e; font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 14.0pt;">“You
are the lucky few. Lucky in your
parents, lucky in your country, lucky that a place like Princeton exists that
can take in lucky people, introduce them to other lucky people, and increase
their chances of becoming even luckier. Lucky that you live in the richest
society the world has ever seen, in a time when no one actually expects you to
sacrifice your interests to anything.” (</span><a href="http://blogs.ajc.com/get-schooled-blog/2012/06/09/author-michael-lewis-commencement-speech-lucky-you/"><span style="font-family: Helvetica;">http://blogs.ajc.com/get-schooled-blog/2012/06/09/author-michael-lewis-commencement-speech-lucky-you/</span></a><span style="font-family: Helvetica;">) <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;"> <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>Kent Bottleshttp://www.blogger.com/profile/12993140567796683570noreply@blogger.com0tag:blogger.com,1999:blog-6653940794693704941.post-12281249006515984852012-08-06T22:19:00.001-04:002012-08-06T22:19:58.876-04:00Activated, Empowered Patients Are Not New<br />
<div class="MsoNormal">
<span style="font-family: Helvetica;">One of the most
inspiring athletes of the 2012 London Olympics is American swimmer Dana Vollmer
who won the gold medal in the 100 meter butterfly by being the first woman to
finish that event in less than 56 seconds. Vollmer exemplifies the engaged, empowered patient, and her
story reminded me of three such patients who took charge of their health long
before there was a formal participatory patient movement. These three pioneers were President
Franklin Delano Roosevelt, writer Norman Cousins, and actress Patricia Neal. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">When Vollmer at the age
of 15 was diagnosed with long QT syndrome, it most likely meant the end of her
competitive swimming career. The
usual treatment for this genetic cardiac electrical disorder that can cause
sudden death due to supraventricular tachycardia is to implant a defibrillator
in the heart. The risk of sudden
death in competitive athletes with this syndrome is up to three times greater
than in sedentary patients. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">However in a dramatic
example of how treatment must be tailored to the individual patient, Vollmer
and her family decided to continue competitive swimming training and to always
have an external defibrillator available should the need arise. It never did, but still the diagnosis
weighed on Vollmer’s mind:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“’I
could die, my heart could just stop…There were definitely times it was scary,
as much as I tried to block it out. If I got lightheaded, I would associate it
with long QT,’ she says. Part of
Olympic training involves underwater work, and for Dana, having to hold her
breath to the point of feeling lightheaded was one of the hardest things to do.
‘Slowly but surely I never fainted and never had symptoms. It just got further and further from my
mind.’” (<a href="http://well.blogs.nytimes.com/2012/07/31/overcoming-a-heart-condition-to-win-olympic-gold/">http://well.blogs.nytimes.com/2012/07/31/overcoming-a-heart-condition-to-win-olympic-gold/</a>)
<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">After being told by
Boston Children’s Hospital expert Dr. Robert Lovett that there was nothing he
could do for the patient’s polio, Franklin Delano Roosevelt created his own
rigorous exercise rehabilitation program. When he purchased a hotel and pool
facilities in Warm Springs, Georgia, other polio victims came to participate in
his unique exercise program that took place in the warm springs pools.
Roosevelt even published his clinical experience in the Journal of the South
Carolina Medical Association and proposed that he present his work at the 1926
American Orthopedic Association annual meeting. When the meeting planners rejected his proposal, FDR went to
the meeting anyway and “secured a commitment from the orthopedists to evaluate
the Warm Springs program. The
association made good on its promise and confirmed the program’s positive
effects.” <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">“’During that first
year, I was doctor and physiotherapist rolled into one,” FDR would later boost.
David Blumenthal and James A.
Morone in The Heart of Power:
Health and Politics in the Oval Office (Berkeley: University of California Press, 2009)
concluded their discussion of this most empowered patient by writing, “No
president has ever come closer to practicing medicine without a license than
Franklin Delano Roosevelt did in the 1920s in rural Georgia.”<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Norman Cousins, the
editor of the Saturday Review for 35 years and the author of 15 books,
described in Anatomy of An Illness as Perceived by the Patient (New York: WW
Norton, 1979) how he decided to treat his ankylosing spondylitis by checking
out of the hospital and into a hotel to watch Marx Brothers movies. He stated, “Medical treatment is a
20-point partnership – the physician has 10 points, the patient has 10
points. If patients are given the
idea that they can do something, they take the treatment better.” (<a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2154152/">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2154152/</a>)
After the publication of his book, Cousins joined the faculty of UCLA School of
Medicine where he examined the usefulness of patient engagement and “’found
myself being pushed into the role of ombudsman for patients who were
complaining about their treatment.’” ((<a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2154152/">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2154152/</a>)
<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">In 1965 the 39-year-old
film actress Patricia Neal suffered a severe stroke that resulted in a coma
that lasted two weeks. When she
woke up unable to speak, unable to walk, and paralyzed, her neurosurgeon said, “’I
don’t know if I’ve done you a favor’” by keeping you alive. Neal’s husband, novelist Roald Dahl, improvised
“a rigorous program of confronting her with tricks, games, and puzzles to
improve her memory and speech.” (<a href="http://www.nytimes.com/1981/12/08/arts/tv-patricia-neal-s-victory-over-crippling-stroke.html">http://www.nytimes.com/1981/12/08/arts/tv-patricia-neal-s-victory-over-crippling-stroke.html</a>)
By not giving up and by not listening to the advice of their physicians, Dahl
and Neal changed the way stroke patients are treated and eventually supported a
special rehabilitation department in her hometown of Knoxville, Tennessee. Two
years after her stroke, Neal starred in the movie The Subject Was Roses. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Vollmer, FDR, Cousins,
and Neal all remind us that activated, engaged patients do better clinically
and often can surprise themselves and their doctors by their efforts. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;"> <o:p></o:p></span></div>Kent Bottleshttp://www.blogger.com/profile/12993140567796683570noreply@blogger.com1tag:blogger.com,1999:blog-6653940794693704941.post-79013092630920364332012-07-31T10:04:00.001-04:002012-07-31T10:04:52.308-04:00The Olympics, Doctors, the NHS, Transformation and Heroes: Why the Difference between the USA and UK, Part III<!--[if gte mso 9]><xml>
<o:OfficeDocumentSettings>
<o:AllowPNG/>
</o:OfficeDocumentSettings>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:WordDocument>
<w:Zoom>0</w:Zoom>
<w:TrackMoves>false</w:TrackMoves>
<w:TrackFormatting/>
<w:PunctuationKerning/>
<w:DrawingGridHorizontalSpacing>18 pt</w:DrawingGridHorizontalSpacing>
<w:DrawingGridVerticalSpacing>18 pt</w:DrawingGridVerticalSpacing>
<w:DisplayHorizontalDrawingGridEvery>0</w:DisplayHorizontalDrawingGridEvery>
<w:DisplayVerticalDrawingGridEvery>0</w:DisplayVerticalDrawingGridEvery>
<w:ValidateAgainstSchemas/>
<w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid>
<w:IgnoreMixedContent>false</w:IgnoreMixedContent>
<w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText>
<w:Compatibility>
<w:BreakWrappedTables/>
<w:DontGrowAutofit/>
<w:DontAutofitConstrainedTables/>
<w:DontVertAlignInTxbx/>
</w:Compatibility>
</w:WordDocument>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:LatentStyles DefLockedState="false" LatentStyleCount="276">
</w:LatentStyles>
</xml><![endif]-->
<!--[if gte mso 10]>
<style>
/* Style Definitions */
table.MsoNormalTable
{mso-style-name:"Table Normal";
mso-tstyle-rowband-size:0;
mso-tstyle-colband-size:0;
mso-style-noshow:yes;
mso-style-parent:"";
mso-padding-alt:0in 5.4pt 0in 5.4pt;
mso-para-margin:0in;
mso-para-margin-bottom:.0001pt;
mso-pagination:widow-orphan;
font-size:12.0pt;
font-family:"Times New Roman";
mso-ascii-font-family:Cambria;
mso-ascii-theme-font:minor-latin;
mso-fareast-font-family:"Times New Roman";
mso-fareast-theme-font:minor-fareast;
mso-hansi-font-family:Cambria;
mso-hansi-theme-font:minor-latin;}
</style>
<![endif]-->
<!--StartFragment-->
<br />
<div class="MsoNormal">
<span style="font-family: Helvetica;">This blog post
originated in my surprise that the Opening Ceremonies of the Olympic Games
honored both the National Health Service and Tim Berners-Lee. Watching the doctors and nurses
and patients dancing in the Olympic Stadium made me wonder why health care
reform united the United Kingdom and seems to be tearing apart the United
States. I also started to wonder
why so many physicians in the United States seem to defend the status quo that
has resulted in the “inconceivable” outcomes documented in Part II of the
blog. How can professionals defend
a system that is so costly and results in such low quality by any objective
measurement? The short answer is that doctors are human beings. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Arrogance and power and
social standing make it hard for any professional to exhibit the humility,
courage, and existential strength that are needed to continuously improve one’s
craft. In examining journalism’s
response to the ongoing News International surveillance, phone hacking, and
bribery of police officers scandal in Great Britain, David Carr wonders why the
offenders are seen as “outliers;” he wonders why there have not been <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“deeply
reported investigative articles about how things went so wrong: the failures of
leadership, the skewed values and willingness of an industry to treat the
public with such contempt. The Guardian correctly suggested that the arrests
were unprecedented in the history of newspapers.”<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Carr examines the many
reasons why 66% of the public no longer trusts newspapers to be accurate, and
he zeroes in on why journalism as an industry has lost its way.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“The
news media often fail to turn the X-ray machine on themselves because, in part,
journalists assign a nobility to the profession that obscures the flaws within
it. We think of ourselves as doing
the People’s work, and write off lapses in ethics and practices as potholes on
the way to a Greater Truth.” (</span><a href="http://www.nytimes.com/2012/07/30/business/media/holding-up-a-mirror-to-journalism-the-media-equation.html?ref=business"><span style="font-family: Helvetica;">http://www.nytimes.com/2012/07/30/business/media/holding-up-a-mirror-to-journalism-the-media-equation.html?ref=business</span></a><span style="font-family: Helvetica;">) <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">I started Part I of this
blog by discussing one of my heroes, Tim Berners-Lee, but now I have to reflect
on one of my heroes who recently passed away: Joe Paterno. A sociology
professor stated,<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“It
makes sense that the catastrophic fall of Paterno correlates with the degree of
hypocrisy people have identified between Paterno – the moral do-gooder – and
this really ugly underbelly of the program he ran that was so morally
contemptible.” (</span><a href="http://blog.pennlive.com/patriotnewssports/2012/07/joe_paterno_provides_a_caution.html"><span style="font-family: Helvetica;">http://blog.pennlive.com/patriotnewssports/2012/07/joe_paterno_provides_a_caution.html</span></a><span style="font-family: Helvetica;">) <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">The Penn State football
program and its coach achieved unparalleled success on the field, and Paterno
became the most powerful person in the entire university. Arrogance and an inbreeding where
leaders were recruited internally created a culture that valued “protecting”
the reputation of the athletic program more than protecting the safety of young
men being abused by Jerry Sandusky.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Like journalists serving
the Greater Truth and Paterno extolling the Grand Experiment of melding
athletics with academics, physicians see themselves as part of a noble
profession ably taking care of patients.
Physicians are famous for not appreciating advice or oversight from
non-physicians. When physicians
and nurses are found to have done the “inconceivable” things we discussed in
Part II, the outlier concept is quickly articulated. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Dr. Kevin Pho criticizes
policy wonks in “The Tension Between Physicians and Health Policy Experts” for
not deferring to physicians on how to reform the American health care delivery
system.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“Yet,
to successfully reform our health system, doctors need to be at the forefront,
not policy experts. And I’m not
saying that because I’m a physician myself.” (</span><a href="http://www.kevinmd.com/blog/2011/05/tension-physicians-health-policy-experts.html"><span style="font-family: Helvetica;">http://www.kevinmd.com/blog/2011/05/tension-physicians-health-policy-experts.html</span></a><span style="font-family: Helvetica;">) <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">The good doctor doth
protest too much. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">This idea that
physicians need to always lead any effort to improve health care delivery does
not make sense. Physicians,
patients, nurses, hospital administrators, legislators, health plan executives,
and employers all have part of the answer to the health care delivery
problem. Robust, long-term
solutions to the complicated problems of health care delivery can only be
crafted when all of the listed players truly understand how the problem looks
and feels to each of the others. <u>Theory U: Leading from the Future as It Emerges</u>
by C. Otto Scharmer (San Francisco:
Berrett-Koehler, 2009) offers a way to gain the wisdom and insight from
all concerned when trying to come up with lasting solutions. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Physicians, like
journalists and football coaches, are human beings. They are no more or less likely than other human beings to
act rationally, irrationally, bravely, cowardly, or ethically. This tension between the idealized view
that many physicians have of themselves and reality was nicely captured in a
series of letters between Arnold Relman, MD, the former editor of The New
England Journal of Medicine and Princeton economist Uwe Reinhardt. Relman thinks physicians are special
and he asks Reinhardt the following question: <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“Do
you really see no difference between physicians and hospitals on the one hand,
and ‘purveyors of other goods and services,’ on the other?”<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Reinhardt is ready with
a long answer that should be read in its entirety. The short answer is that doctors act like any other human
beings. A portion of his
answer includes the following:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“Surely
you will agree that it has been one of American medicine’s more hallowed tenets
that piece-rate compensation is the sine qua non of high quality medical
care. Think about this tenet, We
have here a profession that openly professes that its members are unlikely to
do their best unless they are rewarded in cold cash for every little
ministration rendered their patients.
If an economist made that assertion, one might write it off as one more
of that profession’s kooky beliefs.
But physicians are saying it.” (</span><a href="http://content.healthaffairs.org/content/5/2/5.full.pdf+html"><span style="font-family: Helvetica;">http://content.healthaffairs.org/content/5/2/5.full.pdf+html</span></a><span style="font-family: Helvetica;">) <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Physicians are human
beings who try to do their best in a complicated, dysfunctional, rapidly
changing health care system that too often results in the bad outcomes
documented by Millenson and the ProPublica journalists cited in Part II of this
blog. I agree with Dr. Thomas
Smith of Johns Hopkins who was quoted as saying, “Most doctors are
sleepwalkers, not evildoers.” (</span><a href="http://www.usatoday.com/news/health/story/health/story/2012-01-30/Doctor-exposes-the-dangers-of-overtreatment/52893278/1"><span style="font-family: Helvetica;">http://www.usatoday.com/news/health/story/health/story/2012-01-30/Doctor-exposes-the-dangers-of-overtreatment/52893278/1</span></a><span style="font-family: Helvetica;">) <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Human beings, including
doctors, are not good judges of their own performance and behaviors. Self-deception is part of being human
and has been called “one of the most puzzling things that humans do.”<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“Researchers
disagree over what exactly happens in the brain during self-deception. Social psychologists say people deceive
themselves in an unconscious effort to boost self esteem or feel better.
Evolutionary psychologists, who say different parts of the brain can harbor
conflicting beliefs at the same time, say self-deception is a way of fooling
others to our own advantage.” (</span><a href="http://online.wsj.com/article/SB10000872396390443343704577548973568243982.html"><span style="font-family: Helvetica;">http://online.wsj.com/article/SB10000872396390443343704577548973568243982.html</span></a><span style="font-family: Helvetica;">) <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">What is not
controversial is that human beings deceive themselves and are not good judges
of their own behavior. Children as young as three have a “positivity bias”
where they see themselves as smart regardless of their abilities. Nobelist Daniel Kahneman’s <u>Thinking, Fast and Slow</u> (New York: Farrar, Straus and Giroux, 2011)
catalogs and analyzes the false beliefs that we humans automatically think are
true. The illusion of validity is
the false belief that our own judgment is accurate, and Kahneman admits that
even he cannot escape the cognitive illusion that his own judgments are
reliable. Although he won the
Nobel Prize in Economics for developing the field of behavioral economics, Kahneman
is a still a human being, and human beings harbor cognitive illusions. Another scholarly book on
self-deception worth reading is Robert Trivers’ <u>The
Folly of Fools </u>(New York: Basic Books, 2011).<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">And that is why doctors,
being human, need all the help they can get from check lists, social
scientists, empowered patients, patient families, employers, spouses,
government regulators, individual and group report cards, nurses, and
others. The last word goes to
President Ronald Reagan, “Trust, but verify.” <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<!--EndFragment-->Kent Bottleshttp://www.blogger.com/profile/12993140567796683570noreply@blogger.com0tag:blogger.com,1999:blog-6653940794693704941.post-62583902721031670132012-07-30T10:27:00.001-04:002012-07-30T10:27:57.905-04:00The Olympics, Doctors, the NHS, Transformation and Heroes: Why the Difference between the USA and UK? Part II<!--[if gte mso 9]><xml>
<o:OfficeDocumentSettings>
<o:AllowPNG/>
</o:OfficeDocumentSettings>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:WordDocument>
<w:Zoom>0</w:Zoom>
<w:TrackMoves>false</w:TrackMoves>
<w:TrackFormatting/>
<w:PunctuationKerning/>
<w:DrawingGridHorizontalSpacing>18 pt</w:DrawingGridHorizontalSpacing>
<w:DrawingGridVerticalSpacing>18 pt</w:DrawingGridVerticalSpacing>
<w:DisplayHorizontalDrawingGridEvery>0</w:DisplayHorizontalDrawingGridEvery>
<w:DisplayVerticalDrawingGridEvery>0</w:DisplayVerticalDrawingGridEvery>
<w:ValidateAgainstSchemas/>
<w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid>
<w:IgnoreMixedContent>false</w:IgnoreMixedContent>
<w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText>
<w:Compatibility>
<w:BreakWrappedTables/>
<w:DontGrowAutofit/>
<w:DontAutofitConstrainedTables/>
<w:DontVertAlignInTxbx/>
</w:Compatibility>
</w:WordDocument>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:LatentStyles DefLockedState="false" LatentStyleCount="276">
</w:LatentStyles>
</xml><![endif]-->
<!--[if gte mso 10]>
<style>
/* Style Definitions */
table.MsoNormalTable
{mso-style-name:"Table Normal";
mso-tstyle-rowband-size:0;
mso-tstyle-colband-size:0;
mso-style-noshow:yes;
mso-style-parent:"";
mso-padding-alt:0in 5.4pt 0in 5.4pt;
mso-para-margin:0in;
mso-para-margin-bottom:.0001pt;
mso-pagination:widow-orphan;
font-size:12.0pt;
font-family:"Times New Roman";
mso-ascii-font-family:Cambria;
mso-ascii-theme-font:minor-latin;
mso-fareast-font-family:"Times New Roman";
mso-fareast-theme-font:minor-fareast;
mso-hansi-font-family:Cambria;
mso-hansi-theme-font:minor-latin;}
</style>
<![endif]-->
<!--StartFragment-->
<br />
<div class="MsoNormal">
<!--[if gte mso 9]><xml>
<o:OfficeDocumentSettings>
<o:AllowPNG/>
</o:OfficeDocumentSettings>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:WordDocument>
<w:Zoom>0</w:Zoom>
<w:TrackMoves>false</w:TrackMoves>
<w:TrackFormatting/>
<w:PunctuationKerning/>
<w:DrawingGridHorizontalSpacing>18 pt</w:DrawingGridHorizontalSpacing>
<w:DrawingGridVerticalSpacing>18 pt</w:DrawingGridVerticalSpacing>
<w:DisplayHorizontalDrawingGridEvery>0</w:DisplayHorizontalDrawingGridEvery>
<w:DisplayVerticalDrawingGridEvery>0</w:DisplayVerticalDrawingGridEvery>
<w:ValidateAgainstSchemas/>
<w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid>
<w:IgnoreMixedContent>false</w:IgnoreMixedContent>
<w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText>
<w:Compatibility>
<w:BreakWrappedTables/>
<w:DontGrowAutofit/>
<w:DontAutofitConstrainedTables/>
<w:DontVertAlignInTxbx/>
</w:Compatibility>
</w:WordDocument>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:LatentStyles DefLockedState="false" LatentStyleCount="276">
</w:LatentStyles>
</xml><![endif]-->
<!--[if gte mso 10]>
<style>
/* Style Definitions */
table.MsoNormalTable
{mso-style-name:"Table Normal";
mso-tstyle-rowband-size:0;
mso-tstyle-colband-size:0;
mso-style-noshow:yes;
mso-style-parent:"";
mso-padding-alt:0in 5.4pt 0in 5.4pt;
mso-para-margin:0in;
mso-para-margin-bottom:.0001pt;
mso-pagination:widow-orphan;
font-size:12.0pt;
font-family:"Times New Roman";
mso-ascii-font-family:Cambria;
mso-ascii-theme-font:minor-latin;
mso-fareast-font-family:"Times New Roman";
mso-fareast-theme-font:minor-fareast;
mso-hansi-font-family:Cambria;
mso-hansi-theme-font:minor-latin;}
</style>
<![endif]-->
<!--StartFragment-->
</div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Like many in the United
States, I was surprised when the National Health Service (NHS) was honored
during the Opening Ceremonies of the London Olympic Games. The media guide said, “The NHS is the
institution which more than any other unites our nation. It was founded after World War II on
Aneurin Bevan’s famous principle, ‘No society can legitimately call itself
civilised if a sick person is denied medical aid because of lack of means.’” (<a href="http://capsules.kaiserhealthnews.org/index.php/2012/07/u-k-national-health-service-gets-gold-medal-mention-at-olympics/">http://capsules.kaiserhealthnews.org/index.php/2012/07/u-k-national-health-service-gets-gold-medal-mention-at-olympics/</a>)
<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Should the Bevan
principle make Americans think about what makes a society civilized? Does the American health care delivery
system unite our nation? I could
not help thinking back to the Republican Presidential Debate where the audience
and Ron Paul seemed to be saying that those without health insurance should be
left to die. (<a href="http://www.youtube.com/watch?v=8T9fk7NpgIU">http://www.youtube.com/watch?v=8T9fk7NpgIU</a>)
(<a href="http://www.thedoctorweighsin.com/gop-to-uninsured-feel-free-to-drop-dead/">http://www.thedoctorweighsin.com/gop-to-uninsured-feel-free-to-drop-dead/</a>)
Health care in the United States divides our country into those who believe
health care is a human right and those who think it is not. Paul Starr summarizes this tension by
stating:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“Americans
are still at odds over the most basic question about health care: whether it is
a requirement for a free life that the community has an obligation to provide
or a good that needs to be earned (and if you can’t earn it, too bad for you).”
(Remedy and Reaction: The Peculiar American Struggle Over Health Care Reform,
New Haven: Yale University Press,
2011)<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Starr traces our dilemma
back to the establishment of Medicare as an earned right even though seniors
have never paid enough in payroll taxes to cover their insurance costs and
Medicaid as an unearned benefit that lacks a moral claim on the community. This history has created a “protected
public” who believe they have earned their medical coverage, and they are
largely unwilling to subsidize coverage for the less fortunate. By creating separate health insurance
financing for the elderly, the United States created a political problem that
has caused partisan bickering. It
is noteworthy that the Supreme Court decision upholding most of the Patient
Protection and Affordable Care Act created a way for governors to elect not to
participate in the expansion of the “unearned” benefit of Medicaid. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Although Senate Minority
Leader Mitch McConnell yesterday labeled the American health care delivery
system “the finest in the world,” most Americans recognize the status quo as
unsustainable, expensive, and unsafe.
Otis Brawley, MD, chief medical officer at the American Cancer Society,
has a different take than McConnell:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“Our
medical system fails to provide care when care is needed, and fails to stop
expensive, often unnecessary and frequently harmful interventions, even in
situations when science proves those interventions are the wrong thing to do.” (How We Do Harm: A Doctor Breaks Ranks About Being Sick
in America, New York: St. Martin’s
Press, 2012)<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Michael L. Millenson
reviews the depressing statistics about preventable errors causing death in the
United States in an article titled “The Toll of Preventable Errors: How Many Dead Patients?” According to
Millenson, the best estimate comes from the Agency for Healthcare Research and
Quality; 90,000 hospital patients die each year from preventable,
treatment-caused injuries. Millenson also cites a 2010 study of hospital
error-reduction programs that concluded “harm remain common, with little
evidence of widespread improvements.” (<a href="http://www.thedoctorweighsin.com/the-toll-of-preventable-errors-how-many-dead-patients/">http://www.thedoctorweighsin.com/the-toll-of-preventable-errors-how-many-dead-patients/</a>)
<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">A July 20, 2012 article
titled “Why Can’t Medicine Seem to Fix Simple Mistakes?” provides an overview
of the ongoing patient safety issue in American medicine. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“Time
and again reporters have uncovered unfathomable lapses at medical facilities,
often resulting in patient injuries and death. Time and again, hospital officials have put in place
solutions that seem ridiculously obvious.
And, inconceivably, the fixes are frequently ignored or ineffective.” (<a href="http://www.propublica.org/article/why-cant-medicine-seem-to-fix-simple-mistakes">http://www.propublica.org/article/why-cant-medicine-seem-to-fix-simple-mistakes</a>)
<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">The article describes
five wrong site surgeries at Rhode Island Hospital, nurses at Martin Luther
King Jr./Drew Medical Center ignoring monitors in six cases where patients
died, and the recent death of a 12-year boy from sepsis where important
laboratory results were not reported by NYU’s Langone Medical Center. The article states:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; tab-stops: 184.5pt;">
<span style="font-family: Helvetica;">“That’s what’s so difficult to understand about
medical mistakes. It seems
inconceivable that nurses and doctors would reuse a syringe on multiple
patients or that they would turn down alarms on cardiac monitors after patients
at their hospital had died as a result.” (<a href="http://www.propublica.org/article/why-cant-medicine-seem-to-fix-simple-mistakes">http://www.propublica.org/article/why-cant-medicine-seem-to-fix-simple-mistakes</a>)
<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; tab-stops: 184.5pt;">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">In
Part III of this blog we will explore why human doctors and nurses do “inconceivable”
things. <o:p></o:p></span></div>
<!--EndFragment--><br />
<!--EndFragment-->Kent Bottleshttp://www.blogger.com/profile/12993140567796683570noreply@blogger.com1tag:blogger.com,1999:blog-6653940794693704941.post-11167997904737463882012-07-29T18:53:00.001-04:002012-07-29T18:53:17.128-04:00The Olympics, Doctors, NHS, Transformation, and Heroes: Why the Difference between USA and UK?<!--[if gte mso 9]><xml>
<o:OfficeDocumentSettings>
<o:AllowPNG/>
</o:OfficeDocumentSettings>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:WordDocument>
<w:Zoom>0</w:Zoom>
<w:TrackMoves>false</w:TrackMoves>
<w:TrackFormatting/>
<w:PunctuationKerning/>
<w:DrawingGridHorizontalSpacing>18 pt</w:DrawingGridHorizontalSpacing>
<w:DrawingGridVerticalSpacing>18 pt</w:DrawingGridVerticalSpacing>
<w:DisplayHorizontalDrawingGridEvery>0</w:DisplayHorizontalDrawingGridEvery>
<w:DisplayVerticalDrawingGridEvery>0</w:DisplayVerticalDrawingGridEvery>
<w:ValidateAgainstSchemas/>
<w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid>
<w:IgnoreMixedContent>false</w:IgnoreMixedContent>
<w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText>
<w:Compatibility>
<w:BreakWrappedTables/>
<w:DontGrowAutofit/>
<w:DontAutofitConstrainedTables/>
<w:DontVertAlignInTxbx/>
</w:Compatibility>
</w:WordDocument>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:LatentStyles DefLockedState="false" LatentStyleCount="276">
</w:LatentStyles>
</xml><![endif]-->
<!--[if gte mso 10]>
<style>
/* Style Definitions */
table.MsoNormalTable
{mso-style-name:"Table Normal";
mso-tstyle-rowband-size:0;
mso-tstyle-colband-size:0;
mso-style-noshow:yes;
mso-style-parent:"";
mso-padding-alt:0in 5.4pt 0in 5.4pt;
mso-para-margin:0in;
mso-para-margin-bottom:.0001pt;
mso-pagination:widow-orphan;
font-size:12.0pt;
font-family:"Times New Roman";
mso-ascii-font-family:Cambria;
mso-ascii-theme-font:minor-latin;
mso-fareast-font-family:"Times New Roman";
mso-fareast-theme-font:minor-fareast;
mso-hansi-font-family:Cambria;
mso-hansi-theme-font:minor-latin;}
</style>
<![endif]-->
<!--StartFragment-->
<br />
<div class="MsoNormal">
<span style="font-family: Helvetica;">I was surprised when the
Opening Ceremonies of the Olympics in London honored two of my favorite
institutions: the National Health
Service and the World Wide Web. I was
not surprised when LA Times sports writer Diane Pucin posted the following
tweet: “For the life of me, though, am still baffled by NHS tribute at opening
ceremonies. Like a tribute to
United Health Care or something in US.” @swaldman responded to the sports
writer with “Well, maybe, if United Health Care were government-run and a
source of national pride.” <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">I was not surprised when
Meredith Vieira and Matt Lauer of NBC admitted they had no idea why Tim
Berners-Lee was being honored by sending out a tweet. Ever since I read his book Weaving the Web: The Original Design and Ultimate Destiny
of the World Wide Web by Its Inventor (HarperSanFrancisco, 1999), Berners-Lee
has been one of my heroes. Finally
locating my hard copy of the book in the guest bedroom where my son Colin used
to sleep, I quickly located the marked passage I was looking for:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“People
have sometimes asked me whether I am upset that I have not made a lot of money
from the Web. In fact, I made some
quite conscious decisions about which way to take my life. These I would not
change…. What does distress me, though, is how important a question it seems to
be to some. This happens mostly in
America, not Europe. What is maddening is the terrible notion that a person’s
value depends on how important and financially successful they are, and that
that is measured in terms of money.
That suggests disrespect for the researchers across the globe developing
ideas for the next leaps in science and technology. Core in my upbringing was a value system that put monetary
gain well in its place, behind things like doing what I really want to do. To use net worth as a criterion by
which to judge people is to set our children’s sights on cash rather than on
things that will actually make them happy.”<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">I am certainly not alone
in admiring Berners-Lee, as this passage from a blog by Daniel Nye Griffiths
demonstrates:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 15.0pt; margin-left: .5in; margin-right: 0in; margin-top: 0in; mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<span style="font-family: Helvetica;">“</span><span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 14.0pt;">With less of a
commitment to openness, Berners-Lee could have used the Web to become a very
rich man. Instead, he has used every accolade – Fellow of the Royal Society,
Knight Commander of the Order of the British Empire, one of only 22 holders of
the Order of Merit and recipient of enough honorary doctorates to fill a skip –
as a lever, opening doors for his mission to keep the channels of communication
open, accessible and affordable.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 15.0pt; margin-left: .5in; margin-right: 0in; margin-top: 0in; mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 14.0pt;">Looking to the future, he has championed the idea of the Semantic Web
– a system of data tagging to help search engines to understand questions as
well as find words. Closer to home, he has advised data.gov.uk, and pushed
governments past and present to make their data available for free. If you’ve looked
at an OS map online recently, you have him to thank.” (</span><a href="http://www.high50.com/archives/life-times/berners-lee-come-on-tim"><span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 14.0pt;">http://www.high50.com/archives/life-times/berners-lee-come-on-tim</span></a><span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 14.0pt;">) <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 15.0pt; mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 14.0pt;">The Olympic Opening Ceremonies got me
thinking about heroes, health care, doctors, and the struggle to transform the
American health care delivery system.
Why is our delivery system such a mess? Why aren’t Americans proud of their hospitals and doctors
and sending out tweets like @MaxwellLeslie’s “The NHS is one Britain’s greatest
& most loved institutions, reinforcing the ignorant American stereotype
very well with that tweet” by the Southern California sports writer. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 15.0pt; mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 14.0pt;">Paul Levy, the former hospital CEO,
discussed how Dr. Don Berwick’s praise for the NHS made it impossible for him
to ever be confirmed by the United States Senate as the permanent head of
CMS. Levy quoted Berwick’s speech
on the occasion of the NHS’ 60<sup>th</sup> birthday:<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 15.0pt; margin-left: .5in; margin-right: 0in; margin-top: 0in; mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 14.0pt;">“The National Health Service is one of the truly astounding human
endeavors of modern times. Just
look at what you are trying to be:
comprehensive, equitable, available to all, free at the point of care,
and – more and more – aiming for excellence by world-class standards. And, because you have chosen to use a
nation as the scale and taxation as the funding, the NHS isn’t just technical –
it’s political.” (</span><a href="http://runningahospital.blogspot.com/2012/07/will-nhs-medal.html"><span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 14.0pt;">http://runningahospital.blogspot.com/2012/07/will-nhs-medal.html</span></a><span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 14.0pt;">) <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 15.0pt; mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 14.0pt;">And Levy closed his blog post by
writing, “In the former colonies (the US), we take on the task in a different
way, but we face the same issues.
Indeed, as I have noted, ‘After all, the countries are dealing with the
same organisms, both biologically and politically.’” (</span><a href="http://runningahospital.blogspot.com/2012/07/will-nhs-medal.html"><span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 14.0pt;">http://runningahospital.blogspot.com/2012/07/will-nhs-medal.html</span></a><span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 14.0pt;">) <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 15.0pt; mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 14.0pt;">Since the United States and the United
Kingdom both have health systems that take care of humans and since both operate
under similar democratic political systems, why are the results so
different? <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 15.0pt; mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 14.0pt;">In Part II of this blog post, we will
try to answer this question.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 15.0pt; mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 15.0pt; mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 15.0pt; mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 15.0pt; mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<!--EndFragment-->Kent Bottleshttp://www.blogger.com/profile/12993140567796683570noreply@blogger.com1tag:blogger.com,1999:blog-6653940794693704941.post-34642225938511761832012-07-16T16:26:00.000-04:002012-07-16T16:26:46.709-04:00Health Insurers & the PPACA: Extinction or Reinvention? Part II<!--[if gte mso 9]><xml>
<o:OfficeDocumentSettings>
<o:AllowPNG/>
</o:OfficeDocumentSettings>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:WordDocument>
<w:Zoom>0</w:Zoom>
<w:TrackMoves>false</w:TrackMoves>
<w:TrackFormatting/>
<w:PunctuationKerning/>
<w:DrawingGridHorizontalSpacing>18 pt</w:DrawingGridHorizontalSpacing>
<w:DrawingGridVerticalSpacing>18 pt</w:DrawingGridVerticalSpacing>
<w:DisplayHorizontalDrawingGridEvery>0</w:DisplayHorizontalDrawingGridEvery>
<w:DisplayVerticalDrawingGridEvery>0</w:DisplayVerticalDrawingGridEvery>
<w:ValidateAgainstSchemas/>
<w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid>
<w:IgnoreMixedContent>false</w:IgnoreMixedContent>
<w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText>
<w:Compatibility>
<w:BreakWrappedTables/>
<w:DontGrowAutofit/>
<w:DontAutofitConstrainedTables/>
<w:DontVertAlignInTxbx/>
</w:Compatibility>
</w:WordDocument>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:LatentStyles DefLockedState="false" LatentStyleCount="276">
</w:LatentStyles>
</xml><![endif]-->
<!--[if gte mso 10]>
<style>
/* Style Definitions */
table.MsoNormalTable
{mso-style-name:"Table Normal";
mso-tstyle-rowband-size:0;
mso-tstyle-colband-size:0;
mso-style-noshow:yes;
mso-style-parent:"";
mso-padding-alt:0in 5.4pt 0in 5.4pt;
mso-para-margin:0in;
mso-para-margin-bottom:.0001pt;
mso-pagination:widow-orphan;
font-size:12.0pt;
font-family:"Times New Roman";
mso-ascii-font-family:Cambria;
mso-ascii-theme-font:minor-latin;
mso-fareast-font-family:"Times New Roman";
mso-fareast-theme-font:minor-fareast;
mso-hansi-font-family:Cambria;
mso-hansi-theme-font:minor-latin;}
</style>
<![endif]-->
<!--StartFragment-->
<br />
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Now that the Supreme
Court has upheld the constitutionality of the Patient Protection and Affordable
Care Act (PPACA), health insurers are scrambling to reinvent themselves for an
era of health care reform.<span style="mso-spacerun: yes;"> </span>In Part
I, we quoted Aetna CEO Mark Bertolini as saying he wants to create a business
model that makes sense under the new rules and regulations.<span style="mso-spacerun: yes;"> </span>Bertolini in a speech stated, “We need
to move the system from underwriting risk to managing populations.<span style="mso-spacerun: yes;"> </span>We want to have a different relationship
with the providers, physicians and hospitals we do business with.” (</span><a href="http://www.healthdatamanagement.com/news/HIMSS12-Aetna-CEO-insurers-face-extinction-44041-1.html"><span style="color: windowtext; font-family: Helvetica;">http://www.healthdatamanagement.com/news/HIMSS12-Aetna-CEO-insurers-face-extinction-44041-1.html</span></a><span style="font-family: Helvetica;">) <span style="mso-spacerun: yes;"> </span>Starting with Aetna, Part II will examine the ways that
insurance companies are trying to reinvent themselves for a reformed health
care delivery system that often wonders why we need health insurers at all. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Early this year, Aetna
decided to evolve “’from an insurance carrier to a health solutions company.””
The head of brand and consumer marketing at Aetna stated, “’More and more, the
end consumer is who we need to focus on.’” (</span><a href="http://www.nytimes.com/2012/06/22/us/politics/insurance-companies-are-trying-to-soften-their-image.html?pagewanted=all"><span style="color: windowtext; font-family: Helvetica;">http://www.nytimes.com/2012/06/22/us/politics/insurance-companies-are-trying-to-soften-their-image.html?pagewanted=all</span></a><span style="font-family: Helvetica;">) Aetna has developed Care Pass Platform, an
agnostic tool that all consumers can use to aggregate and organize their
fitness, medical, insurance and nutrition data. Aetna is also partnering with
Medicity to provide smartphone apps for providers and iTriage to provide apps
for consumers. (</span><a href="http://kentbottles.blogspot.com/2012/03/technology-aetna-itriage-and-future-of.html"><span style="color: windowtext; font-family: Helvetica;">http://kentbottles.blogspot.com/2012/03/technology-aetna-itriage-and-future-of.html</span></a><span style="font-family: Helvetica;">) <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Aetna has conducted 57
pilot programs to test ways to decrease per-capita cost and increase the
quality of the health care they deliver; the company is participating in 10
accountable care organizations (ACO) and has plans for 17 more ACO
experiments.<span style="mso-spacerun: yes;"> </span>One successful
diabetes pilot in Pennsylvania resulted in acute sick days dropping by 31% with
the use of case managers. (</span><a href="http://www.washingtonpost.com/blogs/ezra-klein/wp/2012/06/22/aetna-ceo-the-supreme-court-decision-doesnt-matter-the-deficit-does/"><span style="color: windowtext; font-family: Helvetica;">http://www.washingtonpost.com/blogs/ezra-klein/wp/2012/06/22/aetna-ceo-the-supreme-court-decision-doesnt-matter-the-deficit-does/</span></a><span style="font-family: Helvetica;">) <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;"><o:p> </o:p></span><span class="Apple-style-span" style="font-family: Helvetica;"> </span><span class="Apple-style-span" style="font-family: Helvetica;"> </span></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Aetna also spent $1.6
billion in 2011 to buy health care companies, including Medicity, Prodigy
Health Group, Genworth Financial’s Medicare supplement business, and PayFlex
Holdings.<span style="mso-spacerun: yes;"> </span>(</span><a href="http://articles.courant.com/2011-12-16/business/hc-aetna-acquisitions-1217-20111216_1_prodigy-health-group-aetna-health-insurers"><span style="color: windowtext; font-family: Helvetica;">http://articles.courant.com/2011-12-16/business/hc-aetna-acquisitions-1217-20111216_1_prodigy-health-group-aetna-health-insurers</span></a><span style="font-family: Helvetica;">)</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Aetna’s partnership with
Northern Virginia’s Inova Health System to create a health plan where both
partners will share costs and profits is perhaps the company’s most innovative
experiment.<span style="mso-spacerun: yes;"> </span>The partnership will
provide incentives to encourage physicians to not over utilize tests and
procedures and will also measure and reward quality of care.<span style="mso-spacerun: yes;"> </span>Companies will get a rebate if the cost
of the care of their employees is lower than expected. (</span><a href="http://www.washingtonpost.com/business/economy/aetna-and-inova-unveil-joint-venture-for-improved-cost-effective-health-care/2012/06/22/gJQAOyoGvV_story.html"><span style="color: windowtext; font-family: Helvetica;">http://www.washingtonpost.com/business/economy/aetna-and-inova-unveil-joint-venture-for-improved-cost-effective-health-care/2012/06/22/gJQAOyoGvV_story.html</span></a><span style="font-family: Helvetica;">) <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">A different innovative
approach to responding to health care reform is Highmark’s merger with West
Penn Allegheny Health System (WPAHS).<span style="mso-spacerun: yes;">
</span>When first announced in June 2011, the idea inspired Hoover’s health
care industry team to create the following headline:<span style="mso-spacerun: yes;"> </span>“Bizarre Pittsburgh proposal:<span style="mso-spacerun: yes;"> </span>will Highmark – West Penn merger work?” (</span><a href="http://bizmology.hoovers.com/2011/06/29/pittsburgh-proposal-will-a-highmark-west-penn-allegheny-health-merger-bring-positive-change-or-is-it-too-weird-to-work/"><span style="color: windowtext; font-family: Helvetica;">http://bizmology.hoovers.com/2011/06/29/pittsburgh-proposal-will-a-highmark-west-penn-allegheny-health-merger-bring-positive-change-or-is-it-too-weird-to-work/</span></a><span style="font-family: Helvetica;">) <span style="mso-spacerun: yes;"> </span>A
year later in June 2012 Moody’s rating service cited dropping patient volumes
and continued operating losses at WPAHS in reaching the conclusion that the
$475 million infusion of Highmark funds will not be enough to save the
struggling health care system; Moody’s still rates $737 million of WPAHS debt
as junk bonds. (</span><a href="http://www.moodys.com/research/Moodys-affirms-West-Penn-Allegheny-Health-Systems-PA-Caa1-bond--PR_248600"><span style="color: windowtext; font-family: Helvetica;">http://www.moodys.com/research/Moodys-affirms-West-Penn-Allegheny-Health-Systems-PA-Caa1-bond--PR_248600</span></a><span style="font-family: Helvetica;">) <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">The Highmark WPAHS
merger is complicated by Highmark’s unsuccessful attempt to merge with
Independence Blue Cross and failed contract negotiations between Highmark and
University of Pittsburg Medical Center (UPMC), the major health system in the
Western Pennsylvania market that has its own insurance plan that competes with
Highmark.<span style="mso-spacerun: yes;"> </span>As if dueling
advertising campaigns and lawsuits were not enough excitement, the plot
thickened when Highmark fired its CEO Dr. Kenneth Melani, the architect of the
merger, after he fought with his Highmark employee girl friend’s husband.<span style="mso-spacerun: yes;"> </span>Assault charges were dropped against
Melani after he successfully completed an anger management program. (</span><a href="http://pittsburgh.cbslocal.com/2012/06/06/assault-charges-dropped-against-former-highmark-ceo/"><span style="color: windowtext; font-family: Helvetica;">http://pittsburgh.cbslocal.com/2012/06/06/assault-charges-dropped-against-former-highmark-ceo/</span></a><span style="font-family: Helvetica;">) <span style="mso-spacerun: yes;"> </span>One wonders if new Highmark CEO William Winkenwereder, Jr.,
MD will continue to support the merger plans. (</span><a href="http://www.post-gazette.com/stories/local/region/new-ceo-winkenwerder-targets-trust-in-highmark-639015/"><span style="color: windowtext; font-family: Helvetica;">http://www.post-gazette.com/stories/local/region/new-ceo-winkenwerder-targets-trust-in-highmark-639015/</span></a><span style="font-family: Helvetica;">) <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">The Highmark WPAHS merger
is an attempt to create “what health-care thought leader, Clayton Christensen,
in The Innovator’s Prescription, describes as an integrated, fixed-fee provider
system. As such, Highmark and West Penn Allegheny are undertaking a tremendous
change agenda.” (</span><a href="http://www.wphospitalnews.com/the-national-significance-of-the-highmark-and-west-penn-allegheny-merger/"><span style="color: windowtext; font-family: Helvetica;">http://www.wphospitalnews.com/the-national-significance-of-the-highmark-and-west-penn-allegheny-merger/</span></a><span style="font-family: Helvetica;">) <span style="mso-spacerun: yes;"> </span>Other
observers are watching the merger with interest because such vertical mergers
have not been extensively studied or investigated.<span style="mso-spacerun: yes;"> </span>The Western Pennsylvania region clearly needs to try
something new because the status quo is not working: the largest hospitals and
health insurers are engaged in a legal battle; WPAHS, the second largest
hospital system, is on the brink of failure; and health care costs in
Pittsburgh are substantially higher than in similar markets, relative to the
quality of care. (</span><a href="http://www.jdsupra.com/post/documentViewer.aspx?fid=ea6c6a19-8547-4978-bf63-4ea8cf70d1d4"><span style="color: windowtext; font-family: Helvetica;">http://www.jdsupra.com/post/documentViewer.aspx?fid=ea6c6a19-8547-4978-bf63-4ea8cf70d1d4</span></a><span style="font-family: Helvetica;">) <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Wellpoint, which covers
about one third of the nearly 100 million Americans who receive their insurance
from a Blue Cross plan has been investigated by Congress for canceling policies
retroactively in order to achieve at least a $128 million profit. Wellpoint has
also been criticized for having 39 executives who each make more $1 million a
year and for spending $27 million on staff retreats at resorts in 2007 and
2008. (</span><a href="http://www.amazon.com/Deadly-Spin-ebook/dp/B0049195R0/ref=sr_1_1?s=books&ie=UTF8&qid=1342447040&sr=1-1"><span style="color: windowtext; font-family: Helvetica;">http://www.amazon.com/Deadly-Spin-ebook/dp/B0049195R0/ref=sr_1_1?s=books&ie=UTF8&qid=1342447040&sr=1-1</span></a><span style="font-family: Helvetica;">) <span style="mso-spacerun: yes;"> </span>Reform advocates point out that such overhead costs
contribute to the $400 billion a year in administrative costs that would
largely disappear under a single payer system. <span style="mso-spacerun: yes;"> </span>Wellpoint’s response to health care reform has been to spend
$100 million on technology upgrades and to buy Medicaid provider Amerigroup for
$4.46 billion and CareMore for $800 million.<span style="mso-spacerun: yes;"> </span>Angela Braly, Wellpoint’s CEO said, “First and foremost
there are significant growth opportunities ahead in the Medicaid marketplace
resulting from economics, demographics, budgetary issues, as well as healthcare
reform. We expect Medicaid spending under managed care programs to increase by
nearly $100 billion by the end of 2014.” (</span><a href="http://www.chicagotribune.com/business/breaking/chi-wellpoint-to-buy-medicaid-provider-amerigroup-for-446b-20120709,0,7644697.story"><span style="color: windowtext; font-family: Helvetica;">http://www.chicagotribune.com/business/breaking/chi-wellpoint-to-buy-medicaid-provider-amerigroup-for-446b-20120709,0,7644697.story</span></a><span style="font-family: Helvetica;">)<span style="mso-spacerun: yes;">
</span><span style="mso-spacerun: yes;"> </span>At least one critic has
wondered about the wisdom of this purchase, based on two future possibilities:
1) if Romney becomes president and the GOP takes control of the Senate, then
the Medicaid expansion in the PPACA might be overturned and 2) the Supreme
Court ruling left the door open for GOP governors to refuse to participate in
the Medicaid expansion. (</span><a href="http://www.forbes.com/sites/aroy/2012/07/11/wellpoint-buys-amerigroup-bets-big-on-medicaid-expansion-but-will-states-and-voters-cooperate/"><span style="color: windowtext; font-family: Helvetica;">http://www.forbes.com/sites/aroy/2012/07/11/wellpoint-buys-amerigroup-bets-big-on-medicaid-expansion-but-will-states-and-voters-cooperate/</span></a><span style="font-family: Helvetica;">) <span style="mso-spacerun: yes;"> </span>Braly,
of course, is the health insurance executive who stubbornly defended proposed
2010 premium increases in California that President Obama attacked during the
debate over the passage of the PPACA. </span><span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 15.0pt;">Anthem Blue Cross, a
unit of WellPoint, attempted to increase </span><a href="http://www.nytimes.com/2010/02/14/us/14anthem.html?scp=10&sq=wellpoint%20anthem%20rates&st=cse"><u style="text-underline: #14345E;"><span style="color: windowtext; font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 15.0pt; text-decoration: none; text-underline: #14345E; text-underline: none;">premiums for individual
insurance policies</span></u></a><span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 15.0pt;"> in California by an
average of 25 percent, with some rates going up as much as 39 percent. (</span><a href="http://www.nytimes.com/2010/02/25/health/policy/25health.html"><span style="color: windowtext; font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 15.0pt;">http://www.nytimes.com/2010/02/25/health/policy/25health.html</span></a><span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 15.0pt;">) <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 15.0pt;">CIGNA has developed a new ad campaign “Go You”
that focuses on consumers for the first time. The chief communications officer
at CIGNA states, “’It is a shift, it’s an important shift.’”<span style="mso-spacerun: yes;"> </span>In the past insurers addressed their
advertising campaigns at wholesale business accounts, not individual consumers.
</span><span style="font-family: Helvetica;">(</span><a href="http://www.nytimes.com/2012/06/22/us/politics/insurance-companies-are-trying-to-soften-their-image.html?pagewanted=all"><span style="color: windowtext; font-family: Helvetica;">http://www.nytimes.com/2012/06/22/us/politics/insurance-companies-are-trying-to-soften-their-image.html?pagewanted=all</span></a><span style="font-family: Helvetica;">) </span><span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 15.0pt;"><span style="mso-spacerun: yes;"> </span>To bolster this consumer strategy, CIGNA bought Kronos
Optimal Health to obtain their health coaches, health education programs, and
lifestyle management systems.
(http://www.prnewswire.com/news-releases/cignas-mergers-and-acquisitions-will-help-distinguish-them-from-other-national-carriers-101077224.html).
<span style="mso-spacerun: yes;"> </span>CIGNA also spent $3.8 billion in
cash to buy HealthSpring and its 340,000 Medicare Advantage participants in 11
states and its 800,000 member Medicare prescription division. (</span><a href="http://dealbook.nytimes.com/2011/10/24/cigna-to-buy-healthspring-for-3-7-billion/"><span style="color: windowtext; font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 15.0pt;">http://dealbook.nytimes.com/2011/10/24/cigna-to-buy-healthspring-for-3-7-billion/</span></a><span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 15.0pt;">) <span style="mso-spacerun: yes;"> </span>The company is also
expanding their Medicare Advantage position in Texas and Arkansas (</span><a href="http://www.streetinsider.com/Mergers+and+Acquisitions/Cigna+(CI)+to+Buy+Arcadian,+Humana+Medicare+Advantage+Plans+in+Texas,+Arkansas/7545734.html"><span style="color: windowtext; font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 15.0pt;">http://www.streetinsider.com/Mergers+and+Acquisitions/Cigna+(CI)+to+Buy+Arcadian,+Humana+Medicare+Advantage+Plans+in+Texas,+Arkansas/7545734.html</span></a><span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 15.0pt;">). <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 15.0pt;">Humana, like Aetna and CIGNA, is concentrating on
the individual health care consumer with television ads showing “a family
reunion at a summer home, complete with giggling children, cooing grandparents,
bonfires, and swimming at the lake.”</span><span style="font-family: Helvetica;">
(</span><a href="http://www.nytimes.com/2012/06/22/us/politics/insurance-companies-are-trying-to-soften-their-image.html?pagewanted=all"><span style="color: windowtext; font-family: Helvetica;">http://www.nytimes.com/2012/06/22/us/politics/insurance-companies-are-trying-to-soften-their-image.html?pagewanted=all</span></a><span style="font-family: Helvetica;">) In addition to the consumer oriented ad
campaigns, Humana has a new program that rewards members for losing weight or
quitting smoking with points that can be redeemed for hotel reservations,
electronics and clothing.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 16.0pt; mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<span style="font-family: Helvetica;">Humana’s Patient
Centered Medical Home Partnership with WellStar Health System has seen
decreased inpatient and emergency room expenses by 12% and 17%, respectively,
and a decrease in emergency room visits by15% </span><span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 16.0pt;">(</span><a href="http://www.ahipcoverage.com/wp-content/uploads/2012/07/MarketHighlights_PaymentDeliveryReform_1-06-%2012.pdf"><span style="color: windowtext; font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 16.0pt;">http://www.ahipcoverage.com/wp-content/uploads/2012/07/MarketHighlights_PaymentDeliveryReform_1-06-
12.pdf</span></a><span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 16.0pt;">)<span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">On the mergers and
acquisitions front, Humana</span><span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 16.0pt;"> has acquired Concentra,
for $790 million in cash. Concentra provides occupational medicine, urgent
care, physical therapy and wellness services at more than 300 medical centers
in 42 states. (</span><a href="http://dealbook.nytimes.com/2010/11/22/humana-to-buy-concentra/"><span style="color: windowtext; font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 16.0pt;">http://dealbook.nytimes.com/2010/11/22/humana-to-buy-concentra/</span></a><span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 16.0pt;">) The insurer </span><span style="font-family: Helvetica; mso-bidi-font-family: Arial; mso-bidi-font-size: 14.0pt;">has also completed the
acquisition of Arcadian Management Services, a Medicare Advantage health
maintenance organization (</span><a href="http://www.zacks.com/stock/news/72489/humana-closes-arcadian-purchase"><span style="color: windowtext; font-family: Helvetica; mso-bidi-font-family: Arial; mso-bidi-font-size: 14.0pt;">http://www.zacks.com/stock/news/72489/humana-closes-arcadian-purchase</span></a><span style="font-family: Helvetica; mso-bidi-font-family: Arial; mso-bidi-font-size: 14.0pt;">) <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica; mso-bidi-font-family: Arial; mso-bidi-font-size: 14.0pt;">UnitedHealth Group was one of the earliest converts
to evolving from a health insurance company to a health care data mining
company.<span style="mso-spacerun: yes;"> </span>As early as 2007 their
subsidiary Ingenix bought The Lewin Group, a respected health policy think tank
in Northern Virginia. A Lewin report in 2009 claimed to show that a public
option would force 119 million Americans out of their private health plans and
into the government sponsored plan. Although the Lewin report was shown to be
faulty, the GOP used it to great advantage in excluding the public option from
the final PPACA bill. (</span><a href="http://www.amazon.com/Deadly-Spin-ebook/dp/B0049195R0/ref=sr_1_1?s=books&ie=UTF8&qid=1342447040&sr=1-1"><span style="color: windowtext; font-family: Helvetica;">http://www.amazon.com/Deadly-Spin-ebook/dp/B0049195R0/ref=sr_1_1?s=books&ie=UTF8&qid=1342447040&sr=1-1</span></a><span style="font-family: Helvetica;">)</span><span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 15.0pt;"><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 15.0pt;">UnitedHealth Group has also been active in
exploring private sector payment and delivery system pilots. Their Patient
Centered Medical Home model provides primary care providers a prospective care
management fee as well as a performance incentive payment.<span style="mso-spacerun: yes;"> </span>Their ACO pilot with Tucson Medical
Center includes a spending target based on three years experience by each
physician group or hospital and shared savings and bonuses are given to those
that meet their goals. United Healthcare is also experimenting with bundled
payment programs with oncologists in Georgia, Missouri, Ohio, Tennessee, and
Texas.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 16.0pt; mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 16.0pt;">(</span><a href="http://www.ahipcoverage.com/wp-content/uploads/2012/07/MarketHighlights_PaymentDeliveryReform_1-06-%2012.pdf"><span style="color: windowtext; font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 16.0pt;">http://www.ahipcoverage.com/wp-content/uploads/2012/07/MarketHighlights_PaymentDeliveryReform_1-06-
12.pdf</span></a><span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 16.0pt;">)<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 16.0pt; mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 16.0pt;">Whether these branding and advertising
campaigns and payment and delivery system pilots will be successful is an open
question.<span style="mso-spacerun: yes;"> </span>An Edelman global survey
about trust found insurers, banks, and financial service companies at the
bottom of a ranking of 16 industries.<span style="mso-spacerun: yes;">
</span>They found that corporate reputations were determined by high quality
products, transparent and honest business practices, and how companies treat
their employees.<span style="mso-spacerun: yes;"> </span>They also
discovered that when a company is distrusted, 57% of people will believe
negative information when they hear it once or twice and only 15% of people
will believe positive information. (</span><a href="http://www.edelman.com/trust/2011/"><span style="color: windowtext; font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 16.0pt;">http://www.edelman.com/trust/2011/</span></a><span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 16.0pt;">)<span style="mso-spacerun: yes;"> </span>Of all the players in
health care, insurers routinely rank last in terms of consumer trust.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 16.0pt; mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 16.0pt;">“They are among the most disliked
industries in the United States.<span style="mso-spacerun: yes;">
</span>The nature of the business is that they really are not that eager to
O.K. every expense,” said Professor Regina Herzlinger of Harvard Business
School. </span><span style="font-family: Helvetica;">(</span><a href="http://www.nytimes.com/2012/06/22/us/politics/insurance-companies-are-trying-to-soften-their-image.html?pagewanted=all"><span style="color: windowtext; font-family: Helvetica;">http://www.nytimes.com/2012/06/22/us/politics/insurance-companies-are-trying-to-soften-their-image.html?pagewanted=all</span></a><span style="font-family: Helvetica;">)</span><span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 16.0pt;"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 16.0pt; mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<span style="font-family: Helvetica; mso-bidi-font-family: Georgia; mso-bidi-font-size: 16.0pt;">Another expert, Fred Karutz of Silverlink
Communications, thinks that health care insurance companies have a long way to
go because they are new to the retail environment. “As people become consumers,
they seek out value. In the group space, health plans could never hear the
consumer scream, but in the retail space everybody can hear the consumer
scream.”</span><span style="font-family: Helvetica;"> (</span><a href="http://www.nytimes.com/2012/06/22/us/politics/insurance-companies-are-trying-to-soften-their-image.html?pagewanted=all"><span style="color: windowtext; font-family: Helvetica;">http://www.nytimes.com/2012/06/22/us/politics/insurance-companies-are-trying-to-soften-their-image.html?pagewanted=all</span></a><span style="font-family: Helvetica;">)<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 16.0pt; mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<span style="font-family: Helvetica;">The PPACA and the
health care reform movement offer tremendous retail opportunities for health
insurance companies.<span style="mso-spacerun: yes;"> </span>There may be
as many 30 million Americans seeking insurance through the exchanges.<span style="mso-spacerun: yes;"> </span>There will be about 15 million Baby
Boomers who will eligible to sign up for their preferred plan, Medicare
Advantage.<span style="mso-spacerun: yes;"> </span>The Medicaid expansion
could cover as many as 17 million citizens, despite the reservations of many
governors.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 16.0pt; mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<span style="font-family: Helvetica;">Whether health insurance
companies can overcome the mistrust that many consumers feel and whether they
can truly add value to a reformed system remains to be seen.<span style="mso-spacerun: yes;"> </span>They might want to listen to Dr.
Elliott S. Fisher, the ACO guru at Dartmouth:<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 16.0pt; margin-left: .5in; margin-right: 0in; margin-top: 0in; mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<span style="font-family: Helvetica;">“Their future is going to depend on
their ability to demonstrate value to patients and to employers. No one any
longer questions the fact that health care is unaffordable and that the current
way we are doing business isn’t working.” (</span><a href="http://www.nytimes.com/2012/06/22/us/politics/insurance-companies-are-trying-to-soften-their-image.html?pagewanted=all"><span style="color: windowtext; font-family: Helvetica;">http://www.nytimes.com/2012/06/22/us/politics/insurance-companies-are-trying-to-soften-their-image.html?pagewanted=all</span></a><span style="font-family: Helvetica;">)<o:p></o:p></span></div>
<!--EndFragment-->Kent Bottleshttp://www.blogger.com/profile/12993140567796683570noreply@blogger.com3tag:blogger.com,1999:blog-6653940794693704941.post-34431927318753716412012-07-16T10:52:00.001-04:002012-07-16T10:52:52.333-04:00Health Insurers & the PPACA: Extinction or Reinvention? Part I<!--[if gte mso 9]><xml>
<o:OfficeDocumentSettings>
<o:AllowPNG/>
</o:OfficeDocumentSettings>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:WordDocument>
<w:Zoom>0</w:Zoom>
<w:TrackMoves>false</w:TrackMoves>
<w:TrackFormatting/>
<w:PunctuationKerning/>
<w:DrawingGridHorizontalSpacing>18 pt</w:DrawingGridHorizontalSpacing>
<w:DrawingGridVerticalSpacing>18 pt</w:DrawingGridVerticalSpacing>
<w:DisplayHorizontalDrawingGridEvery>0</w:DisplayHorizontalDrawingGridEvery>
<w:DisplayVerticalDrawingGridEvery>0</w:DisplayVerticalDrawingGridEvery>
<w:ValidateAgainstSchemas/>
<w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid>
<w:IgnoreMixedContent>false</w:IgnoreMixedContent>
<w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText>
<w:Compatibility>
<w:BreakWrappedTables/>
<w:DontGrowAutofit/>
<w:DontAutofitConstrainedTables/>
<w:DontVertAlignInTxbx/>
</w:Compatibility>
</w:WordDocument>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:LatentStyles DefLockedState="false" LatentStyleCount="276">
</w:LatentStyles>
</xml><![endif]-->
<!--[if gte mso 10]>
<style>
/* Style Definitions */
table.MsoNormalTable
{mso-style-name:"Table Normal";
mso-tstyle-rowband-size:0;
mso-tstyle-colband-size:0;
mso-style-noshow:yes;
mso-style-parent:"";
mso-padding-alt:0in 5.4pt 0in 5.4pt;
mso-para-margin:0in;
mso-para-margin-bottom:.0001pt;
mso-pagination:widow-orphan;
font-size:12.0pt;
font-family:"Times New Roman";
mso-ascii-font-family:Cambria;
mso-ascii-theme-font:minor-latin;
mso-fareast-font-family:"Times New Roman";
mso-fareast-theme-font:minor-fareast;
mso-hansi-font-family:Cambria;
mso-hansi-theme-font:minor-latin;}
</style>
<![endif]-->
<!--StartFragment-->
<br />
<div class="MsoNormal">
<span style="font-family: Helvetica;">With the Supreme Court
of the United States upholding the constitutionality of most of the Patient
Protection and Affordable Care Act (PPACA), now is a good time to examine the
tortured relationship between the health insurers and health care reform. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Key to such an
understanding is realizing that the insurance industry often conducts a
“deception-based PR strategy [with] two active fronts:” “a ‘charm offensive’
designed to create an image of the industry as an advocate of reform” and “a
secret, fearmongering campaign using front groups and business and political
allies as shills to disseminate misinformation and lies, with the sole intent
of killing any reform that might hinder profits.” (</span><a href="http://www.amazon.com/Deadly-Spin-ebook/dp/B0049195R0/ref=sr_1_1?s=books&ie=UTF8&qid=1342447040&sr=1-1"><span style="font-family: Helvetica;">http://www.amazon.com/Deadly-Spin-ebook/dp/B0049195R0/ref=sr_1_1?s=books&ie=UTF8&qid=1342447040&sr=1-1</span></a><span style="font-family: Helvetica;">) <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">The two front PR
strategy was certainly in full swing when one compares Karen Ignagni’s White
House statement of support for the PPACA with America’s Health Insurance Plans
(AHIP) secret funneling of money to the Chamber of Commerce’s efforts to derail
health care reform.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Following the “charm
offensive” playbook, Ignagni, the president of AHIP who makes $1.5 million in
salary and bonuses as the industry’s chief lobbyist, spoke at President Obama’s
health care summit on March 5, 2009:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“Thank
you, Mr. President. Thank you for inviting us to participate in this
forum.<span style="mso-spacerun: yes;"> </span>I think, on behalf of our
entire membership, they would want to be able to say to you this afternoon and
everyone here that we understand we have to earn a seat at this table. We’ve
already offered a comprehensive series of proposals.<span style="mso-spacerun: yes;"> </span>We want to work with you. We want to work with the members
of Congress on a bipartisan basis here.<span style="mso-spacerun: yes;">
</span>You have our commitment.<span style="mso-spacerun: yes;"> </span>We
hear the American people about what’s not working.<span style="mso-spacerun: yes;"> </span>We’ve taken that seriously. You have our commitment to play,
to contribute, and to help pass health care reform this year.”(</span><a href="http://www.amazon.com/Deadly-Spin-ebook/dp/B0049195R0/ref=sr_1_1?s=books&ie=UTF8&qid=1342447040&sr=1-1"><span style="font-family: Helvetica;">http://www.amazon.com/Deadly-Spin-ebook/dp/B0049195R0/ref=sr_1_1?s=books&ie=UTF8&qid=1342447040&sr=1-1</span></a><span style="font-family: Helvetica;">)<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Ignagni did not speak
about the second front, the fearmongering campaign in which AHIP would play a
central role.<span style="mso-spacerun: yes;"> </span>Three years after
the 2009 White House Summit, the National Journal revealed that AHIP sent the
Chamber of Commerce a total of $102.4 million to be used in lobbying against
the PPACA. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“The
backchannel spending allowed insurers to publicly stake out a pro-reform
position while privately funding the leading anti-reform lobbying group in
Washington. The chamber spent tens of millions of dollars bankrolling efforts
to kill health care reform.” (</span><a href="http://influencealley.nationaljournal.com/2012/06/exclusive-ahip-gave-more-than.php/"><span style="font-family: Helvetica;">http://influencealley.nationaljournal.com/2012/06/exclusive-ahip-gave-more-than.php/</span></a><span style="font-family: Helvetica;">) <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">While the Chamber and
AHIP efforts to kill the health reform legislation were ultimately
unsuccessful, they have certainly contributed to the confusion and division
among the American people about the PPACA.<span style="mso-spacerun: yes;"> </span>The talking points created by the Strategic Communications
Advisory Committee of the AHIP were disseminated to the American public by an
array of conservative groups (US Chamber of Commerce, Karl Rove’s Crossroads
GPS, and the American Action Network) that spent $235 million on ads attacking
the PPACA since its passage in March 2010.<span style="mso-spacerun: yes;"> </span>Only $69 million was spent by groups supporting the law. (</span><a href="http://www.nytimes.com/2012/06/21/health/policy/health-care-law-loses-ad-war.html?pagewanted=all"><span style="font-family: Helvetica;">http://www.nytimes.com/2012/06/21/health/policy/health-care-law-loses-ad-war.html?pagewanted=all</span></a><span style="font-family: Helvetica;">) <span style="mso-spacerun: yes;"> </span>A
group of Aetna shareholders is challenging the insurer for donating over $7
million through AHIP to the US Chamber of Commerce and to the American Action
Network.<span style="mso-spacerun: yes;"> </span>Mercy Investment Services
and the Sisters of Charity of Saint Elizabeth claims Aetna “is not in
compliance with its corporate political and lobbying disclosure policy.” (</span><a href="http://thinkprogress.org/health/2012/07/14/517291/aetna-shareholders-dismayed-over-insurers-donations-to-anti-obamacare-campaigns/"><span style="font-family: Helvetica;">http://thinkprogress.org/health/2012/07/14/517291/aetna-shareholders-dismayed-over-insurers-donations-to-anti-obamacare-campaigns/</span></a><span style="font-family: Helvetica;">) <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">An article titled
“Distaste for Health Care Law Reflects Spending on Ads” documents how citizens
who live near me in the Philadelphia suburbs and would be helped by the PPACA
regard it negatively.<span style="mso-spacerun: yes;"> </span>They have seen
the ads from the fearmongering PR campaign, and the ads work. (</span><a href="http://www.nytimes.com/2012/06/21/health/policy/health-care-law-loses-ad-war.html?pagewanted=all"><span style="font-family: Helvetica;">http://www.nytimes.com/2012/06/21/health/policy/health-care-law-loses-ad-war.html?pagewanted=all</span></a><span style="font-family: Helvetica;">) <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Today (July 16, 2012)
two years after the passage of the law, there is an op-ed in the New York Times
titled Five Obamacare Myths.<span style="mso-spacerun: yes;"> </span>The
piece, subtitled “Cutting through slogans and scare stories,” lists five
myths:<span style="mso-spacerun: yes;"> </span>PPACA is a job-killer;
PPACA is a federal takeover of health insurance; the unfettered marketplace is
a better solution; the States will fix health care without federal involvement;
running on the PPACA as an achievement is a bad idea. (</span><a href="http://www.nytimes.com/2012/07/16/opinion/keller-five-obamacare-myths.html?ref=opinion"><span style="font-family: Helvetica;">http://www.nytimes.com/2012/07/16/opinion/keller-five-obamacare-myths.html?ref=opinion</span></a><span style="font-family: Helvetica;">) <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">The Kaiser Family
Foundation has done a number of polls and found that the American public is
evenly split 41% to 41% between those who favor the PPACA and those who oppose
it.<span style="mso-spacerun: yes;"> </span>The surveys also demonstrate
that many Americans do not really understand what is in the law, but after the
Supreme Court ruling a majority (56%) believe the detractors should stop trying
to repeal the law and move on to other problems facing the nation (</span><a href="http://healthreform.kff.org/en/public-opinion.aspx"><span style="font-family: Helvetica;">http://healthreform.kff.org/en/public-opinion.aspx</span></a><span style="font-family: Helvetica;">) <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">What does the insurance
industry do now that the Supreme Court has largely upheld the PPACA?<span style="mso-spacerun: yes;"> </span>Keeping in mind the industry’s history
of having a two front PR campaign with a public and secret private face, it
seems apparent that the health insurance companies need to reinvent their
business model.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Aetna CEO Mark Bertolini
has been the most outspoken industry leader in declaring the old profitable
business model dead.<span style="mso-spacerun: yes;"> </span>“The system
doesn’t work, it’s broke today. The end of insurance companies, the way we’ve
run the business in the past, is here.”<span style="mso-spacerun: yes;"> </span>Bertolini identifies a convergence of regulatory,
demographic, and economic factors including the PPACA ban on medial
underwriting and the medical loss ratio rules as resulting in a traditional
business model that no longer works.<span style="mso-spacerun: yes;">
</span>And Bertolini does not see the results of the presidential election
changing what insurance companies need to do to reinvent themselves.<span style="mso-spacerun: yes;"> </span>“Reform is not going to stop. It won’t
go away.”<span style="mso-spacerun: yes;"> </span>At least publicly,
Bertolini is embracing the PPACA.<span style="mso-spacerun: yes;">
</span>“We got pulled through the crucible against our will and have been
reshaped because of it. For most of what has already been implemented, it has
been a pretty good thing.”<span style="mso-spacerun: yes;"> </span>(</span><a href="http://www.healthdatamanagement.com/news/HIMSS12-Aetna-CEO-insurers-face-extinction-44041-1.html"><span style="font-family: Helvetica;">http://www.healthdatamanagement.com/news/HIMSS12-Aetna-CEO-insurers-face-extinction-44041-1.html</span></a><span style="font-family: Helvetica;">) <o:p></o:p></span></div>
<div class="MsoNormal" style="tab-stops: 294.0pt;">
<span style="font-family: Helvetica;"><span style="mso-tab-count: 1;"> </span><o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Part II will examine how
health insurers are trying to reinvent themselves and their business model to
respond to health care reform.<span style="mso-spacerun: yes;">
</span><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<!--EndFragment-->Kent Bottleshttp://www.blogger.com/profile/12993140567796683570noreply@blogger.com0tag:blogger.com,1999:blog-6653940794693704941.post-45459831924117717182012-07-16T10:38:00.001-04:002012-07-16T10:38:14.917-04:00Health Insurers & the PPACA: Extinction or Reinvention?<!--[if gte mso 9]><xml>
<o:OfficeDocumentSettings>
<o:AllowPNG/>
</o:OfficeDocumentSettings>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:WordDocument>
<w:Zoom>0</w:Zoom>
<w:TrackMoves>false</w:TrackMoves>
<w:TrackFormatting/>
<w:PunctuationKerning/>
<w:DrawingGridHorizontalSpacing>18 pt</w:DrawingGridHorizontalSpacing>
<w:DrawingGridVerticalSpacing>18 pt</w:DrawingGridVerticalSpacing>
<w:DisplayHorizontalDrawingGridEvery>0</w:DisplayHorizontalDrawingGridEvery>
<w:DisplayVerticalDrawingGridEvery>0</w:DisplayVerticalDrawingGridEvery>
<w:ValidateAgainstSchemas/>
<w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid>
<w:IgnoreMixedContent>false</w:IgnoreMixedContent>
<w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText>
<w:Compatibility>
<w:BreakWrappedTables/>
<w:DontGrowAutofit/>
<w:DontAutofitConstrainedTables/>
<w:DontVertAlignInTxbx/>
</w:Compatibility>
</w:WordDocument>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:LatentStyles DefLockedState="false" LatentStyleCount="276">
</w:LatentStyles>
</xml><![endif]-->
<!--[if gte mso 10]>
<style>
/* Style Definitions */
table.MsoNormalTable
{mso-style-name:"Table Normal";
mso-tstyle-rowband-size:0;
mso-tstyle-colband-size:0;
mso-style-noshow:yes;
mso-style-parent:"";
mso-padding-alt:0in 5.4pt 0in 5.4pt;
mso-para-margin:0in;
mso-para-margin-bottom:.0001pt;
mso-pagination:widow-orphan;
font-size:12.0pt;
font-family:"Times New Roman";
mso-ascii-font-family:Cambria;
mso-ascii-theme-font:minor-latin;
mso-fareast-font-family:"Times New Roman";
mso-fareast-theme-font:minor-fareast;
mso-hansi-font-family:Cambria;
mso-hansi-theme-font:minor-latin;}
</style>
<![endif]-->
<!--StartFragment-->
<br />
<div class="MsoNormal">
<span style="font-family: Helvetica;">the Supreme Court of the
United States upholding the constitutionality of most of the Patient Protection
and Affordable Care Act (PPACA), now is a good time to examine the tortured
relationship between the health insurers and health care reform. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Key to such an
understanding is realizing that the insurance industry often conducts a “deception-based
PR strategy [with] two active fronts:” “a ‘charm offensive’ designed to create
an image of the industry as an advocate of reform” and “a secret, fearmongering
campaign using front groups and business and political allies as shills to
disseminate misinformation and lies, with the sole intent of killing any reform
that might hinder profits.” (<a href="http://www.amazon.com/Deadly-Spin-ebook/dp/B0049195R0/ref=sr_1_1?s=books&ie=UTF8&qid=1342447040&sr=1-1">http://www.amazon.com/Deadly-Spin-ebook/dp/B0049195R0/ref=sr_1_1?s=books&ie=UTF8&qid=1342447040&sr=1-1</a>)
<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">The two front PR
strategy was certainly in full swing when one compares Karen Ignagni’s White
House statement of support for the PPACA with America’s Health Insurance Plans
(AHIP) secret funneling of money to the Chamber of Commerce’s efforts to derail
health care reform.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Following the “charm
offensive” playbook, Ignagni, the president of AHIP who makes $1.5 million in
salary and bonuses as the industry’s chief lobbyist, spoke at President Obama’s
health care summit on March 5, 2009:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“Thank
you, Mr. President. Thank you for inviting us to participate in this
forum.<span style="mso-spacerun: yes;"> </span>I think, on behalf of our
entire membership, they would want to be able to say to you this afternoon and
everyone here that we understand we have to earn a seat at this table. We’ve
already offered a comprehensive series of proposals.<span style="mso-spacerun: yes;"> </span>We want to work with you. We want to work with the members
of Congress on a bipartisan basis here.<span style="mso-spacerun: yes;">
</span>You have our commitment.<span style="mso-spacerun: yes;"> </span>We
hear the American people about what’s not working.<span style="mso-spacerun: yes;"> </span>We’ve taken that seriously. You have our commitment to play,
to contribute, and to help pass health care reform this year.”(<a href="http://www.amazon.com/Deadly-Spin-ebook/dp/B0049195R0/ref=sr_1_1?s=books&ie=UTF8&qid=1342447040&sr=1-1">http://www.amazon.com/Deadly-Spin-ebook/dp/B0049195R0/ref=sr_1_1?s=books&ie=UTF8&qid=1342447040&sr=1-1</a>)<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Ignagni did not speak
about the second front, the fearmongering campaign in which AHIP would play a
central role.<span style="mso-spacerun: yes;"> </span>Three years after
the 2009 White House Summit, the National Journal revealed that AHIP sent the
Chamber of Commerce a total of $102.4 million to be used in lobbying against
the PPACA. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica;">“The
backchannel spending allowed insurers to publicly stake out a pro-reform
position while privately funding the leading anti-reform lobbying group in
Washington. The chamber spent tens of millions of dollars bankrolling efforts
to kill health care reform.” (<a href="http://influencealley.nationaljournal.com/2012/06/exclusive-ahip-gave-more-than.php/">http://influencealley.nationaljournal.com/2012/06/exclusive-ahip-gave-more-than.php/</a>)
<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">While the Chamber and
AHIP efforts to kill the health reform legislation were ultimately
unsuccessful, they have certainly contributed to the confusion and division
among the American people about the PPACA.<span style="mso-spacerun: yes;"> </span>The talking points created by the Strategic Communications
Advisory Committee of the AHIP were disseminated to the American public by an
array of conservative groups (US Chamber of Commerce, Karl Rove’s Crossroads
GPS, and the American Action Network) that spent $235 million on ads attacking
the PPACA since its passage in March 2010.<span style="mso-spacerun: yes;"> </span>Only $69 million was spent by groups supporting the law. (<a href="http://www.nytimes.com/2012/06/21/health/policy/health-care-law-loses-ad-war.html?pagewanted=all">http://www.nytimes.com/2012/06/21/health/policy/health-care-law-loses-ad-war.html?pagewanted=all</a>)
<span style="mso-spacerun: yes;"> </span>A group of Aetna shareholders is
challenging the insurer for donating over $7 million through AHIP to the US
Chamber of Commerce and to the American Action Network.<span style="mso-spacerun: yes;"> </span>Mercy Investment Services and the
Sisters of Charity of Saint Elizabeth claims Aetna “is not in compliance with
its corporate political and lobbying disclosure policy.” (<a href="http://thinkprogress.org/health/2012/07/14/517291/aetna-shareholders-dismayed-over-insurers-donations-to-anti-obamacare-campaigns/">http://thinkprogress.org/health/2012/07/14/517291/aetna-shareholders-dismayed-over-insurers-donations-to-anti-obamacare-campaigns/</a>)
<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">An article titled “Distaste
for Health Care Law Reflects Spending on Ads” documents how citizens who live
near me in the Philadelphia suburbs and would be helped by the PPACA regard it
negatively.<span style="mso-spacerun: yes;"> </span>They have seen the ads
from the fearmongering PR campaign, and the ads work. (<a href="http://www.nytimes.com/2012/06/21/health/policy/health-care-law-loses-ad-war.html?pagewanted=all">http://www.nytimes.com/2012/06/21/health/policy/health-care-law-loses-ad-war.html?pagewanted=all</a>)
<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Today (July 16, 2012)
two years after the passage of the law, there is an op-ed in the New York Times
titled Five Obamacare Myths.<span style="mso-spacerun: yes;"> </span>The
piece, subtitled “Cutting through slogans and scare stories,” lists five
myths:<span style="mso-spacerun: yes;"> </span>PPACA is a job-killer;
PPACA is a federal takeover of health insurance; the unfettered marketplace is
a better solution; the States will fix health care without federal involvement;
running on the PPACA as an achievement is a bad idea. (<a href="http://www.nytimes.com/2012/07/16/opinion/keller-five-obamacare-myths.html?ref=opinion">http://www.nytimes.com/2012/07/16/opinion/keller-five-obamacare-myths.html?ref=opinion</a>)
<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">The Kaiser Family Foundation
has done a number of polls and found that the American public is evenly split
41% to 41% between those who favor the PPACA and those who oppose it.<span style="mso-spacerun: yes;"> </span>The surveys also demonstrate that many
Americans do not really understand what is in the law, but after the Supreme
Court ruling a majority (56%) believe the detractors should stop trying to
repeal the law and move on to other problems facing the nation (<a href="http://healthreform.kff.org/en/public-opinion.aspx">http://healthreform.kff.org/en/public-opinion.aspx</a>)
<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">What does the insurance
industry do now that the Supreme Court has largely upheld the PPACA?<span style="mso-spacerun: yes;"> </span>Keeping in mind the industry’s history
of having a two front PR campaign with a public and secret private face, it
seems apparent that the health insurance companies need to reinvent their
business model.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Aetna CEO Mark Bertolini
has been the most outspoken industry leader in declaring the old profitable
business model dead.<span style="mso-spacerun: yes;"> </span>“The system
doesn’t work, it’s broke today. The end of insurance companies, the way we’ve
run the business in the past, is here.”<span style="mso-spacerun: yes;"> </span>Bertolini identifies a convergence of regulatory,
demographic, and economic factors including the PPACA ban on medial
underwriting and the medical loss ratio rules as resulting in a traditional business
model that no longer works.<span style="mso-spacerun: yes;"> </span>And
Bertolini does not see the results of the presidential election changing what
insurance companies need to do to reinvent themselves.<span style="mso-spacerun: yes;"> </span>“Reform is not going to stop. It won’t
go away.”<span style="mso-spacerun: yes;"> </span>At least publicly,
Bertolini is embracing the PPACA.<span style="mso-spacerun: yes;"> </span>“We
got pulled through the crucible against our will and have been reshaped because
of it. For most of what has already been implemented, it has been a pretty good
thing.”<span style="mso-spacerun: yes;"> </span>(<a href="http://www.healthdatamanagement.com/news/HIMSS12-Aetna-CEO-insurers-face-extinction-44041-1.html">http://www.healthdatamanagement.com/news/HIMSS12-Aetna-CEO-insurers-face-extinction-44041-1.html</a>)
<o:p></o:p></span></div>
<div class="MsoNormal" style="tab-stops: 294.0pt;">
<span style="font-family: Helvetica;"><span style="mso-tab-count: 1;"> </span><o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Helvetica;">Part II will examine how
health insurers are trying to reinvent themselves and their business model to
respond to health care reform.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<!--EndFragment-->Kent Bottleshttp://www.blogger.com/profile/12993140567796683570noreply@blogger.com0tag:blogger.com,1999:blog-6653940794693704941.post-39079772619808848262012-07-07T16:48:00.001-04:002012-07-07T16:48:25.680-04:00The SCOTUS & the PPACA: The Medicaid Expansion Decision<style>
<!--
/* Font Definitions */
@font-face
{font-family:"Courier New";
panose-1:2 7 3 9 2 2 5 2 4 4;
mso-font-charset:0;
mso-generic-font-family:auto;
mso-font-pitch:variable;
mso-font-signature:3 0 0 0 1 0;}
@font-face
{font-family:Times;
panose-1:2 0 5 0 0 0 0 0 0 0;
mso-font-charset:0;
mso-generic-font-family:auto;
mso-font-pitch:variable;
mso-font-signature:3 0 0 0 1 0;}
@font-face
{font-family:Wingdings;
panose-1:5 2 1 2 1 8 4 8 7 8;
mso-font-charset:2;
mso-generic-font-family:auto;
mso-font-pitch:variable;
mso-font-signature:0 0 65536 0 -2147483648 0;}
@font-face
{font-family:Cambria;
panose-1:2 4 5 3 5 4 6 3 2 4;
mso-font-charset:0;
mso-generic-font-family:auto;
mso-font-pitch:variable;
mso-font-signature:3 0 0 0 1 0;}
/* Style Definitions */
p.MsoNormal, li.MsoNormal, div.MsoNormal
{mso-style-parent:"";
margin:0in;
margin-bottom:.0001pt;
mso-pagination:widow-orphan;
font-size:10.0pt;
mso-bidi-font-size:12.0pt;
font-family:"Times New Roman";
mso-fareast-font-family:Cambria;
mso-fareast-theme-font:minor-latin;
mso-bidi-font-family:"Times New Roman";
mso-bidi-theme-font:minor-bidi;}
a:link, span.MsoHyperlink
{mso-style-noshow:yes;
color:blue;
text-decoration:underline;
text-underline:single;}
a:visited, span.MsoHyperlinkFollowed
{mso-style-noshow:yes;
color:purple;
text-decoration:underline;
text-underline:single;}
p
{margin:0in;
margin-bottom:.0001pt;
mso-pagination:widow-orphan;
font-size:10.0pt;
font-family:"Times New Roman";
mso-ascii-font-family:Times;
mso-fareast-font-family:Cambria;
mso-fareast-theme-font:minor-latin;
mso-hansi-font-family:Times;
mso-bidi-font-family:"Times New Roman";}
p.MsoListParagraph, li.MsoListParagraph, div.MsoListParagraph
{margin-top:0in;
margin-right:0in;
margin-bottom:0in;
margin-left:.5in;
margin-bottom:.0001pt;
mso-add-space:auto;
mso-pagination:widow-orphan;
font-size:10.0pt;
mso-bidi-font-size:12.0pt;
font-family:"Times New Roman";
mso-fareast-font-family:Cambria;
mso-fareast-theme-font:minor-latin;
mso-bidi-font-family:"Times New Roman";
mso-bidi-theme-font:minor-bidi;}
p.MsoListParagraphCxSpFirst, li.MsoListParagraphCxSpFirst, div.MsoListParagraphCxSpFirst
{mso-style-type:export-only;
margin-top:0in;
margin-right:0in;
margin-bottom:0in;
margin-left:.5in;
margin-bottom:.0001pt;
mso-add-space:auto;
mso-pagination:widow-orphan;
font-size:10.0pt;
mso-bidi-font-size:12.0pt;
font-family:"Times New Roman";
mso-fareast-font-family:Cambria;
mso-fareast-theme-font:minor-latin;
mso-bidi-font-family:"Times New Roman";
mso-bidi-theme-font:minor-bidi;}
p.MsoListParagraphCxSpMiddle, li.MsoListParagraphCxSpMiddle, div.MsoListParagraphCxSpMiddle
{mso-style-type:export-only;
margin-top:0in;
margin-right:0in;
margin-bottom:0in;
margin-left:.5in;
margin-bottom:.0001pt;
mso-add-space:auto;
mso-pagination:widow-orphan;
font-size:10.0pt;
mso-bidi-font-size:12.0pt;
font-family:"Times New Roman";
mso-fareast-font-family:Cambria;
mso-fareast-theme-font:minor-latin;
mso-bidi-font-family:"Times New Roman";
mso-bidi-theme-font:minor-bidi;}
p.MsoListParagraphCxSpLast, li.MsoListParagraphCxSpLast, div.MsoListParagraphCxSpLast
{mso-style-type:export-only;
margin-top:0in;
margin-right:0in;
margin-bottom:0in;
margin-left:.5in;
margin-bottom:.0001pt;
mso-add-space:auto;
mso-pagination:widow-orphan;
font-size:10.0pt;
mso-bidi-font-size:12.0pt;
font-family:"Times New Roman";
mso-fareast-font-family:Cambria;
mso-fareast-theme-font:minor-latin;
mso-bidi-font-family:"Times New Roman";
mso-bidi-theme-font:minor-bidi;}
@page Section1
{size:8.5in 11.0in;
margin:1.0in 1.25in 1.0in 1.25in;
mso-header-margin:.5in;
mso-footer-margin:.5in;
mso-paper-source:0;}
div.Section1
{page:Section1;}
/* List Definitions */
@list l0
{mso-list-id:725765855;
mso-list-type:hybrid;
mso-list-template-ids:791422534 1579188690 67698691 67698693 67698689 67698691 67698693 67698689 67698691 67698693;}
@list l0:level1
{mso-level-number-format:bullet;
mso-level-text:;
mso-level-tab-stop:none;
mso-level-number-position:left;
margin-left:.35in;
text-indent:-.05in;
font-family:Symbol;}
ol
{margin-bottom:0in;}
ul
{margin-bottom:0in;}
-->
</style>
<br />
<div class="MsoNormal">
<span style="font-family: Helvetica; font-size: 12.0pt;">There
were many surprises when the Supreme Court (SCOTUS) issued its long-awaited
decision on the Patient Protection and Affordable Care Act (PPACA).<span style="mso-spacerun: yes;"> </span>I have written elsewhere why I think
Chief Justice John Roberts surprised us all by siding with the four
Democratically appointed justices to rule the individual mandate
constitutional. (<a href="http://www.thedoctorweighsin.com/why-did-chief-justice-roberts-do-it/">http://www.thedoctorweighsin.com/why-did-chief-justice-roberts-do-it/</a>)
<span style="mso-spacerun: yes;"> </span>These five justices also surprised
us by basing that ruling not on the commerce clause, but on the federal
government’s right to tax citizens.<span style="mso-spacerun: yes;">
</span>The SCOTUS by a 9 to 7 vote also ruled that the Medicaid expansion was
constitutional as long as states would not lose all their existing federal
funding if they choose not to expand coverage as called for in the PPACA.<span style="mso-spacerun: yes;"> </span>This blog will examine the
ramifications of the Medicaid decision, which was also a surprise.<span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica; font-size: 12.0pt;">Much of
the debate around the PPACA had concentrated on the individual mandate and not
the Medicaid expansion, which as originally approved by Congress would have
added up to 17 million Americans to the Medicaid health insurance program.<span style="mso-spacerun: yes;"> </span>Health care reform advocates welcomed
this expansion because it extended care to poor people, but some state
officials, especially Republicans, opposed it because the states have budget
deficits and no easy way to pay for the perceived new costs associated with
expansion.<span style="mso-spacerun: yes;"> </span>Medicaid provides
health insurance for low income Americans and is jointly funded by the federal
and state governments.<span style="mso-spacerun: yes;"> </span>Although
states do not have to participate, all states at the present time do take part
in the matching program and agree to abide by the rules.<span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica; font-size: 12.0pt;">Prior
to passage of the PPACA, Medicaid covered:<span style="mso-spacerun: yes;"> </span>pregnant women and children under 6 who had family incomes
at or below 133% the Federal Poverty Level, children 6 through 18 with family
incomes at or below 100% the Federal Poverty Level, parents and caretaker
relatives on the cash assistance program, and elderly and disabled people with
Supplemental Security Income benefits.<span style="mso-spacerun: yes;">
</span>Beginning in January 2014, The PPACA requires participating states to
cover almost all people under 65 earning household incomes at or below 133% the
Federal Poverty Level.<span style="mso-spacerun: yes;"> </span>The 2012
levels are $14,856 per year per person and $30,657 per year per household of
four.<span style="mso-spacerun: yes;"> </span>From 2014 to 2016, the
federal government will pay all of the costs of the expansion; after 2016 there
is a gradual decrease in federal support to 90% in 2020 and thereafter. The
single best summary of the entire SCOTUS ruling can be found at the Kaiser
Family Foundation here <a href="http://www.kff.org/healthreform/8332.cfm">http://www.kff.org/healthreform/8332.cfm</a>.
</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica; font-size: 12.0pt;">The
SCOTUS ruling on Medicaid expansion is complicated, but the take home message
is that the expansion is constitutional as long as the HHS Secretary is not
able to take away existing federal support to states that decide not to
participate in the expansion.<span style="mso-spacerun: yes;"> </span>All
other provisions in the PPACA are left intact.</span></div>
<div class="MsoNormal">
<span style="font-family: Helvetica; font-size: 12.0pt;">New
Medicaid provisions in the PPACA include:</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoListParagraphCxSpFirst" style="margin-left: .35in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.05in;">
<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: Helvetica; font-size: 12.0pt;">Increase in primary care
provider payments</span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: .35in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.05in;">
<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: Helvetica; font-size: 12.0pt;">Options to expand home and
community-based services</span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: .35in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.05in;">
<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: Helvetica; font-size: 12.0pt;">Reductions in disproportionate
share hospital payments</span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: .35in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.05in;">
<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: Helvetica; font-size: 12.0pt;">States maintaining eligibility
requirements in place as of March 23, 2010</span></div>
<div class="MsoListParagraphCxSpLast" style="margin-left: .35in; mso-add-space: auto;">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica; font-size: 12.0pt;">Health
care reform advocates were pleased that the Medicaid expansion was upheld, but
they worry that the SCOTUS ruling would allow states to opt out of the
expansion.<span style="mso-spacerun: yes;"> </span>Mental Health America,
an advocacy group, stated, “The expansion of Medicaid also requires those who
are newly eligible to receive mental health and substance use services at
parity with other benefits.<span style="mso-spacerun: yes;"> </span>State
participation in the Medicaid expansion is therefore critically important.” (<a href="http://www.sacbee.com/2012/06/28/4596221/statement-of-mental-health-america.html">http://www.sacbee.com/2012/06/28/4596221/statement-of-mental-health-america.html</a>)
<span style="mso-spacerun: yes;"> </span>Other advocates noted that the
SCOTUS ruling left the door open for states to make it harder for adults to
qualify for Medicaid.<span style="mso-spacerun: yes;"> </span>States could
throw some low-income adults “into a black hole with nowhere to turn for
coverage," said Deborah Bachrach, who was New York’s Medicaid director
until 2010.<span style="mso-spacerun: yes;"> </span>(<a href="http://www.kaiserhealthnews.org/Stories/2012/July/03/states-could-cut-medicaid-rolls-after-ruling.aspx">http://www.kaiserhealthnews.org/Stories/2012/July/03/states-could-cut-medicaid-rolls-after-ruling.aspx</a>)
<span style="mso-spacerun: yes;"> </span>Another complicating factor
is that under the PPACA most individuals with incomes less than 100% the
Federal Poverty Level are not eligible for subsidies to purchase insurance at
the newly formed state insurance exchanges and so may end up without access to
insurance.<span style="mso-spacerun: yes;"> </span>Such worries were
confirmed as real when Maine’s Attorney General William Schneider announced
plans to strike more than 20,000 Medicaid recipients from the state’s program
to save $10 million for the state’s strapped budget.<span style="mso-spacerun: yes;"> </span>Not everyone agrees that the Attorney General will be allowed
to make this cut.<span style="mso-spacerun: yes;"> </span>“‘The court
decision was not crystal clear,’ said Alan Weil, a former Medicaid director and
head of the nonpartisan National Academy for State Health Policy.<span style="mso-spacerun: yes;"> </span>‘I’ve been telling people [the rules]
are still there.’” (<a href="http://online.wsj.com/article/SB10001424052702303684004577511103843368654.html">http://online.wsj.com/article/SB10001424052702303684004577511103843368654.html</a>)<span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica; font-size: 12.0pt;">The
progressive take on the SCOTUS ruling affecting the Medicaid expansion can
perhaps be best summarized by Ed Kilgore:</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Helvetica; font-size: 12.0pt;">“The sad truth is that Republican governors and state
legislators have been claiming ever since ACA was enacted that the expansion,
even with the ‘sweet’ super-matches, would bankrupt their budgets. And the even
sadder truth is that many of these solons don’t think of this as primarily a
fiscal issue, but as an ideological test of their hatred of the ‘welfare
state.’ There’s a reason southern Republicans, perhaps even more than their
compatriots elsewhere, love Paul Ryan’s Medicaid ‘block grant’ proposal. They
want significant reductions in the existing Medicaid program, along with
structural changes that would make it unrecognizable as a low-income
entitlement. This involves a philosophical objection to giving poor people free
health insurance, not just a budgetary concern.” (<a href="http://www.tnr.com/blog/plank/104458/why-the-obamacare-ruling-isnt-the-slam-dunk-most-people-think">http://www.tnr.com/blog/plank/104458/why-the-obamacare-ruling-isnt-the-slam-dunk-most-people-think</a>)
</span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica; font-size: 12.0pt;">The
reactions of many GOP governors seemed to confirm Kilgore’s conclusions.<span style="mso-spacerun: yes;"> </span>“We’re not going to shove more South
Carolinians into a broken system that further ties our hands when we know the
best way to find South Carolina solutions for South Carolina health problems is
through the flexibility that block grants provide,” said Rob Godfrey, spokesman
for Gov. Nikki Haley. (<a href="http://www.washingtonpost.com/business/economy/health-care-laws-medicaid-provision-too-good-to-pass-up/2012/07/02/gJQABxkJJW_story.html">http://www.washingtonpost.com/business/economy/health-care-laws-medicaid-provision-too-good-to-pass-up/2012/07/02/gJQABxkJJW_story.html</a>)
”‘Floridians are interested in jobs and economic growth, a quality education
for their children, and keeping the cost of living low,’ Governor Scott said. ‘Neither
of these major provisions in ObamaCare will achieve those goals, and since
Florida is legally allowed to opt out, that’s the right decision for our
citizens.’”(<a href="http://hotair.com/archives/2012/07/02/gov-rick-scott-no-medicare-expansion-for-florida-thanks/">http://hotair.com/archives/2012/07/02/gov-rick-scott-no-medicare-expansion-for-florida-thanks/</a>)
Similar defiant pronouncements were issued by Louisiana’s Governor Bobby Jindal
and Wisconsin’s Governor Scott Walker. One might assume that a conservative
state like Arizona with a controversial governor who is no friend of President
Obama would be likely to refuse to participate in the Medicaid expansion.<span style="mso-spacerun: yes;"> </span>For a fascinating look at how
complicated and not straightforward Arizona’s decision actually is please go to
<a href="http://www.azcentral.com/arizonarepublic/opinions/articles/2012/07/05/20120705robert-robb-arizona-has-hard-choice-make.html">http://www.azcentral.com/arizoannarepublic/opinions/articles/2012/07/05/20120705robert-robb-arizona-has-hard-choice-make.html</a>.
</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica; font-size: 12.0pt;">At the
end of the day, it may be hard for GOP governors and legislatures to pass up
participating in the expansion.<span style="mso-spacerun: yes;">
</span>While the GOP has focused on the costs passed onto to the states, some
detailed analysis shows that the Medicaid expansion can save money for the
states.<span style="mso-spacerun: yes;"> </span>Some state and local
governments currently help hospitals cope with providing uncompensated care for
uninsured patients to the tune of $10.5 billion or 18.5% of uncompensated care
nationally.<span style="mso-spacerun: yes;"> </span>Having more patients
covered by Medicaid would bring these costs down, which is why hospitals are
lobbying so hard for their states to participate in the expanded program. (<a href="http://www.washingtonpost.com/blogs/ezra-klein/wp/2012/07/05/how-the-medicaid-expansion-also-saves-states-money/">http://www.washingtonpost.com/blogs/ezra-klein/wp/2012/07/05/how-the-medicaid-expansion-also-saves-states-money/</a>)
<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>“’Texas hospitals recognize there are concerns with expanding
the Medicaid population, but given the state’s high number of uninsured, all
options for gaining insurance coverage must be closely considered,” Dan Stultz,
executive director of the Texas Hospital Association, said in a statement.
‘Without the Medicaid expansion, many will remain uninsured, shifting costs to
the insured and increasing uncompensated care to health-care providers.’”<span style="mso-spacerun: yes;"> </span>The Texas Hospital Association has
never been known for their progressive views, and yet all hospitals are
lobbying for states to participate in the Medicaid expansion (<a href="http://www.governing.com/blogs/view/gov-hospitals-likely-to-lobby-states-on-medicaid-expansion.html">http://www.governing.com/blogs/view/gov-hospitals-likely-to-lobby-states-on-medicaid-expansion.html</a>).
</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Helvetica; font-size: 12.0pt;">Expansion
of Medicaid would also reduce state spending on mental health services for poor
and uninsured patients; state and local governments spent $16.3 billion for
such services, 42% of the cost of state mental health services in 2009. The
Center on Budget and Policy Priorities estimates that state Medicaid spending
will ultimately go up by 2.8% by 2022 if states join the expansion. However,
that estimate “’actually overstates the net impact on state budgets because it
does not reflect the savings that state and local governments will realize in
health care costs for the uninsured…In fact states could end up with a net
gain.’” (<a href="http://www.washingtonpost.com/blogs/ezra-klein/wp/2012/07/05/how-the-medicaid-expansion-also-saves-states-money/">http://www.washingtonpost.com/blogs/ezra-klein/wp/2012/07/05/how-the-medicaid-expansion-also-saves-states-money/</a>)<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>For a state-by-state rundown on the Medicaid expansion
please go to this link to a New York Times blog post. <a href="http://economix.blogs.nytimes.com/2012/07/02/how-much-would-the-medicaid-expansion-cost-your-state/">http://economix.blogs.nytimes.com/2012/07/02/how-much-would-the-medicaid-expansion-cost-your-state/</a>.
</span></div>
<div class="MsoNormal">
<br /></div>
<div style="margin-bottom: .1pt; margin-left: 0in; margin-right: 0in; margin-top: .1pt;">
<span style="font-family: Helvetica; font-size: 12.0pt; mso-bidi-font-size: 10.0pt;">The
economic and political realities of the Medicaid expansion have already entered
into some gubernatorial races. <span style="mso-spacerun: yes;"> </span>Robert
Blendon, professor of health policy and political analysis at Harvard, said,<span style="mso-spacerun: yes;"> </span>“’Democratic candidates will say we
should implement the law and put in exchanges and go after as much funding for
coverage as possible, while Republican will say it’s too expensive.’” <span style="mso-spacerun: yes;"> </span>“’Medicaid will be an issue anywhere
Democrats have a chance to win,’ said Len Nichols, director of the Center for
Health Policy Research and Ethics at George Mason University. That includes
states such as West Virginia, North Carolina, Washington state and possibly
Missouri, he said.” (<a href="http://www.pennlive.com/newsflash/index.ssf/story/medicaid-expansion-already-an-issue-in-some-gubernatorial-races/68c350064991ce90c070836422118994">http://www.pennlive.com/newsflash/index.ssf/story/medicaid-expansion-already-an-issue-in-some-gubernatorial-races/68c350064991ce90c070836422118994</a>)<span style="mso-spacerun: yes;"> </span>Democratic candidates will probably
push for states to participate in the PPACA’s Medicaid expansion because if
they do not, their state budgets will end up subsidizing Medicaid coverage for
lower income people in other states that do sign up for the program.<span style="mso-spacerun: yes;"> </span></span></div>
<div style="margin-bottom: .1pt; margin-left: 0in; margin-right: 0in; margin-top: .1pt;">
<br /></div>
<div style="margin-bottom: .1pt; margin-left: 0in; margin-right: 0in; margin-top: .1pt;">
<span style="font-family: Helvetica; font-size: 12.0pt; mso-bidi-font-size: 10.0pt;">Governors
who refuse to participate in the Medicaid expansion may face a backlash from
voters like:</span></div>
<div style="margin-bottom: .1pt; margin-left: 0in; margin-right: 0in; margin-top: .1pt;">
<br /></div>
<div style="margin-bottom: .1pt; margin-left: .5in; margin-right: 0in; margin-top: .1pt; tab-stops: 238.5pt;">
<span style="font-family: Helvetica; font-size: 12.0pt; mso-bidi-font-size: 10.0pt;">“Bunnie Gronborg, 64, of Festus, Mo., [who] said she has
two sons in their 30s who are single fathers who lost construction jobs and now
lack health insurance. She had hoped they could be covered by the Medicaid
expansion, and she doesn't buy the explanation that the state cannot afford it.
‘There's absolutely no reason’ to reject the expansion,’ except being
vindictive and playing political games with people's actual health care,’
Gronborg said.” (<a href="http://www.huffingtonpost.com/2012/06/29/medicaid-expansion_n_1638720.html">http://www.huffingtonpost.com/2012/06/29/medicaid-expansion_n_1638720.html</a>)
</span></div>
<div style="margin-bottom: .1pt; margin-left: .5in; margin-right: 0in; margin-top: .1pt;">
<br /></div>
<div style="margin-bottom: .1pt; margin-left: 0in; margin-right: 0in; margin-top: .1pt;">
<span style="font-family: Helvetica; font-size: 12.0pt; mso-bidi-font-size: 10.0pt;">Ezra
Klein thinks that the Medicaid expansion is just too good a deal for states to
pass up, even though some GOP governors will be tempted to gain political
points with the base by refusing to participate:</span></div>
<div style="margin-bottom: .1pt; margin-left: 0in; margin-right: 0in; margin-top: .1pt;">
<br /></div>
<div style="margin-bottom: .1pt; margin-left: .5in; margin-right: 0in; margin-top: .1pt;">
<span style="font-family: Helvetica; font-size: 12.0pt; mso-bidi-font-size: 10.0pt;">“And
governors also have to answer to non-Republican voters who don’t want their
state missing out on billions in federal dollars, and to the hospitals in their
state who have to treat uninsured patients that end up in their emergency
rooms, and the insured voters who end up paying for their uninsured brethren.”
(<a href="http://www.washingtonpost.com/business/economy/health-care-laws-medicaid-provision-too-good-to-pass-up/2012/07/02/gJQABxkJJW_story.html">http://www.washingtonpost.com/business/economy/health-care-laws-medicaid-provision-too-good-to-pass-up/2012/07/02/gJQABxkJJW_story.html</a>)</span></div>
<div style="margin-bottom: .1pt; margin-left: 0in; margin-right: 0in; margin-top: .1pt;">
<br /></div>
<div style="margin-bottom: .1pt; margin-left: 0in; margin-right: 0in; margin-top: .1pt;">
<span style="font-family: Helvetica; font-size: 12.0pt; mso-bidi-font-size: 10.0pt;">Another
hard to predict political result of the SCOTUS ruling on both the individual
mandate and the Medicaid expansion is the affect it will have on future SCOTUS
decisions.<span style="mso-spacerun: yes;"> </span>Some conservatives are
so mad at Chief Justice Roberts that they are calling him a traitor and saying
he should be impeached.<span style="mso-spacerun: yes;"> </span>How will
the Chief Justice react to the fallout?<span style="mso-spacerun: yes;">
</span>Reagan appointee conservative federal judge Richard Posner speculates on
how Chief Justice Roberts will respond to his new situation:</span></div>
<div style="margin-bottom: .1pt; margin-left: 0in; margin-right: 0in; margin-top: .1pt;">
<br /></div>
<div style="margin-bottom: .1pt; margin-left: .5in; margin-right: 0in; margin-top: .1pt;">
<span style="font-family: Helvetica; font-size: 12.0pt; mso-bidi-font-size: 10.0pt;">“‘These
right-wingers who are blasting [Chief Justice John] Roberts are making a very
serious mistake. I mean, what would you do if you were Roberts?’ Judge Richard
Posner, of the 7th U.S. Circuit Court of Appeals, <span style="mso-field-code: "HYPERLINK \0022http\:\/\/www\.npr\.org\/blogs\/itsallpolitics\/2012\/07\/05\/156319272\/federal-judge-richard-posner-the-gop-has-made-me-less-conservative\0022 \\t \0022_blank\0022";"><span class="MsoHyperlink">told NPR</span></span>. ‘All of a sudden you find out that
the people that you thought were your friends have turned against you, they
despise you, they mistreat you, they leak to the press, what do you do? Do you
become more conservative? Or do you say, ‘What am I doing with this crowd of
lunatics?’”(<a href="http://www.politico.com/news/stories/0712/78182.html">http://www.politico.com/news/stories/0712/78182.html</a>)
</span></div>
<div style="margin-bottom: .1pt; margin-left: 0in; margin-right: 0in; margin-top: .1pt;">
<br /></div>
<div style="margin-bottom: .1pt; margin-left: 0in; margin-right: 0in; margin-top: .1pt;">
<span style="font-family: Helvetica; font-size: 12.0pt; mso-bidi-font-size: 10.0pt;">Before
the SCOTUS decided the case of National Federation of Independent Business v. Sibelius,
most of the attention was concentrated on the constitutionality of the
individual mandate.<span style="mso-spacerun: yes;"> </span>This blog post
has examined the reasons why the SCOTUS treatment of the PPACA Medicaid
expansion may have more important and more lasting effects on the
transformation of the American health care clinical delivery system. </span></div>
<div style="margin-bottom: .1pt; margin-left: .5in; margin-right: 0in; margin-top: .1pt;">
<br /></div>
<div class="MsoNormal" style="background: white;">
<span style="color: black; font-family: Helvetica; font-size: 12.0pt;"><br style="mso-special-character: line-break;" />
<br style="mso-special-character: line-break;" />
</span></div>
<div style="margin-bottom: .1pt; margin-left: 0in; margin-right: 0in; margin-top: .1pt;">
<br /></div>
<div style="margin-bottom: .1pt; margin-left: 0in; margin-right: 0in; margin-top: .1pt;">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div style="margin-bottom: .1pt; margin-left: 0in; margin-right: 0in; margin-top: .1pt;">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>Kent Bottleshttp://www.blogger.com/profile/12993140567796683570noreply@blogger.com1