Wednesday, December 30, 2009

Some Good Reading

This may already be well known to many of you, but I learned recently that David Brooks of the New York Times issues annual "Sidney Awards" for the best magazine essays of the year.  As Brooks says it, "the idea is to celebrate (and provide online links to) long-form articles that have narrative drive and social impact."  See his Christmas Day Op Ed, with said links, here.

His Op Ed caught me eye, because I had read two of the pieces Brooks mentions -- both on health care issues - and thought they were fabulous.  These pieces are great not only for the masterful selection of the topics covered, but also for their brilliant prose.  The first is what Brooks describes as "the most influential essay of 2009."  I agree.  It is "The Cost Conundrum" by Surgeon and writer Atul Gawande and appears in the New Yorker.  The second is “How American Health Care Killed My Father” by David Goldhill and appeared in The Atlantic.  If you haven't read them, and seek a fuller understanding of health care issues, you should.  I highly recommend them. 

Finding some unexpected time on Christmas Day, I decided I would try a few of the non-health care articles Brooks recommends.  They too were great.  One was what Brooks describes as " the most powerful essay" of the year.  It is “Trial by Fire” by David Grann in The New Yorker and discusses Grann's investigation of the circumstances around the case of Cameron Todd Willingham, who was executed in 2004 for murdering his three children by setting their house on fire.  It is an amazing, and highly disturbing, story and very well researched and written.  You should especially read this if you happen to be in favor of the death penalty (which I am not). 

Finally, I also read Matt Labash's article in the The Weekly Standard called “A Rake’s Progress” -- a "sympathetic and gripping profile of Marion Barry, the former Washington, D.C., mayor, crack-smoker and recent girlfriend-stalker."  Barry is truly an enigma and Labash does a beautiful job of bringing his many colors to life. 

So, if you happen to be lucky and find yourself with a few extra minutes (or perhaps hours, if you are as slow a reader as I am) over this New Year's weekend, I am sure you will not be disappointed by these great reads.  Enjoy and Happy New Year!

Tuesday, December 29, 2009

A Day of Skiing Gone Bad

Perhaps some of you skiers (and non-skiers) with small children might appreciate this - or at least relate!

The idea was good. We would go to the Trapp Family lodge in Stowe, Vermont for a few days of post-Christmas rest and relaxation with the kids (ages 11 and 6). Everything seemed fine until Monday when we decided to go downhill skiing with the children (neither of whom loves to ski - so we would go for only the afternoon). The "I hate skiing" chants on the way to the Mountain should have been our first clue.  But we persisted. After putting on her boots, our 6-year-old daughter had a total melt down. Everything hurt. Many noble attempts to convince her it would be fun (and some bribing) did not change her mind. We had to abort. She and I would sit in the lodge while the other two went skiing. They went skiing in a blizzard - it was miserable. My daughter and I could not find a seat anywhere in the over-packed lodge.  We ate next to the trash can. It too was miserable. At 3:30 (about 2 hours and $150 later) - finally, we could put this not-so-good-day behind us.

But wait.  As we were walking to the car, I overheard someone say to his friend, "I guess there was a bad accident on Mountain Road." Uh-oh. This couldn't be good. Turns out there was a perfect storm of sorts: (1) a blizzard, (2) at the same time as the closing of the lifts when everyone was leaving, and (3) a 5-car pileup on the one access road.  Needless to say, we sat in the parking lot for almost two hours without moving. We then realized we had very little gas and at this rate we would surely run out before making it to town (we were ever-so-fortunate to have a car that tells you how many miles you have left on your tank; so we anxiously watched it slowly work its way down to almost zero).

My wife kept wisely reminding all of us that things could be much worse.  While very true, it didn't seem to help. 

After moving 0.2 miles in 2.5 hours, we had to abort again. We turned off at the Stowe Mountain Lodge.  It was a zoo.  No food - the restaurant was booked and would not have an opening for three hours. My wife begged the bartender for two bags of chips so we could feed the kids. At 7:30, in hopes the traffic had started to abate, I decided to try to make the expedition for gas myself (it was mostly downhill, so if I ran out I knew there was a chance I could glide to the station). But I made it (on fumes). Back up the hill to get the family. Got in a fight with my wife (of course) over some stupid issue. Arrived back at our lodge at 9 p.m. (5.5 hours after we finished skiing) - missed the evening movie.  No family member was speaking to any other. Aren't family vacations wonderful!

Friday, December 25, 2009

What You Won't Hear About in the Senate Bill

This past summer, I wrote an op ed in the Boston Globe entitled Retooling the Medicare/Medicaid Model.  In the piece, I discuss the enormous fragmentation and dysfunction that exists between the Medicare and Medicaid programs.  Although housed within one agency, these two gargantuan government programs are incredibly siloed and often work at cross purposes, thereby adding significant cost to the system.  This is seen most clearly in the so-called dual-eligible population -those high cost individuals who are on both programs.  Here is what I recommended: 

"The Obama administration can reorganize CMS so that it focuses as much on the unique needs of populations as it does on the rules of payment. CMS should create a program integration unit devoted exclusively to breaking down silos between the two programs and working with states to eliminate barriers to seamless care for dual eligibles. Doing so will go a long way to reducing costs - and free up resources for more far-reaching reform."

I was delighted to read recently that the Senate bill does just that.  Buried on page 517 of the bill, in section 2602, it establishes a Federal Coordinated Health Care Office within CMS for the purpose of, "bring[ing] together officers and employees of the Medicare and Medicaid programs at [CMS] in order to more effectively integrate benefits under [both programs] and . . .  improve the coordination between the Federal Government and States."

Hooray!  And the best part -- unlike the several-year delay of most major sections of the bill, this one will become effective in March, 2010.  You will not hear or read about this provision because it does not make for a good sound bite.  But this new Office - if it realizes even half of its promise -- will have a profound impact on improving care and reducing cost for some of the costliest individuals on our public programs.  So tell that to the next person who tells you that the bill will do nothing to bend the cost curve!  Please read my Op-Ed for more background.  And let's hope this provision makes it through conference.

Thursday, December 24, 2009

Poem on Health Reform

Ron Pollack is the President of Families USA and a strong advocate of health reform.  He wrote this poem as he waited for the vote on Sunday night. Thanks to Scott Harshbarger for passing it along.  Have a wonderful Christmas everyone!


Twas the night before Christmas and all through the Senate
The Democrats were working for a fundamental tenet:
All Americans should have health care at a reasonable price
By forcing insurance companies to finally play nice.

The reform bill they pushed took some very strong positions,
Like no one denied coverage due to pre-existing conditions.
Premiums, in the future, would need to be fair
With no differences for women and people needing care.

The Democrats made sure that the bill they designed
Would give folks *cross the nation some real peace of mind.
Health care would not end if jobs changed or were lost
As all could choose health plans at an affordable cost.

For seniors needing medicines, the bill had much to extol:
It plugged gaps in their coverage, like the bad *doughnut hole.*
And for empty-nesting parents, there was reason to rejoice
Kids could keep family coverage, this was now a parent*s choice.

But all Republicans scoffed and persistently said *no*
With the sometimes exception of their colleague, Ms. Snowe.
With obstructions and filibusters, they tried every delay
To stop the bill and kill reform, before Christmas day.

So Leader Reid called his colleagues from left and from right,
For all 60 to join him, lest they lose this big fight.
Now Nelson, now Lincoln, now Franken and Wyden,
On Lieberman, on Bingaman, on Harkin and Cardin.

Christmas eve turned to night, and when the votes were all counted,
The filibusters and obstructions were completely surmounted.
The vote was inspired by the memory of Ted
Who*d applaud the victory for the cause he had led.

The work isn*t over, there*s much yet to be done
The Senate and the House bills must be merged into one.
But the vote on Christmas eve offers reason to cheer
*Cause health care reform will pass in the new year.

So call your fine leaders, and let your voice be heard,
With letters and emails, we must spread the word.
Our message is clear, and it shines a bright light*
*Health care coverage for all, and for all it*s our right.*


It's done!  Moves on to conference.

Tuesday, December 22, 2009

July 2, 2009

That day may go down in history as one of the pivotal events in bringing about national health reform - a goal that has eluded national leaders for a generation.  That was the day that Senator Edward Kennedy delivered a letter to the leaders of our state: the Governor, the Senate President and the Speaker of the House, urging them to amend the law to provide for a temporary gubernatorial appointment (pending the results of a special election) "should a senate vacancy occur."   Of course, we all knew what vacancy he was talking about: the one that would be brought about by his impending death. 

At a time when this man had everything else in the world to think about, when he had every right to wallow in self pity, he chose instead to make this urgent appeal because he knew that it could make all the difference in the world.  He invoked the names of John Adams and Daniel Webster to underscore the fact that the "voices and views" of Massachusetts representatives in Congress "have shaped America's progress." 

As it turns out, Senator Kennedy's words were prophetic.  Paul Kirk - the Senator appointed by Governor Patrick after the law was changed - will likely cast the 60th and deciding vote to pass health reform in the Senate.  Without him, they would not have the votes.  And by the time a new Senator will be elected and sworn in, it probably will be too late. 

Ted Kennedy's emotional plea undoubtedly had a large impact on the Governor and the Massachusetts legislature to amend the law, as there was strong political pressure to do otherwise.  Ted Kennedy will no doubt be in the history books alongside Adams and Webster.  And for his many acts over his long career, this one on July 2nd may turn out to be one of the most significant in shaping America's progress on an issue so near and dear to his heart.

Sunday, December 20, 2009

The sausage will taste so good

I love a nice hot sausage at Fenway on a summer evening.  But I know that if I had to see that sausage being made, I would probably get sick to my stomach.  The debate on health reform now taking place in the United States Senate is like watching sausage being made in the worst possible conditions.  It is frankly painful to watch.  An article in today's New York Times describes it as follows:

"Nasty charges of bribery. Senators cut off mid-speech. Accusations of politics put over patriotism. Talk of double-crosses."

But I must confess to feeling a sense of enormous excitement when I learned of the deal struck over the weekend to finally bring Nebraska Senator Ben Neslon into the fold.  They now have 60 votes.  The deal may actually hold together.  The most significant reform of our health system in a generation may actually happen.  Thirty million Americans may actually get health insurance. 

There are still plenty of ways it can fail, but for the first time in a while I can see a clear path to victory.  And I know that when that happens -- like the taste of that wonderful sausage at Fenway -- I will think not of how it was made, but how wonderful it tastes!

Thursday, December 17, 2009

Another Lawyer Gets the Nod

Lawyers often have a very difficult time transitioning from being the lawyer to being the chief executive in an organization.  I think it stems in part from the discomfort they have in moving from being the adviser to being the decision maker.  It may also be due to the fact that most people think of lawyers in a very narrow way.  This is perhaps one reason why a string of very qualified Attorneys General in our state have not been able to become Governor.  But good lawyers, who can view their role in a broader way, and who have vision, can make great leaders.  Their analytical training, their ability to understand complexity and make it simple, and their understanding of the value of good and fair process, are wonderful qualities in a leader.  And I am delighted to see that there seems to be a growing number who are able to make the transition - and to do so successfully.  Jim Roosevelt, the CEO of Tufts Health Plan (and former General Counsel) did it in health care.  Deval Patrick, our Governor and former lawyer in a number of key roles, did it in government.  And we learn today that Brian Moynihan, the General Counsel of Bank of America just five years ago, with no particular background in banking, will now become the CEO of the nation's largest bank.  I don't know much about Brian's background, but given my firm belief in the value my profession has to offer beyond just the law, I will be rooting for him to succeed. 

Tuesday, December 15, 2009

The President Agrees

"If we don't do something, premiums are guaranteed to rise." 
       -President Obama speaking today on the cost of doing nothing on health reform.  He surely must have read my November 24th post below.

Thursday, December 10, 2009

How Google is Changing the World (and improving health)

I recently became a member of the Trustee Advisory Council of the Massachusetts Hospital Association.  The Council is made up mostly of trustees of hospitals in the state (I am a rare exception) to provide valuable advice and input to the MHA from a trustee's perspective.  Today, as part of my responsibility to the Council, I attended the 30th Annual NEHA Trustees conference for hospital trustees throughout New England.  The keynote address was given by a guy named Ron Galloway, a columnist and director of the documentary film rebooting healthcare.  His talk was entitled The Top 12 Trends Shaping Healthcare.  He focused on technology and its possibilities in driving greater efficiencies and improving health.  He gave many fascinating examples, including what Google is now doing to help researchers and the public better identify health information and trends.  It turns out that by collecting data on certain search queries by Google users in a particular region, Google can actually predict flu outbrakes as well as - and perhaps even better than - our public health agencies.  If you are interested, check out the site called Google Flu trends and see for yourself.  Here is how Google describes it:

"We've found that certain search terms are good indicators of flu activity. Google Flu Trends uses aggregated Google search data to estimate flu activity."

The table below - taken right from the site - shows Google estimates (in blue) of flu activity around the world based solely on user queries in a particular region.  This is superimposed over official flu estimates from the U.S. Centers for Disease Control.  What is amazing is how similar they are.  What's more, by updating its data every day, Google can actually serve as a far better early warning system for public health outbreaks than the CDC, which updates its data once per week.  Pretty unbelievable, isn't it?  Imagine the possibilities! 

Wednesday, December 9, 2009

Cost of doing nothing just got higher

In my "cost of doing nothing" post on November 24, I explore some of the implications of not passing health reform.  One implication is that our health care costs will continue to spiral out of control.  That would be bad enough, but it might be tolerable (or at least more tolerable) if we were getting good value for that excess cost.  But we are not.  A new international report just released (and reported on by the Globe today) finds that:

The United States ranks near the bottom in life expectancy among wealthy nations despite spending more than double per person on health care than the industrialized world’s average, an economic group said yesterday.  Life expectancy at birth in the United States was 78.1 years in 2007, according to the Organization for Economic Cooperation and Development.  That’s a year less than the organization’s average of 79.1, and puts the United States just ahead of the Czech Republic, Poland, and Mexico ..."

Admittedly, there are a number of factors that go into life expectancy.  But one factor is how good a job we do as a nation in keeping people healthy.  And the sober reality is that we are not doing that good a job.

Tuesday, December 8, 2009

Heavage is Back

On the evening of September 20, 1975, I wore a powder blue leisure suit, with open shirt, to my Bar Mitzvah party.  I didn't think I'd ever have to do that again.  So imagine my distress then when I read an article in the Wall Street Journal last week that "male heavage" is back.   The first line of the article says it all. 

"Man cleavage -- plunging necklines slit open to reveal chest hair, pectoral muscles, maybe more -- is back."

Aaaagh!  Do we really need to go there again?!  Didn't we suffer enough the first time around?  I think I'll be sitting this one out.

Saturday, December 5, 2009

Some Welcome Efficiency

In my role, I get to see and hear about some amazing accomplishments in healthcare delivery. I also get to see and hear about some unfathomable inefficiencies. Today I took my son to Framingham Pediatrics to get a flu shot. We were met at the door by someone giving us a form to fill out. She directed us immediately to another nurse who reviewed the form, asked my son to have his arm ready and immediately directed us to an exam room. When we arrived at the room, we were met by another woman who reviewed the form and administered the injection. Total time from entry to exit: about two minutes. It was one of the most efficient processes I have ever seen in healthcare. Kudos to Framingham Pediatrics! There is hope.

More on Mammograms

Earlier this week, I commented in a post about the recent flap over the recommendations on mammograms.  One of the reasons an issue like this can become so political - and the debate so insidious - is that there is always someone with an unfortunate anecdote.  We should not dismiss anecdotes and real, human stories for helping to give meaning to public policy issues.  But if anecdotes become the basis for health policy, we are all in trouble.  In this Op Ed Friday in the Baltimore Sun, Dr. Miriam Alexander, president-elect of the American College of Preventive Medicine and a faculty member at the Johns Hopkins School of Public Health, offers a cogent defense of the taskforce recommendation and an explanation of the process.  It is worth a read.  Here is a taste:
"The task force, using rigorous methodologies, examines the scientific evidence for preventive services. It carefully weighs the benefits and the drawbacks before making its recommendations - based on what's best for whole populations, not each individual."

Thursday, December 3, 2009

Scott Harshbarger's Public Service Legacy

I am taking a short respite from health care issues to comment briefly on public service. Last evening, I attended the 2d Annual Harshbarger Reunion. It was a gathering of lawyers (I hope that in itself doesn't cause you to stop reading!) at Suffolk Law School in Boston. These lawyers all had at least one thing in common: they previously worked for Scott Harshbarger when he was Attorney General of the Commonwealth. Scott had this great way of attracting and retaining incredibly talented individuals into public service. Some of these individuals have remained in the AG's Office, providing outstanding representation to the Commonwealth (two at the gathering had argued before the United States Supreme Court within the last several years). Others have gone on to pursue very successful careers, many of these in public service or pursuing public causes. Here is a small sampling from just those former colleagues I had a chance to catch up with at the event: one is an Appeals Court Judge; one is a Boston Municipal Court Judge; one works for Oxfam America; one works for the Commonwealth Health Insurance Connector; one works for the U.S. Court of Appeals; one is an investment banker; one is a partner in a large law firm; and one runs a fraud unit at a large health insurer.

Incredible diversity, commitment and accomplishment. This is a great a credit to these individuals. But I can't help but think it is also a credit to the wonderful inspiration Scott gave all of us to serve a larger cause than ourselves and to make a difference.  It is certainly something I will never forget about my time working for him. It is also something I suspect the public knows very little about because it doesn't make flashy headlines.  But it does make a worthy and noble legacy.

Monday, November 30, 2009

The Poisoned Well

The Engage with Grace movement (see post below) was so impressive because it sought to bring about real and meaningful conversations about important - but difficult -- health care topics.  If we are to succeed as a nation in improving our health outcomes and lowering cost (or at least lowering the rate of cost growth), we need to get much more comfortable having these difficult conversations.  Yet, we continue to allow certain voices to poison the well, as occurred earlier this year with bogus claims of "death panels", which was followed by the immediate stripping of reasaonble provisions from reform legislation in order to avoid the topic like the plague. 

It looks like this may be happening again on another topic: whether women under 50 should get routine annual mammograms.

Wednesday, November 25, 2009

Engage with grace

One of the things all hospital lawyers have to deal with is sorting through issues surrounding family disputes over end-of-life decisions. This is never the happiest part of our job. We see the pain and sadness that often results when individuals and families chose to avoid advanced discussion about end-of-life issues.

Last Thanksgiving weekend, many bloggers participated in the first documented blog rally to promote Engage With Grace - a movement aimed at having all of us understand and communicate our end-of-life wishes.

It was a great success, with over 100 bloggers in the healthcare space and beyond participating and spreading the word. Plus, it was timed to coincide with a weekend when most of us are with the very people with whom we should be having these tough conversations - our closest friends and family.

The original mission - to get more and more people talking about their end of life wishes - hasn't changed. And in light of the the craziness, scare tactics and misinformation in Congress this year over "death panels", it is all the more important to bring sensible, clear information to this important topic.

At the heart of Engage With Grace are five questions designed to get the conversation started. We've included them at the top of this post. They're not easy questions, but they are important. Having a template like this - just five questions in plain, simple language - can deflate some of the complexity, formality and even misnomers that have sometimes surrounded the end-of-life discussion.

So with that, think about them, document them, share them.  If you want to learn more, check out David Harlow's excellent post on his blog from last year.  Wishing you and yours a holiday that's fulfilling in all the right ways.

Tuesday, November 24, 2009

The cost of doing nothing

There has been enormous focus - as there should be - on the cost of national health reform. But in order to have a meaningful debate, we must also consider the cost of no reform. Here are just a few basic facts about the status quo. Per capita spending on health care in the United States is this highest of any country in the World. But not just a little higher. It is double the spending in other industrialized countries with high standards of living. This includes Germany, Canada, France, Australia and the United Kingdom. But that's not all. Our costs are growing at a faster rate than these other countries and our health spending is a higher percentage of GDP than these other countries. In short, by any conceivable measure, we are a huge outlier compared to the rest of the planet. But surely we must be delivering better quality of care for all of this extra spending, right? Wrong. Under most standard measures of quality (except perhaps for "rescue" care), other countries are delivering far better results than we are. If we were a business, we would be on the verge of bankruptcy. And the only way a business avoids bankruptcy is to substantially reform its business. (If you are interested in two views on the economic benefit lost from not pasing health reform, see this Op Ed in the Globe from earlier this month by Linda Bilmes and Rosemary Day.

Monday, November 23, 2009

Hospital boards have work to do

Earlier this month, a survey by Harvard researchers found that the practices of hospital boards of directors can have a positive impact on the quality of care in their institutions. That's the good news. The bad news is that the survey also found that only half of all hospital boards surveyed ranked quality as one of their top priorities. And only 20% believed that the board can have a strong influence over quality.

This study should be a wake up call to all hospital boards. How a board engages and what it chooses to focus on does make a big difference. That is why the Institute for Health Care Improvement launched a "Boards on Board" initiative to get boards to focus not just on finances, but on improving the quality of care in their institutions. There is still plenty of opportunity for improvement and boards have an important role to play in helping us get there. The study appears in the journal Health Affairs and you can find it on their website. It was conducted and written by Ashish K. Jha and Arnold M. Epstein.

Sunday, November 22, 2009

The Big Cost Shift

Health care reform moved one step closer to reality last evening when the Senate attained the necessary 60 votes to begin debate. Passage is still anything but certain, but it is looking more promising than just a few short weeks ago when many wrote it off as all but dead. One remaining concern is that many in our country do not see the uninsured as "their" problem and lack sympathy because they believe the uninsured will always get care they need in an emergency room if they have a true crisis. The Obama administration and Congressional leaders have failed to clearly and directly rebut these misperceptions. For health reform to gain broader support, we need to do a much better job of getting people with insurance to understand that the plight of those without insurance is their problem too. Here is how we can do it.

Those who lack insurance do in fact show up in emergency rooms and they are taken care of. But this becomes what is known in the hospital world as uncompensated care. Hospitals are required to provide the care, but in order to survive, they must find a way -- like all businesses in similar circumstances - to cover the costs of that care. So they shift the cost of that care to private payers (the same way they do for underpayments from Medicaid and Medicare, our government programs that pay all hospitals at rates that are below their costs). They do so by negotiating higher rates from private payers. Those private payers then pass on these higher rates to employers in the form of higher premiums. And those employers then pass on those higher premiums to their employees. The result is that all employees are in fact already paying the cost of uncompensated care. It is indeed a societal problem. What's worse, when those who lack insurance seek care in the emergency room, they are doing so in the most expensive setting - so the costs are extremely high. If they had insurance, they would get preventive care (at much lower cost) and would be able to avoid those expensive ER visits and hospitalizations. That is a key reason we need health care reform.

Until the public clearly understands the big cost shift that goes on in our health care system, we will continue to struggle to gain broad support for national health reform.

Saturday, November 21, 2009


Welcome to my new blog. Ruminatio is the Latin word for rumination, which means "a musing or continued thinking on a subject." Health care is in great need of continued thinking. In this blog, I will try to stimulate thinking around ideas for improvement and innovation in health care. And my focus will be mainly on topics that are not well developed in the media or well understood by the general public. This is what I have tried to do in my writings -- for recent examples, see articles in the side bar. I hope you enjoy it and, most of all, provide your ruminations as well.