Wednesday, November 24, 2010

Hospital Mistakes Still Happening

The New York Times today reports on a study, to be released tomorrow in the New England Journal of Medicine, that demonstrates hospitals are not making enough progress on improving patient safety.  The study was conducted over a 5 year period in 10 North Carolina hospitals.  The result is sobering:

"[I]nstead of improvements, the researchers found a high rate of problems. About 18 percent of patients were harmed by medical care, some more than once, and 63.1 percent of the injuries were judged to be preventable. Most of the problems were temporary and treatable, but some were serious, and a few — 2.4 percent — caused or contributed to a patient’s death, the study found."

You can find the story here.  Hospitals are incredibly complex places and there are no simple solutions.  But the fact remains that many of these problems are quite preventable, and far too few hospitals are employing the kind of solutions that we now know prevents these kinds of mistakes.  This study, like many others, should be another wake up call to all of us for greater vigilance in attacking this problem.

Friday, August 20, 2010

Separate Doctors from Industry

UMass Memorial Chief Medical Officer Stephen Tosi and I argue, in this Boston Globe Op Ed, that it is now time for all teaching hospitals and medical schools to place more appropriate restrictions on the relationships between physicians and the pharmaceutical and medical device industries.  We cite UMass Memorial's positive experience as a reason why these organizations have nothing to fear by doing so. 

Perhaps some might take note.  The Atlantic Wire, (which "focuses on the columnists and commentators leading the national dialogue") listed the piece as one of its 5 Best Monday columns.  See the others here

Wednesday, August 11, 2010

More on End of Life

In another great piece of writing that we have come to expect from Atul Gawande, he grapples with end of life decision making, and exposes how ill prepared our medical system is for dealing with this issue. 

"Modern medicine is good at staving off death with aggressive interventions—and bad at knowing when to focus, instead, on improving the days that terminal patients have left."
You can find the New Yorker article - entitled Letting Go - here.

Tuesday, July 13, 2010

It's Brown and Obama!

Usually my predictions are wrong.  So when I occasionally make a correct one, I must take note.  Back in February shortly after Senator Brown was elected, and then again in April (see this post for history), I predicted that Scott Brown may end up finding more common ground with President Obama than the National Republican party.  That may be turning out to be the case.  As noted in this story in today's Boston Globe, he is about to hand the President another major political victory on financial reform. 

Monday, June 21, 2010

Amazing Story

I have written before about end of life issues.  (See here for the Engage with Grace blog rally).  Nowhere have I seen a more profound story to make this all real than this one in yesterday's New York Times Sunday Magazine.  Tragic and well told, this story of a pacemaker that "broke [a] father's heart" is a must read for anyone serious about trying to better understand the incredibly difficult and painful choices that many of us will have the misfortune of having to make at some point in our lives.

Thursday, June 17, 2010

Public Support for Reform Rising

"I thought when people began to realize what was in the health care package that they would see it's a good, solid program and that would dispel some of the misinformation."
                                   -Claudia Harris, 72, of Orem, Utah, an English professor at BYU

Turns out Claudia may be right!  See this article on a new poll showing the highest level of public support since the passage of reform.

Sunday, May 30, 2010

Hubris in Health Care

Do you think it exists?  Read my piece this week in the Boston Globe Magazine and let me know what you think.

Friday, April 30, 2010

On Law Day - Support Equal Justice

Tomorrow - May 1 - is Law Day.  It is a time to momentarily reflect on the rule of law in our society.  In an "As I See It" column in today's Telegram and Gazette (link here), Joe Fournier and I advocate for support of civil legal aid - a program that provides legal assistance to low income individuals who cannot afford an attorney.  We do so through the eyes of one Worcester man who was helped enormously by the great support of the Legal Assistance Corporation of Central Massachusetts.  Please read his story.   And please do what you can to support legal aid and promote equal justice in our community.

Tuesday, April 20, 2010

Serious Reportable Events

The Massachusetts Department of Public Health just released their annual report of serious reportable events in Massachusetts hospitals.  You can see the report here.  There were 383 in total for 2009, up from 338 the year before.  The biggest increase was in pressure ulcers, but the DPH thinks this may be due to better reporting as opposed to an increase in the incident rate.  Falls continue to make up a majority of the events (52%), although they were down from last year (to read why I think falls should not be included on this list, see my October, 2009 Op-Ed here). 

In general, it looks like Massachusetts hospitals are doing better than their peers in other states.  But there were still 24 wrong side surgeries last year.  On this one, the benchmarks shouldn't matter.  There shouldn't be any.  How many commercial airplanes go to the wrong city?

Wednesday, April 14, 2010

A Blessing In Disguise?

In this post from February 4, I noted that, contrary to the conventional wisdom, we should not be "surprised if the agenda Brown ends up mucking up is not that of the President, but the national Republican Party."  It looks like that may becoming more of a reality, as Brown's snub of the Tea Party this week was just the latest in a string of moves that have frustrated his original supporters.  In this article today in Yahoo News, noting these developments, the writer ponders whether Brown has become a blessing in disguise for the Democrats.  That might be a stretch, but it is further reason not to put too much faith in "conventional wisdom."

Sunday, March 28, 2010

Dissecting the Republican Position

Let's consider:

1. The Republicans say there has been totalitarianism. It seems to me the majority ruled, as it has done since the founding of our Republic. Totalitarianism?

2. The Republicans say they have been entirely shut out of the process. But the fact is that more than 200 Republican amendments were accepted in the health reform bill as part of the process. Shut out?

3. A Republican leader predicted that the passage of the bill would be "Armageddon." That could be up there with the "Mission Accomplished" banner as one of the biggest political blunders of all time.

4. Senator Brown says it will not help Massachusetts. But the facts are that thousands of low income individuals will now be eligible for new subsidies, almost 80,000 seniors will benefit from the donut hole fix and Massachusetts will receive an extra hundreds of millions of dollars in Medicaid matching funds. It is hard to understand how one could rationally say this does not benefit Massachusetts.

5. Republicans say mandates are un-American and unconstitutional. But they were for them before they were against them. In an interesting article in today's Globe, the AP documents how the health insurance mandate began as a Republican idea in the 90's as an alternative to the Clinton plan. But when the Dems picked it up, they had to be against it.

6. And how about Romney? You'd think he would learn, as his wishy-washy position on abortion over the years could have cost him the nomination in 2008. Yet here he is, the leader who deserves enormous credit for spearheading the successful reform plan in Massachusetts -- upon which the federal plan was based - and now he opposes the federal plan and wants it repealed. How he thinks he can credibly even think about running for President, given such a disingenuous flip-flop, is beyond me.

7.  The Republicans claim this is a big government take-over and we are leading to socialized medicine.  Again, this ignores reality.  There is no public option.  The states create exchanges, simply to allow individuals who lack private insurance to gain better bargaining power in the purchase of insurance through private plans.  There is no new public plan or government take-over.  There is greater government regulation over insurance companies -- but even Republicans say they want this and the public surely does. 

8. The Republicans repeatedly say that the American people overwhelmingly are against this bill.  Yet, a Gallup poll conducted right after passage showed that 49% of Americans support the legislation and 40% do not. 

9.  Finally, the Republican strategy is now to run in the Fall on repeal of the law. Repeal?! Do they know that repealing the law requires not just taking over the majority in both houses, but actually taking over a veto-proof majority, which all experts from all sides believe is virtually impossible. And that's now their strategy?

They took a big gamble. They all voted against it. They hoped it would take down the Obama Presidency. But they lost. It didn't. And now they are left to explain how their strategy was actually in the interest of the American people, and not just a raw political scheme. They will have a tough time.

Monday, March 22, 2010

Sunday, March 21, 2010

The End In Sight!

It's hard to believe, but by the end of today we may actually have a health reform bill moving to the President's desk for signature (followed by passage in the Senate of a reconciliation bill to fix the worst parts of the Senate bill). If it happens, it will not only be a great victory for our President, who will have achieved more than any other President since 1965, but also (and more importantly) a great victory for our nation.  It's going to be close and no one is claiming victory yet.  But I knew things were looking up when I read that nuns had departed with the Catholic Church to support the legislation. 

On this, the frist full day of Spring, hope springs eternal!

Saturday, March 13, 2010

A Good Clean Joke

With all the seriousness of health reform, I thought it might be time for a good joke (courtesy of my friend Gary Lapidas). So here it is:

Two middle aged men, Art and Phil, were best friends.  And more than anything, they loved baseball.  They would often watch games together and root for their favorite team, the Boston Red Sox.  They could not imagine life without baseball.  That got them to wondering -- do they play baseball in heaven?   They would often discuss this, debating back and forth.  Finally, they decided to enter into a pact.  Whoever arrived in heaven first would promise to somehow come back and let the other know whether they play baseball in heaven. 

Years went by and they became old, but continued to enjoy baseball together.  Sadly, Art suffered a stroke and died.  Phil was forlorn but he often wondered whether his friend Art was playing baseball in heaven.  One day as Phil was having a quiet breakfast alone, Art suddenly appeared in front of him. 

"Oh my gosh, Art, is that really you?!"

"Yes it is, Phil." said Art. 

"Well, tell me, do they play baseball in heaven?" said Phil. 

"Well Phil. I have good news and bad news.  The good news is that they do play baseball in heaven."

"Oh that is wonderful Art.  And what is the bad news?"

"The bad news is that you're pitching tomorrow." 

Wednesday, March 3, 2010

Obama Should Go Further

President Obama will speak today about four proposals of Republicans that he will accept in the health reform legislation, apparently setting the groundwork for a reconciliation vote.  Unfortunately, he does not go far enough on malpractice reform.  Here is what he said, from the NYT:

"The president said he also supported providing $50 million in grants to states to help them test alternatives to the current system of resolving medical malpractice claims. But Mr. Obama stopped far short of endorsing Republican proposals to impose hard limits on damage awards in medical malpractice lawsuits."

He should go further. 

Monday, March 1, 2010

The Cost of Doing Nothing - Version II

Avid readers of this blog (all three of you!) may recall this old post of mine from November discussing the significant cost of doing nothing on health reform.  See this interesting story in the New York Times over the weekend, by the same title, and essentially making the same points. 

Thursday, February 25, 2010

The Health Care Summit: Analysis and A Way Forward

A very interesting day indeed. On the substance, both sides scored points and put forth thoughtful and credible arguments about how to move forward on health reform. Before going any further, let's stop and celebrate that point alone. How refreshing! Real dialogue and debate on meaningful issues. Sure, there was some posturing and demagoguery, but no talk of death panels (at least not that I heard) or other misinformation and distortion that has been spewed about over the past year. That alone is a big win for our country.

In the end, score it a tie on the substance. Few will be moved from their positions by the substantive arguments. But here's the interesting thing. This public debate has not been about the substance. The irony is that the public hates the bill, but likes everything in it. The debate, sadly, has been more about process and size and scope. The public is incredibly confused and, given the economic climate, quite scared about what they perceive (correctly) to be a massive change that may cost a lot of money. And that has been fully and effectively manipulated by Republicans in saying it is too big and we should start over. (It is also quite cynical because you have to be from Mars to not know that their true goal is to cause a massive failure by the President, then criticize him for wasting everyone's time and not getting anything done while he had a majority, all in the hopes of gaining seats in November).

And this leads to my reason for believing that politically, today will prove to be a huge win for the President. First, he demonstrated to the country he is serious about these issues, wants to engage in real dialogue to try to forge a compromise, and showed courage to put himself out there to the World to debate the substance of such important topics (could you imagine George W. Bush doing this?). And as usual, he was quite articulate and came across as very sincere. The public likes him and this will add greatly to his credibility on this issue. Whether or not they agree with everything that is in the bill, they will believe that he really does want to do the right thing for the country and for them (and they will likely respect and reward that, notwithstanding their concerns with the bill, in the same way the country did not like many of Bush's policies after 9-11, but nevertheless respected and rewarded him for wanting to do everything he could to protect them. I believe this is the main reason Bush won the election in 2004).

Second, the Republicans were in a bit of a bind. They have been saying all along the entire legislation is crap. Yet today they engaged in a serious debate about issues in these bills and actually reached agreement in several areas, thereby giving validity to at least certain portions of the bills. The fact is that many provisions of the bills were put in at the request of Republicans. So they have now conceded (implicitly or otherwise) that there are some substantive and serious provisions in the legislation. And given the fact that the President took the initiative to proactively reach out to them to forge a compromise, they will be under intense pressure now to actually make some compromises of their own or they will truly look like the "Party of No." Thus, no longer will they be able to effectively pursue their slash and burn agenda of dismissing and trashing the whole bill.

Now for the way forward. As I have said all along, the House should pass the Senate bill.  But here are three specific ways they should improve it. First, they should remove all of the most egregious "special deals." Even though these deals exist in all legislation, this issue has done more than anything else to infect the process and distract and outrage the public. And there is no substantive defense to most of it. It undermines the Dems efforts to try to act with integrity in the best interest of the country at large. And of course stripping the bill of these deals removes the best talking point of the Republicans. Second, the Senate should agree to other modest changes by the House to give them a "win" and allow them to claim victory in making improvements to the bill. It won't change much about the substance, but it will go a long way to making house members feel better and give them something to run on in November (i.e., "thanks to my insistence, we actually improved the bill."). 3. Finally, and this will be most controversial, the Democrats should add a serious and meaningful provision on malpractice reform. It is simply indefensible, in this age of out-of-control healthcare costs, to not take on this issue. It is true that actual malpractice costs add relatively little to the cost of health care. But defensive medicine (the practice of ordering tests and procedures for fear of being sued if you don't) adds quite a bit. And by not taking it on, you appear as if you are trying to curry favor with trial lawyers. The fact is that everyone must give their pound of flesh if we are to succeed in this effort and the failure to address this issue in such a comprehensive bill is a huge and unacceptable void.

If the Dems do these three things, they have preserved the "heart" of their comprehensive reform, which is good for the country. But they have also improved the bill, stripped it of its most insidious components, and added an issue that should have been in from the beginning. They will also being showing real compromise, which will improve public support, and they will put the Republicans in a real box. How could the Republicans ever say the Dems did not compromise in good faith when they added perhaps their number one priority (malpractice reform). This will probably result in a few Republican votes. But even if it doesn't, the Dems will gain the upper hand politically and can move to reconciliation in a far better posture to defend their actions come November. One can hope. What say you?

Wednesday, February 24, 2010

National Health Reform Will Benefit Massachusetts

See this excellent Op Ed (although I am admitedly biased) in today's Globe co-authored by UMass Memorial CEO (and my boss) John O'Brien dispelling the myth that national health reform will do nothing to benefit Massachusetts.  As he and his co-author Phil Edmundson note, it will actually do quite a bit. 

Tuesday, February 23, 2010

From Ronald Reagan to Goat

Last evening, Senator Scott Brown announced that he would join 4 other Republicans to vote with Democrats against a Republican filibuster designed to stop a vote on President Obama's jobs bill.  As I predicted in my February 4 post, Brown may end up frustrating Republicans more than the President.  I just didn't think it would happen this soon.  In this story from the LA Times, James Oliphant notes that on account of this vote, almost overnight Scott Brown "has gone from being the darling of America's conservative activists to being their goat."  Oliphant notes that many of these activists were hailing Brown to be the next Ronald Reagan who could usher in a new era of conservatism, but now only days later they have exploded into the blogosphere with this:

"Cries of "letdown," "betrayal," "sellout," and "RINO" -- "Republican in name only" -- flew around Twitter. By late Tuesday afternoon, more than 4,200 people had left comments on Brown's Facebook page, most harshly negative."

Perhaps this says something about those activists who supported Scott Brown.  But it clearly says something about Scott Brown.  It says that in this early test, he is putting his money where his mouth is and trying to be the independent voice he claimed he would be.  Let's hope it continues. 

Saturday, February 13, 2010

Congratulations Eric Schultz

Harvard Pilgrim Health Care announced Wednesday that Eric Schultz will become its next CEO, replacing Charlie Baker who left the plan to run for Governor.  Eric has served for 10 years as the CEO of Fallon Community Health Plan in Worcester.  Eric is a very good and seasoned health plan executive.  More importantly, he is a great guy and I wish him all the success in his new role.  Harvard Pilgrim is lucky to get him. 

I also want to say a word about the guy who didn't get the job: Bruce Bullen, the long-serving Harvard Pilgrim COO.  Many don't know that Bruce served as the state's Medicaid Director for 10 years and transformed that program to become one of the best in the country.  Having served briefly in that role, I have a sense of how hard it is.  But Bruce made it look easy.  He was responsible for the first federal waiver (under the Weld Administration), which served as the foundation on which health reform in the state was able to happen.  And then he went on to help Charlie turn around Harvard Pilgrim.  He is an exceptional and smart executive and I know he will go on to continued success in whatever endeavor he decides to pursue.

Thursday, February 11, 2010

Music to My Eyes

Judy Feder wrote a thoughtful story today for Kaiser Health News that makes the case - far better than I did in yesterday’s post - on why the House should vote to accept the Senate bill. It is a must-read. Her concluding remarks say it all: "But after decades of trying and failing, hoping and waiting, can anyone who truly values reform say no to this opportunity to get to work? To me, that would be unconscionable."

Wednesday, February 10, 2010

The Public Wants Health Reform

The Democrats are cowering.  They are panicking.  They are so freaked out by Scott Brown's election that they are becoming somewhat irrational and interpreting the election in the wrong way.  They think the country has lost its energy for health reform.  But they are wrong.  And if they don't figure it out soon, they will likely face very serious consequences in November.  The fact is that the public still wants health reform and they trust Democrats more than Republicans on the subject.  This has just been confirmed in a Washington Post poll.  You can find the story here.  The bottom line is that nearly two thirds of those polled (and 56% of independents!) want Congress and the President to keep working to pass health reform.  See the poll results below. 

And when it comes to which party is doing more to compromise with the other - Obama trounces the Republicans.  About half of those polled believe Obama is doing about the right amount to compromise (and the same amount felt he is doing too little).  But only 30% believe Republicans are doing the right amount and 58% believe Republicans are not doing enough.  See these results below. 

The point is that not much has changed other than an election in Massachusetts.  And even the Brown folks acknowledge that the election had as much to do with terrorism (Brown effectively used the Christmas attempted plane bombing incident and Obama's insistence on civil (and not military) trials, to stir up fears) as it did with health reform.  (For my sober analysis of the election, read here.)  The House should wake up and pass the Senate bill.  That is the quickest way of getting this done and starting down the path of meaningful reform.  The problems with the bill can and will be fixed when cooler heads prevail.  In time, the many benefits of the bill will come to light more clearly and these Dems will have something good to run on.  Keep hope alive!

Tuesday, February 9, 2010

It Takes A Village

For seniors, part of the difficulty of staying out of a nursing home is the inability to do the little things: transportation, home visits, shopping.  See this interesting story about a new concept of senior "aging-in-place" villages cropping up around the country, where volunteers support seniors with those basic needs to help them be able to stay at home.  Although still an experiment, the concept seems to be picking up steam in many places, including Boston.  Perhaps it takes a village after all.  (And if you are interested in a unique healthcare model in Massachusetts for integrating care for seniors, see my Boston Globe op ed in the side bar from 7-20-09 entitled Retooling the Medicare/Medicaid Model).

Thursday, February 4, 2010

Brown and Obama: New Best Friends?

The conventional wisdom says that Senator Brown will be that 41st vote that mucks up the President's agenda. Maybe. But conventional wisdom is often wrong. Here's why I think it might be wrong in this case. Senator Brown and President Obama have a lot in common right now. The President desperately needs to show the nation that he can get things done; as a result, he will be willing to compromise and make more deals than before Brown was elected. And Scott Brown may be just the person with whom to make a deal. Brown needs to desperately show Massachusetts voters that he is not in lock-step with the national Republican Party and he is the true independent voice he claims. Brown's reelection will come very soon (less than three years) and he knows that when the current political tsunami subsides, Massachusetts voters are still generally a very liberal lot and will not tolerate a Senator who follows the national Republican party line.  Given these political realties for both Senator Brown and President Obama (realities which will trump ideology every day of the week), don't be surprised if the agenda Brown ends up mucking up is not that of the President, but the national Republican party.

Monday, February 1, 2010

What's Up in Idaho and North Dakota?

These are the only two states not represented on a list of contributors to the campaigns of Scott Brown and Martha Coakley in the last three weeks of their campaign.  For details, see here.  Many find it surprising that residents in the other 48 states gave to one or the other of the candidates (Brown: 48 states;  Coakley: 44 states).  But with the 41st vote in the balance, it should be no surprise the election generated such national interest.  My question is what the heck is going on in Idaho and North Dakota?  Are they pathetically out-of-touch or far more evolved than the rest of us?  I am starting to lean toward the latter explanation.

Wednesday, January 27, 2010

An Independent Voice in Washington?

Scott Brown is on a three day tour of Massachusetts to thank voters for his dramatic victory last week.  Interestingly, although Republicans all over the country are talking about him, he does not talk much about Republicans.  Instead, he says his goal is to assure voters that he will be "an independent voice in Washington.”  I find that encouraging.  But it caused me to wonder:  given such talk of being independent, I wonder whether he might choose to become one?  Senators Bernie Sanders of Vermont and Joe Lieberman of Connecticut have shunned both political parties to become the two Independents in the Senate.  If Senator-elect Brown truly aspires to be the independent voice he claims, might he do the same?

Tuesday, January 26, 2010

Pass the Senate Bill

On January 20, I wrote a long-winded post providing my "sober analysis" of the Massachusetts Senate race.  My conclusion was that the only viable option on health reform is for the House to pass the Senate bill.  Yesterday, a prominent voice joined the drumbeat.  As noted in The Hill, former Senator Tom Daschle, the almost-Secretary of Health and Human Services, called on House Democrats to do the same.  “You could argue that there is just as much political downside to not to pass this than to pass this,” Daschle said.  He is right.  But more importantly, it is good policy.  As I have said before, the bill is far from perfect, but it will meet the moral imperative of covering 30 million individuals who now lack health insurance in the richest nation in the world.  And it will start us down the long and necessary road of transforming our healthcare system.  Saying "no" is easy.  And there are many naysayers.  Some say it does not do enough to bend the cost curve.  They are right.  But doing nothing is worse and will almost-certainly lead to implosion of the system.  Moreover, the bill does plant many important seeds (via PILOT programs) to start to bend that curve.  So it is a start we can build on.  The House should have the courage to say yes.  It is harder than saying no, but it will pay dividends for generations.

Monday, January 25, 2010

Primary Care Docs - A New Challenge

Primary care physicians have it tough these days. Low reimbursement, endless regulation and no time for patients. But it may be getting worse. Now they may have to worry about of meteorites! See for yourself in this video, which shows the hole left by a meteorite that crashed through the ceiling of a Virginia family practice last week, almost striking the physician. Perhaps Chicken Little had it right!

Wednesday, January 20, 2010

A Sober Analysis - What Next?

Scott Brown deserves a ton of credit. He ran a fabulous - indeed almost flawless - campaign. He pulled off a phenomenal upset and, despite my own grave concerns about his policy positions, I will give the him the full benefit of the doubt along with my support and respect as our next Senator.

So what went wrong and what does it mean for the future of health reform? The pundits are salivating over many different theories: "It is a referendum on health form." "It is a referendum on Obama." "Coakley just blew it." But like most things in politics, there is no simple or easy answer. Without taking anything away from Scott Brown, I think it boils down the following five factors :

1. It's the economy, stupid. People vote with their pocketbooks. The economy is in awful shape. Despite unfathomable amounts of government money that has been spent on a stimulus package (and even more to save the big banks - which are about to pay billions of dollars in bonuses despite it) people are still suffering. They are rightfully frustrated and angry on account of the economy and this vote in large part was an outlet for that anger.

2. All politics are local. All of the pundits are focusing on the national reasons and implications of this vote. But the fact is that there were compelling local issues that probably played a larger role. Massachusetts is not a Democratic state. It is an Independent state that usually (but not always) votes Democratic. Fifty percent of voters are independent. Massachusetts voters believe deeply in a check and balance in government, which is why they have voted for so many Republican Governors. But three years ago, they went a bit out of their comfort zone by voting for a Democratic Governor, thereby giving complete control to the Democrats and eliminating the check that normally exists. They have been greatly disappointed by doing so.  Governor Patrick has not lived up to their high expectations, the Speaker of the House had to resign and could become the fourth successive Speaker of the House to be indicted, and a state Senator is now in jail for driving drunk, leaving the scene of an accident, and then violating his probation. The public is disgusted, as they should be, and the Dems are in charge. Voting for Scott Brown was a convenient outlet for bringing back some form of the check they believe in, particularly where he was running against a Democrat who appeared at times as though she was "entitled" to the seat. 

3. Government is getting too big. TARP, bank bailouts, insurance company bailouts and now a potential health care bill that will cost almost $1 trillion. The Republican rhetoric that Obama wants to make us a socialist republic is starting to resonate. People are losing everything while government is gaining more and getting bigger. That is very scary and frustrating to most ordinary citizens and Brown was quite adept at capitalizing on this feeling. 

4. Campaign missteps. Martha Coakley probably will become the Bill Buckner of the Massachusetts Democratic party. While a tempting analogy, this is unfair and not deserved. Yes, she ran a too-safe campaign. Yes, she made some grave mistakes and did not react quickly enough (or well enough) when she needed to. But to blame this all on her is to be dishonest.  It certainly contributed, but there was much more at play.

5. National health reform. There is no question that concern over national health reform played some role in Brown's success. He campaigned hard on being that 41st vote to stop it. But notice I put this last on the list. Contrary to most conventional wisdom, I think this is the least significant factor in Brown's success. It is true that the public is getting weary of health reform and only 38% of the public approve of the job Mr. Obama is doing on the subject, according to a new Wall Street Journal poll. But here is what people overlook. As the WSJ also noted, "People are even less happy with Republicans in Congress [on the issue of health reform] with just 26% approval. . ." So the frustration and confusion over health reform does not inure to the benefit of Republicans. And it is not as if they are feeling ideologically more aligned with Republicans on this subject. I believe it is simply that they don't like the process; it feels very big; they don't understand the details; and most people do not like big change.  Moreover, because Massachusetts citizens already have health reform, most people in our state (other than those of us who live and breath it every day) just do not care enough about what happens to the rest of the country on this issue (especially when compared to the other issues noted above). 

So what should the Dems do on health reform? There are only two viable options: (1) the House accepts the Senate version; or (2) the "conference" committee (aka the Democratic leadership) tries to negotiate a watered-down, less ambitious bill that some Republicans could support. I see the first options as the only viable alternative.  Here are its advantages. It will get a bill done, which is critical to the Democrats if they are to have any hope in November. They have been in charge and spent a year on this. If they come away with nothing, they are dead. It will also get it done quickly and move it off the agenda for now. This too is critical so Obama can get to focusing on jobs and the economy, which the public cares much more about right now. This endless debate is wearing people down and they don't want to hear it anymore. It will also allow time to pass and emotions to subside so that the Dems can communicate more effectively to the public about all the good this bill will do for them and that, too, will give the Democratic House members something very good to run on in the Fall. Finally, it is less costly and less ambitious than the House bill and if there is any message to be taken by this vote yesterday, I believe it is that we need to be less aggressive rather than more aggressive on health reform.

So why not try to negotiate a watered-down bill?  It is simply too risky, the process will be further dragged out and the Republicans are not to be trusted.  They simply have too strong an interest in continuing to stall and throw bombs because they know that no bill at all will serve them better in the Fall.  But why should the House accept the Senate version given their disagreements with some provisions?  Because it is clear that is the best they will get right now.  A watered-down bill from the conference will be even further to the right of where the Senate is now (and even further from the House). The only way to get Republican support is to add things the House members will hate. So, while the House might have to hold their nose to approve the Senate bill, all other options are worse from their perspective. This will get it done.  The House should suck it up and vote for the Senate bill, which will still result in a monumental accomplishment. Some of the concerns can be fixed later, since most of it does not take place for several years. There is no perfect solution, but this is the best result under the circumstances.  Anything else gets more ugly.  The House should take this step.

Saturday, January 16, 2010

An Open Letter to Martha Coakley

Dear Martha: you followed a play-it-safe strategy. You followed the conventional wisdom -- that short of making a big mistake, it was virtually impossible under basic math principles for Scott Brown to win. It worked in the primary. So you listened to your strategists and you played it safe. Let's leave to a later day the question of whether it was reasonable for you to deploy this strategy in the first place.  For now, let's be clear on one thing: the strategy was an abysmal failure. It must change. And it must change now. 

At bottom, the public doesn't like play-it-safers. Whether or not you feel this way (and I believe you do not), it conveys a sense of entitlement. "It is my seat to lose, so I need not stoop to get into it with you on the issues," it suggests. Meanwhile, Scott Brown, whose stance on most issues is miles apart from most Massachusetts citizens, is fighting his heart out for the seat. He is showing passion and, in so doing, sending the message that he wants this much more than you.  He is winning hearts and minds. 

Voters in Massachusetts are not dumb. But they are not nearly as ideological as people think. They value the good, old fashioned Yankee tradition of hard work and grit over ideology. A demonstration of good character can make up for a lot of bad ideology. What they despise more than anything is a sense of entitlement.

Martha, here's the good news. This is still salvageable. There are three critical days left and it is plenty of time to turn things around. But here is what you must do. You can no longer go out and "not lose" this election. You must now go out and win it. To do so, you need to show us the real Martha. Throw out the playbook, stop listening to your strategists and show us your passion; show us why you want it; what inspires you to fight against domestic violence, as you have; why you care deeply for the victim; the underdog, the little guy. Show us that humor you say you have at home.  Give us a little Capuano or Hilary. Fight to earn this seat!! Show us why you share our deepest held beliefs and why you will be by far the best steward of our values in the Senate. 

Don't give us legal mumbo jumbo, or dispassionate, calm talk when discussing the amendment that Scott Brown supported, which would have allowed health care workers to opt out of providing birth control to rape victims. Tells us why it matters and what is says about Scott Brown. Explain it to us in the way that Yvonne Abraham did in the Globe this week: 

"Imagine this for a minute. You have just been brutally assaulted, and you’re traumatized. You’ve worked up the courage to go to the hospital. You’re terrified the animal who did this to you has gotten you pregnant. But the nurse who is seeing you happens to believe you should bear your rapist’s child. Now, on top of dealing with the horror of this crime, you have to work to get the care the law says you’re entitled to. Maybe you get lucky and you’re at a big hospital, and somebody else is available to give you the pill. Maybe it’s the middle of the night, and nobody else is available. Now what do you do? Start again at another hospital? What if the other hospital is miles away?"

That is what I mean by passion; by making it real. 

In closing, Martha, be assured you can still win this race and win it big. Don't panic on account of the mob mentality that is seeming to develop around you. All you need to do is stay calm, be yourself and show us your passion. Go win this race. 

Very truly yours,

Doug Brown

Thursday, January 14, 2010

Fat Is In - Should it Be?

In the Boston Globe's G magazine on Tuesday, Leah Mennies ran a story about Lesley Kinzel who is 300 pounds and proud to be fat.  Kinzel "feels free of society's obsession with the 'compulsory skinniness'" and has a fat activist blog called Fatshionista that receives 70,000 hits a month.  I applaud Mennies for bringing the story to us and Kinzel for raising public awareness of how obsessed we are with skinniness.  Such a culture is not healthy for any of us, particularly our young girls, and these efforts will help to change that.  Nevertheless, there is a part of me that is somewhat troubled with the story.  As I have noted in a prior post, obesity is a huge problem in our country and has been growing at an explosive rate.  It is causing enormous personal pain for many and it is greatly contributing to our exploding health care costs.  I don't believe it is something we should be actively encouraging.  Isn't there a middle ground between moving society away from a skinny culture, allowing people to feel good about themselves - wherever they are - and at the same time not promoting obesity?  I am curious as to other views.  As always, I am open to be corrected or educated on what I am missing.

Monday, January 11, 2010

Patient Experience at AMCs

Why aren't teaching hospitals providing a better overall experience for their patients?  That is a question I explore in an Op Ed today in the Boston Globe.  You can find it here.  The one great thing about writing Op Ed pieces is that it forces you to distill your thoughts to their true essence, since 700 words is not a lot of space.   The one great thing about blogs is that it allows you to expand upon your Op Eds!  So here are a few additional points. 

First, a few more words about Clinton Hospital.  Their performance really is remarkable, even for a small hospital.  Of the 10 patient satisfaction measures reported on (the  results of the survey questions I mention in the piece), Clinton is in the top 10 percentile in the nation on 8 of them.  I have not found a hospital anywhere that performs that well.  There may not be one.  What is their secret?  Not a magic formula.  Clinton President and CEO Sheila Daly tells me it's all about culture.  "Our staff does not know any other way.  Putting the patient first is just how it has always been here." 

Second, there has been much discussion of late about the relationship between cost and quality.  But not much about cost and experience.  A few weeks ago, the New York Times did an interesting story on end-of-life care.  It highlighted UCLA - one of the most prominent academic medical centers in the country.  UCLA has been receiving the kind of attention lately it can do without.  According to Medicare data, it is one of the most expensive hospitals in the country.  For the last six months of life, spending at UCLA is double the rate of the Mayo Clinic ($50,000 versus $25,000), with no better quality outcomes.  White House Budget Director Peter Orzag says this of the disparity: “One of them costs twice as much as the other, and I can tell you that we have no idea what we’re getting in exchange for the extra $25,000 a year at U.C.L.A. Medical.”

U.C.L.A. Chief Executive David T. Feinberg says what "we're getting" is a full court press to save lives.  “If you come into this hospital, we’re not going to let you die,” he said in the story.  But one thing we're not getting for all that extra spending is a better patient experience.  Of the 10 publicly reported patient experience measures, Clinton beats U.C.L.A. on 9 of them (and the 10th was a tie).  The U.C.L.A. scores are worse than the national average on 6 of the 10 measures (on 2 of the remaining 4, they are tied with the average).   In fairness, like many AMCs, they do beat the average on two important measures (overall rating and likelihood of recommending the hospital).  My point here is not to trash U.C.L.A -- it is a great hospital.  It is simply to demonstrate how far all AMCs still have to go in improving the patient experience.

Sunday, January 10, 2010

A Novel New Year's Resolution

Imagine if every New Year, we all had to click the "refresh" button on our  most deeply held beliefs.  We would have to look anew, with an entirely open mind, at issues we have long since closed our mind to.  Abortion foes would have to immerse themselves in understanding the complexities of choice.  Those who support choice would have to immerse themselves in understanding the moral dimensions and complexities of abortion.  If we all had to do this, would it change many minds?  Probably not.  But in enhancing a deeper understanding, I think it would greatly elevate the discourse and result in less polarizing rhetoric and more pragmatic solutions to our nation's largest challenges. 

Wednesday, January 6, 2010

This Just In - Health Spending Slows in 2008

It is a good news bad news story.  In 2008, we just learned, health spending in the United States slowed to its slowest rate in almost 50 years.  That's the good part.  The bad part is that, even at this relatively slow rate, it still amounted to $7,681 per person, the highest of any industrialized country in the World.  Click on the chart below from Kaiser Foundation to get a sense of how much higher we are than other countries (and note: this is from 2007 when we were below $7,000!).  The other bad news is that health spending  has increased as a percentage of GDP and the probable reason for the decline in 2008 is that people who have lost jobs (and insurance) are choosing to avoid or defer needed healthcare.  You can read the full Health Affairs story here

Monday, January 4, 2010

The Governance Imperative for Nonprofit Hospitals

In this month's issue of Trustee Magazine (the American Hospital Association's magazine for hospital trustees), I wrote a Viewpoint article urging nonprofit hospital boards to step up their governance and focus on promoting and improving community health.  I offer three specific ways they can start.  You can find the article here.  I include excerpts below.  I'd love to hear any views (even opposing ones) on the article and the topic. 

"Nonprofit hospitals are in the cross­hairs. With state and federal governments in need of money, and some nonprofit organizations appearing to shirk their community responsibility, many are questioning the continued wisdom of the long-standing tax exemption afforded these institutions.

These qualms are unfortunate. The nonprofit hospital sector offers an essential and unparalleled community resource. Over 2,900 hospitals in our country—almost 60 percent of the total—are nonprofit. Eliminating the tax exemption would cripple these organizations at a time when our nation most needs them. But to whom much is given, much is expected. The public expects more. And they deserve more.

* * *

Nonprofit hospitals are the heart and soul of communities. They exist not for the benefit of shareholders, but for the benefit of stakeholders who make up the community at large. They provide critical, and often unprofitable, services. For these reasons, much is at stake in this debate, and nonprofit hospitals must better demonstrate that they are worthy of continued government subsidy. Their boards would do well to step up their accountability, improve their overall governance, and remain keenly focused on the goal of promoting and improving community health."

Friday, January 1, 2010

Will Republicans Suffer the Fate of Icarus?

In Greek mythology, Icarus and his father Daedalus (an inventor) were imprisoned by King Minos of Crete. Daedalus knew that the only escape route was by air, so he used his skills to build wings - made of wax - for himself and Icarus. Daedalus warned Icarus not to overreach; for if he flew too high, the sun could melt the wax of his wings. You know the end of the story -- Icarus fell in love with flight and through his exhilaration, he ignored his father's warning and flew higher and higher. The sun melted the wax on his wings and he fell into the water and drowned.

Republicans seem to me to be getting dangerously close to the sun. In their apparent exhilaration by Obama's shrinking poll numbers and national ambivalence on health reform legislation, they have plowed full steam ahead to do everything possible to oppose national health reform. Now they are even taking the fight outside of the legislative process.  Thirteen Republican state attorneys general, led by South Carolina AG Henry McMaster, are threatening to sue the federal government over the deal that was cut with Senator Ben Nelson from Nebraska -- to fund 100% of the state's Medicaid expansions -- to secure his vote for the bill. As far as I can tell, there is no remotely-legitimate legal basis for this suit. I wonder if these attorneys general have contemplated suit when their states have been beneficiaries of numerous Congressional earmarks over the years?

I also see in a story from that the Republicans are launching an effort to repeal the bill (before it is even passed, mind you!) to curry favor in the 2010 Congressional elections.

Here's the deal. Are there legitimate things to gripe about in the bill? Absolutely. But the Republican strategy has not been to constructively discuss those issues and try to improve the bill. It has been an all out assault. Moreover, despite some concerns, at the end of the day, the American public tends to be reasonable and pragmatic. And notwithstanding some not-so-good things in the bill, any ordinary, reasonable, prudent person (a term we use in the law) cannot deny the inescapable conclusion that this bill will do a ton of good, which far outweighs the not-so-good. For crying out loud, it will provide health insurance to 31,000,000 people who do not have it today! It advances the ball on improving quality, promoting efficiency and bending the cost curve. See my prior posts (you can look at the category list under "health reform") for the many other ways this bill does good.

Perhaps the Republicans know something I do not (very likely). But I cannot help but think that through their unwavering efforts to do nothing other than try to kill the most significant advancement of social health legislation in a generation, they will be seen at the end of the day to be brazenly placing their own political interest above the national interest. Political parties - both Democrat and Republican - have a dubious history of overreaching when they feel the exhilaration of flight. It looks to me like that may be about to happen again.