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.