posted by Ben Foss
on November 20, 2009
Today's posting is about treating people with dignity and respect.
Looking at all the press, ironically, my favorite were the blog entries that used the following words to describe our users - the blind and dyslexic as (and I am quoting here):
"THE LAZY AND INFIRM"
First, I want to say something I mean in complete earnestness: THANK YOU.
Thank you to the journalists who wrote these sorts of headlines. I am guessing that their editors thought it would generate traffic to have an edgy headline, so thank you to you too editors with this sentiment. Thank you because you voiced the thoughts of a lot of people.
Continued
posted by Eric Dishman
on November 19, 2009
I am not a breast cancer expert. Nor are the majority of you who are reading this. Nor are the hundreds of millions of Americans witnessing the media- and partisan-fed furor over the change in guidelines about breast cancer screening for women between 40 and 50 years of age. I'm pretty sure no one in Congress is a bona fide breast cancer expert. For that matter, neither are most physicians or nurses. And I'm willing to bet that most, if not all, of the news and radio personalities pontificating and practicing "armchair medicine" about breast cancer on the airwaves are untrained in advanced oncology or health outcomes research. Which is why someone--in this case the committee of actual breast cancer experts convened by the U.S. Preventive Services Task Force (USPSTF)--has to take on the challenge of researching, analyzing, and updating recommendations for the screening of breast cancer and hundreds of other conditions, tests, and therapies.
So what's the news? Based on new studies and analysis, the USPSTF experts have updated their 2002 recommendation about when women should begin regular mammography screenings (you can read it verbatim here). Specifically, it says: "The USPSTF recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms." The AHRQ website then goes on to provide a well-reasoned explanation of the scientific and medical studies that led the committee to come to this conclusion (see here).
My non-expert reading of their report leads me to conclude that, frankly, the mammography tests for women at that age are pretty inaccurate (there is a high number of false positives), and we are putting a lot of women through tests that have high emotional and economic costs with much risk for very little reward. But the report clearly says this decision should be an "individual one" and "take patient context into account"--in other words, it doesn't prevent women and their doctors in any way from deciding to have a mammographic screening for their personal healthcare history and situation. I found this advice from the Susan Komen Breast Cancer Foundation to be a wise and reasonable response:
How should women respond to this news? Calmly. There has always been debate about whether or not to recommend routine screening mammography for women in their 40s. The focus of the debate is the balance of risks and benefits. The most important potential benefit of screening mammography is a modest reduction in breast cancer mortality. Potential risks of mammography include false-positive test results (which lead to stress and additional testing), false-negative test results (a missed cancer), and overdiagnosis. Overdiagnosis refers to the diagnosis of a cancer that will never cause health problems during the life of a patient. Overdiagnosis leads to unnecessary cancer treatment.
So if this is simply a routine update--though it does reverse the recommendation compared to 2002--based on new scientific evidence, and everyone still has the freedom to choose mammography in consultation with their doctor, how has this created such a firestorm? The problem is that these new recommendations--having emerged at a critical moment in healthcare reform as the House version has passed and as Senator Reid is launching debate of the newly minted 2000 plus page bill in the Senate--are being politicized to try to influence the controversial bills being voted upon. Sadly, I think this controversy has far less to do with cancer and care for patients and much more to do with politics and quests for power. It is much more about the "politics of proof" for how we decide which medical devices, tests, and treatments are effective and which ones really aren't worth the effort. Thus, hidden behind this debate about cancer is really a political fight about what is called Comparative Effectiveness Research (CER) and the large amount of tax-payer money to pay for it.
Comparative Effectiveness Research (CER) is a political hot potato that most people don't understand, if they have even heard of it. The stimulus package put $1.1B into the CER program (see this link for more info) with $300 million going to the Agency for Healthcare Research and Quality (from which the USPSTF that produced this breast cancer report is managed), $400 million to the National Institutes of Health, and $400 million to the Office of the Secretary of Health and Human Services to "conduct, support, or synthesize research that compares the clinical outcomes, effectiveness, and appropriateness of items, services, and procedures that are used to prevent, diagnose, or treat diseases, disorders, and other health conditions." In other words, these dollars will be used to help inform patients and providers which treatments, interventions, therapies, and clinical practices achieve the best results for people and under what care models. There is a federal coordination Council to oversee this initial stimulus investment, and the healthcare reform bills are very likely to create a nonprofit corporation and ongoing funding mechanism of $1 per patient each year from both Medicare and private plans to sustain CER for the long haul.
Anytime you start talking about sums of money this large, politics inevitably comes knocking on the door very quickly. First, there is a political tussle within the government to see which of these agencies, if any, will ultimately end up controlling the CER funds and research agenda. John Inglehart recently published an overview of the Institute of Medicine's recommendations for CER in the New England Journal of Medicine, which helps to further explain all of this and to give examples of the kinds of questions this research would pursue. Second, CER has become a partisan wedge by which some politicians claim that this will lead to government rationing and the removal of choice for patients. Third, there are some healthcare and medical industries who are resisting CER because they fear that a particular drug or medical device--particularly "higher end" or "premium" versions--may be deemed by the research to be incrementally unnecessary or ineffective when placed under this kind of comparative scrutiny. For example, does some new blockbuster pain drug really deliver improved health benefits over the "old" drug?
To me, Comparative Effectiveness continues a common-sense tradition of evidence-based medicine that uses science and clinical trials to help doctors determine which treatments provide the best options for which patients. As a patient, I'm pretty glad we're not using leeches to "cure" my flu bug anymore or exposing cancer patients I work with to dangerous and unnecessary amounts of radiation and chemotherapy like we did only a decade ago. Times change, technologies improve, researchers make new discoveries, and physicians change "best practices" based on the latest, greatest information. Yes, sometimes the experts prove to be wrong later on (and change their recommendations) and, yes, there are huge economic implications to this kind of research. But what is the alternative? To simply guess which devices work best? To continue to use outdated, ineffective, even dangerous therapies? To pay 10 or even 100 times more for some new intervention even though there is no evidence that it produces any significant improvement in health or recovery over cheaper, older alternatives? To put ourselves through often painful and emotionally-wrenching procedures when they may not even work?
Thus, some Republicans have seized upon this breast cancer controversy--and on the emotions of millions of women and families--as yet another reason to delay or stop healthcare reform, and, without most of the public even realizing it, to launch salvos on the Comparative Effectiveness programs that are already in the stimulus package. Out comes the "R" word again--"rationing"--with headline-grabbing, fear-fanning sound bites claiming that the federal government is going to do something bad to patients. I scanned six different cable channels this morning and heard the most preposterous claims from partisan pundits: from "this is the beginning of the end of Americans' freedom to choose their medical care" to "the President wants to take away early detection of cancer to save money to pay for his expensive healthcare reform bill." This kind of rhetoric that preys upon fears about cancer is immoral and, to my thinking, amounts to emotional terrorism that ends up hurting everyone in the long run.
At the same time, many Democrats have failed to seize upon this controversy as an opportunity to engage the country in very important discussions about the entitlements, expectations, and economics of healthcare. Simply put, the Administration has, once again, failed to lead on a such a complex, emotional topic, instead hiding behind technicalities, avoiding the political hot potatoes, and issuing ambiguous statements that hurt their own principles of CER and evidence-based medicine by distancing themselves from the panel's recommendation. For example, Secretary Sebelius, on almost every channel this morning and in her recent press release says:
The U.S. Preventive Task Force is an outside independent panel of doctors and scientists who make recommendations. They do not set federal policy and they don't determine what services are covered by the federal government....My message to women is simple. Mammograms have always been an important life-saving tool in the fight against breast cancer and they still are today. Keep doing what you have been doing for years -- talk to your doctor about your individual history, ask questions, and make the decision that is right for you.
Yes, a doctor should ultimately be weighing these new facts in deciding what diagnostics to put patients through. But there is no political courage or conviction in these and other statements coming from many Democrats, as if some poll numbers or focus groups have left them afraid to tackle the real, hard issues around healthcare entitlements head on.
I hope and pray the President himself will use this breast cancer controversy as a way to start a thoughtful, nuanced dialogue with the country, even it if it is hard, complex, and politically unpalatable or unpopular. We, as Americans, have to face the hard facts that we all need to change our I-deserve-every-test-in-the-book attitudes if we're going to save this country's healthcare system and economy. We simply cannot afford to perpetuate and pay for healthcare treatments, tests, and practices that don't work...or that themselves are risky without much reward...or that don't work well enough to warrant paying for them. We simply cannot afford a smorgasbord approach to all-you-can-eat healthcare; we need to put our expectations on a diet. Smart, compassionate, evidence-based rationing of healthcare resources has been--and always will be--a necessary part of the care experience unless and until money grows on trees.
In doing cancer patient advocacy for the past two decades, I can promise you that these ethical and economic dilemmas come up all the time. And that most patients are very capable--in moments of calm consultation with their families, friends, and providers--to evaluate tradeoffs between treatments and tests, effectiveness, and quality of life. If empowered and educated, we all can (and should) do our own "comparative effectiveness" studies for our own specific healthcare situations. Dealing with cancer--or any major illness--can be a terrifying experience, and in the midst of those moments of panic about suffering or death, it's easy to embrace the notion that we want to be treated by "any means necessary" and to live "at any cost." But we have to balance those emotions and entitlements with the evidence and economics of care. And the sooner we, as a nation, can start to have a healthy dialogue about these hard, personal issues, the better off we will be. It's hard to imagine healthcare reform producing any meaningful result if we don't.
posted by Eric Dishman
on November 13, 2009
"Janice" is dreading her 65th birthday next month, and not for the reasons you might imagine. She is actually proud to be turning 65, especially because doctors told her ten years ago that she only had a year to live. I met her in 1999 when she was first diagnosed with a rare disorder that's not really considered cancer but gets treated similarly with chemotherapy for the rest of her life. Little did they know that Janice would deny the manifest destiny of their numbers game, well outliving their most optimistic expectations. I have been helping her navigate a complex chemotherapy regimen for many years. But now we face a much more difficult dilemma: navigating her insurance situation as she fast approaches and financially needs Medicare.
But let me back up a bit. After tormenting over the decision, Janice finally took early retirement three years ago from the retail company where she had worked for two decades. She could no longer muster the energy to manage her career, her disease, and the bureaucracy of coordinating her disease. Like most people, she took COBRA insurance for the first 18 months, hemorrhaging money from her savings account, until she was forced to take money from her 401k prematurely with penalties because the "hardship paperwork" was just too complicated and time-consuming for her to figure out. (Her COBRA ran out and she had to pay exorbitant dollars for a private plan because of her pre-existing condition...which was another battle...but I don't have the energy to cover that one here today.)
We spent eight months during that COBRA period faxing, phoning, and fighting a Dilbertesque battle with her insurance company and the hospital where she was being treated. Janice, on the advice from her doctor, wanted to receive two chemotherapy treatments per week through infusion in her home (costing $213 per episode) instead of having to find rides for the fifty minute pilgrimage to the hospital (costing over $2000 per episode for the same bag of IV fluids). Even though the hospital had a home health and infusion division... even though Janice's condition could safely and effectively be treated in her own home...even though it was 1/10th the cost to get that treatment at home compared to the hospital...and even though an open IV port for Janice puts her at even more risk of picking up a dangerous and expensive-to-treat infection (or now H1N1) every time she visits the hospital...the company refused to let her have treatment at home because "home care is only available to frail seniors over the age of 65." Simply put, she wasn't sick enough or old enough yet for the safer, cheaper course of treatment.
Those months were an exercise in finger-pointing futility and frustration, as each department blamed the ridiculousness of the situation (no one could argue with the fact that it was safer, cheaper, and better for Janice to receive treatment at home) on every other department, on Medicare, on state regulations, on patient privacy rules, on liability insurance, even on some obscure fire code (we never understood that one). Everyone defaulted to "no" from the start. Everyone claimed "I don't have the power to fix this problem." Everyone blamed "the system" that they were somehow absolving themselves from being a part of. Eventually, a lawyer friend of one of my co-workers got involved, we bugged the CEO of the hospital endlessly, and we convinced a doctor to convince a panel of administrators that Janice was not likely to live much longer anyway. We got approval for Janice to get chemotherapy infusion at home.
. . . . . . . . . . . . . . .
Now it is November 2009 and healthcare reform is in the (hot) air. Janice is weeks away from the miracle of her 65th birthday, which she has been eager to celebrate for years because she can finally stop the steady flow of her 401k dollars to her private insurance plan. But a few months ago, her eagerness transformed into hopelessness. We began delving into the impenetrable maze of Medicare plans and terms, while Janice also started preparing for a big birthday bash for herself with friends and family in her Idaho home town. After much investigation and department-to-department shuffling all over again, Janice found out that Medicare was not willing to let her continue her chemotherapy at home. She would have to get treatment at a hospital or a nursing home--again, at far greater cost, risk, and hassle. One of the Medicare folks actually told her: "You're too sick but also too young and capable to get home care." Simply put, she was now too sick but still not old and frail enough for the safer, cheaper course of treatment.
In all the moments of bad news these 10 long years--her diagnosis, the death of her husband, the advancement of her disease, the bouts of painful side effects, the battle with her private insurance company, the fight over her preexisting condition--I have never seen Janice face such despair. I think she was almost serious when she asked me to take a hammer to her knees to cripple her enough to be eligible for home based care. And she said to me only days ago something I've heard from so many seriously, chronically ill patients before: "It's not the disease I can't handle; it's the healthcare system I can't survive."
And then she sent me the following words to put verbatim into this blog: "I'm not asking for help or a hand out from anyone. I've got a good support network, and I'll figure this problem out, too, like all the others. But wake up out there! Medicare may not be the Holy Grail you are hoping for. Do your homework early and often--and well before you turn 65! Because common sense in healthcare is quite uncommon."
. . . . . . . . . . . . . . .
So wouldn't you think Janice's predicament would be something that healthcare reform is trying to fix? Well, think again. While the ink isn't final or dry on the healthcare reform bills, so far Congress is mostly going the wrong way on home-based care for things like infusion of chemotherapy, home dialysis, getting medical durable equipment to the home, or providing home care for seniors and seriously ill chronic patients. While I've been out trying to make the case for even more home-based care using technologies for remote patient monitoring and independent living, the traditional home care industries have been under attack. Medicare is reducing reimbursement rates to the point that many small and medium-sized home care organizations will be forced out of business. The last thing I want to do is to inadvertently wipe out traditional home care as we make way for new kinds of care technologies and services in the home. We ought to be building upon that foundation and tradition instead of chipping away at it!
When home care is often cheaper, more effective, safer, and much preferred by patients, why is it under threat? I don't entirely know. In part, because of rare instances of fraud and abuse by a few bad apple home care companies, some in Congress, CMS, and the Congressional Budget Office are over-reacting...are throwing the baby out with the bathwater. In part, it is due to a false impression that quality cannot be proven and measured in home care encounters as well as it can be in clinical encounters. Other detractors use a chicken-and-egg argument that there is not enough "evidence" that home-based care works, but, when you try to get funding to create that evidence, they use the very lack of evidence as a means of not funding the studies because home care is such a small niche. And I suspect, in part, the pushback on home care is due to perversities in the system that may make it easier for plans to get reimbursed for hospital visits than home visits.
But as I, and many of my colleagues from dozens of organizations, work these issues on the Hill, there is another more troubling reason why home based care is under threat. The infinite loop of finger pointing by different government agencies means most everyone is reticent to take up the charge, even if they believe in the power and effectiveness of home care. Each Congressional committee we go to says, "Sorry, not our area of focus" and points us to another committee. While there a few exceptions, this fragmentation of responsibility and accountability occurs as you literally traverse office by office with each of them pointing you to the next door down the hallway with an implied or explicit "not my problem." And now those hallways are filled with whispers and finger-pointing to another culprit: the Congressional Budget Office, or the "CBO," for short. As one staffer put it to me, "Home care can't pass the score-ability sniff test." I've heard this refrain dozens of times--and more and more recently as the reform bills near fruition. Somehow score-ability has become more important than care-ability of patients.
I'm not an expert in federal budgets, the CBO, or CMS...but I am an expert in human behavior. And it doesn't take a social science degree to see that people--even powerful policy makers--are living in fear of the power of the CBO--as they work on healthcare reform legislation. And it doesn't take powerful observational skills to see that people--even powerful policy makers--are now scapegoating the CBO as the catch-all excuse for refusing to move forward on legislation that their constituents are advocating for. And it doesn't take an advanced degree in economics to know there is something strange afoot when an accounting organization isn't willing to comprehend the risk/reward ratio and ROI of treating someone for $200 per day at home instead of $2000 per day at a hospital. It is the infinite loop of finger-pointing by an un-interoperable government....agency by agency....department by department...committee by committee...looping from Congress to CMS to the CBO and back again...that often keeps us going nowhere.
. . . . . . . . . . . . . . .
I may not understand all of the reasons, nuances, and history of these issues deeply enough. I probably don't. But I do understand, very deeply, that day after day people like Janice are needlessly suffering--and that we are wasting billions of healthcare dollars--because of the unquestioned bureaucracies that we all tolerate, and thus, perpetuate. There is no doubt that the majority of people in Congress, in CMS, in the CBO, and in any other government acronym you can list here, are good people doing the best they can within the positions and policies they have inherited. But there is also no doubt that good people end up doing bad things to patients when administrators or policy makers hide behind finger-pointing, that's-just-the-way-it-is, and not-my-departmentalism.
I hear lots of talk from Congressional members lately who lament that these healthcare reform bills will put bureaucrats in charge of care decisions instead of the patient making common sense decisions in consultation with his or her providers. Ask Janice and the doctor who prescribed her chemotherapy at home--and the millions of patients and doctors like them who are caught up in the infinite loops of these bureaucracies--who is really making the care decisions today. From my many perspectives--patient, patient advocate, policy advocate, researcher, innovator--we could all use a healthy dose of common sense, creative compassion, and a commitment to truly putting patients--not bureaucratic processes and procedures--first.
Meanwhile...Happy Birthday, Janice! And thanks for letting me share your story. I'll call you tomorrow to work with you some more on your insurance plan. Hang on--they're promising healthcare reform is on the way!
posted by Ben Foss
on November 10, 2009
I am so proud of the team that put the Intel® Reader together, and as someone who has difficulty reading standard print myself, I am very excited to see it entering the market. I filed the first patents on this technology a number of years ago and am thrilled to see the results of the hundreds of people who have worked so hard to make this Intel branded product possible. As the director of access technology in the Digital Health Group at Intel, I would like to tell you my personal thoughts on this introduction.
The Intel Reader is a mobile handheld device designed to increase independence for people who have learning disabilities such as dyslexia, or have low-vision, blindness or for anyone who struggles with reading standard print. It is going to be a great tool for people like me who have difficulty with text. I am dyslexic and was in special education throughout elementary school. When I was growing up, my 'reading technology' was my mom and my 'accommodation specialist' was my dad. I, like most students, was tested on my ability to learn to read, and I failed miserably.
Continued
posted by Eric Dishman
on November 03, 2009
What will it take to get our nation to prepare for the Age Wave and the chronic disease epidemic that is already here? What do we have to do to make home-based care a fundamental priority for government, healthcare, and industry? And if we're not going to drive care to the home and to the consumer in this round of healthcare reform, when exactly will we get to it?
Maybe you can tell I'm feeling a little impatient and impertinent.
For the past 18 months (indeed for the past 18 years!), I have enlisted in a campaign to change our ways of thinking about healthcare and long term care. In the early 1990s, while working for Paul Allen's think-tank, Interval Research, we did a project called "ElderSpace" that showed great promise to use technologies to help improve nursing homes--or even better, to help people to age-in-place from their own homes. And for the past 10 years at Intel, we've done pilot after pilot of home-based technologies that show enormous promise for helping seniors to live with comfort, independence, and dignity from wherever they choose, even in the midst of chronic conditions and injuries that often emerge as we grow older.
While we've won small battles here and there, we've continued to lose the war to an army of stubborn assumptions and cultural expectations that healthcare has to be done in institutions like hospitals and care facilities, instead of homes and neighborhoods. Trip after trip to D.C., speech after speech to every association that will listen, meeting after meeting with members of Congress, I hear the same old tunes: "we need to focus on the doctors and the hospitals first"...or "let's maybe do a small pilot of home based care"...or "we'll get to that idea at some point in the future." And I watch the debate and important legislative agendas get hijacked by public options, Congressional Budget Office scores, and whatever headlined hot topic can raise ratings and the national blood pressure for a news cycle or two.
No, no, NO! No more delays or distractions! No more blue ribbon commissions, 10-year studies, "small pilots," or rainchecks to get to this topic some other day. The time is now. The need is now. The opportunity is now. And we need leadership to reinvent our care paradigm, not excuses, avoidance, and obfuscation. We need a revolutionary war for independence from clinic-centric care models--a clean break from our 200 year old hospital-centric tradition--that gives us new ideas, new freedoms, and new opportunities. Okay, okay, maybe I'm overdoing it here...maybe that's too strong of a metaphor...but after so many years in the trenches on this issue and getting the run-around or outright silence, some loud and revolutionary language may be in order!
But there is some small progress--some reason for hope.
Back in May, Senator Ron Wyden of Oregon and Congressman Ed Markey of Massachusetts introduced the Independence at Home Act (S.1131) as amendments to healthcare reform legislation in the Senate and House. The Independence At Home Act has now been included in the recently combined version of the House bill (the 1990-page version that I am still trying to wade through) which is rumored to hit the floor for a vote as early as Saturday, if the Congressional Budget Office scoring comes in soon.
You can read the full text of the bill and track its progress at the Govtrack site. The American Academy of Home Care Physicians has a summary here. And I also like the American Academy of Nurse Practitioners summary located here. But the gist of this act, as its name suggests, is that it assumes the home as the primary locus of care from the outset for Medicare patients who are dealing with multiple chronic conditions. It rewards coordinated, interdisciplinary care teams for delivering high quality care in the home to some of the most frail, vulnerable, and expensive patients in our system. The bad news is that the Act has been reduced from its original version to only do this as a Medicare demonstration pilot in 13 states (more pilots!), but the good news is that there are mechanisms to continue and scale up the model if it delivers upon the promise of high quality care at lower costs. Most important to me is that it provides care for seniors and chronic disease patients from the comfort of their own homes, where they have the best chances at remaining independent, recovering from illness, being free from infection, avoiding additional hospitalizations, and having social support from friends and family in the community.
So I am cautiously optimistic. On the one hand, 18 years of this fight has made me a little jaded because the final bill, with all of the details to be ironed out, has not been voted upon and signed yet. And our clinic-centric mentality has proven to be a strong gravity from which our culture has yet to reach escape velocity. But on the other hand, Independence at Home has so many of the most important, game-changing elements of healthcare reform that we really need to make happen nationwide: care coordination, interdisciplinary care, payment for outcomes, cost savings, quality improvements, and a focus on the home as a key place for care delivery. And with examples that already show its effectiveness (the Veteran's Administration has been doing a similar model with their Home Based Primary Care program for years--which I will blog about soon), Independence at Home, while a small step on the healthcare reform journey, may end up being a huge step for humankind.
So send your impatient and impertinent cards, letters, and emails to your Congressional members and tell them to keep Independence at Home alive and well in the health reform bill...and to make home based care a national priority now, not later. Our swiftly aging planet needs it.
posted by Eric Dishman
on October 30, 2009
Okay, TED MED 2009, after a 5-year hiatus for this conference series, is now over....and I, for one, am glad the conference is back. I'm mentally exhausted as I force myself to pound out these thoughts on the flight back to Portland. The Thursday and Friday sessions brought forth different messages and perspectives about healthcare, and I realize that part of the magic of the event is the juxtaposition of so many aspects of healthcare next to one another. One minute, it is tissue engineering, the next minute is robotics, next is prosthetics, then behavior change, then medical visualization, then consumer health technologies like the cell phone and telehealth, then stem cells, then personalized genomics. It's part of the reason that it's so important for participants to stay for the whole event (and thankfully, most of them...even the "stars"...do). You need to experience the systemic view that TED MED ultimately gives you by journeying to so many different healthcare places over four jam-packed days.
One of the things I really like about TED MED is that the "e" in TED stands for "entertainment," and the theme of this particular conference was around "story." The juxtaposition of amazing breakthroughs in cancer research (with deeply technical talks that I could only admire from a surface level understanding) next to great song, poetry, and passionate story-telling challenged both mind and heart. Performer Sekou Andrews opened the conference on Tuesday with a vibrant performance piece that somehow synthesized and foreshadowed the titles and concepts for almost all of the talks we would see over the course of the week. Eric Mead and David Blaine doing magic tricks on stage and around the event was not only fun but evinced an undercurrent of mystery and questioning-of-your-beliefs that helped undercut the seriousness and surety of the science. Dave Stewart came up on stage yesterday with a fabulous singer and violinist who played the song they wrote for the "Stand Up for Cancer" campaign, as well as his classic "Here Comes the Rain Again." And there were great songs throughout all the days from singer, song-writer Jill Sobule.
Here were some of my other highlights and impressions from the rest of the meeting:
· Dean Ornish and Deepak Chopra had an interesting dialogue about prevention, behavior change, mindfulness, and other "low tech" ways to better manage health, which was a refreshing counterpoint to all the "high tech" interventions the day before. Dean's comments that healthcare reform is too focused on payment and too little on chronic disease prevention, even reversal, was music to my ears. He showed data about how lifestyle changes--more than just diet--can actually reverse heart disease, even contribute to slowing the progression of prostate cancer and the reduction of PSA numbers.
· Deepak, whose comic timing and wit on stage must rival any of the major comedians on late night television, talked about having to change our "memes" (ideas that replicate) beyond traditional models of medical care. He talked a lot about how we have to use "cyberspace" like Twitter and social media to reach critical mass on messaging about very different notions of healthcare. Both of them gave evidence that "genes are our predisposition but not our fate," and that lifestyle, attitude, and meditation can directly affect how long we live and our disease states. Deepak gave compelling evidence that the real epidemics on our hands are depression, loneliness, and isolation (he said we are 3 to 7 times more likely to die if socially isolated)...that isolation is at the root of our suffering and illness. Really made me feel like so much of the work we've focused on at Intel around building Social Health and community through new technologies will be a game-changer some day.
· Peter Diamandis, head of the X-Prize foundation, announced the five 10,000 patient cohorts they will fund with Wellpoint with the goal of having three-year innovations/interventions that can measurably improve community health. I love this. Rapid innovation. Measurable. Results oriented. On a large scale. We need more of this.
· Andrew Weil gave a talk on Integrative Medicine, with two opening points that really resonated with me: 1) that we only give lip service to health promotion and prevention because all of our industry is focused on disease treatment; and 2) that our interventions have come to depend on increasingly expensive technologies. Hey, I work for a "high tech" company, but so many of the pilots of personal health technologies Intel has done are simple, inexpensive, "low hanging fruit" opportunities to do disease prevention, early detection, or behavior change with the broadband, PCs, cell phones, and home sensor nets we've already got. It does seem that we, as a culture, are addicted to the expensive and complex, and dismissive of the simple and affordable. It's almost as if we don't believe we are getting good care unless it is expensive, complex, and high tech.
· Dean Kamen gave what was probably my favorite talk of the week. He stood simply, almost uncomfortably, on the side edge of the stage. And, in a calm, almost imperceptible voice, told amazing stories about building robotic prosthetics for veterans who were returning from Iraq and Afghanistan with leg and arm amputations. The stories, the videos of these amazing machines that they engineered in record time, and the results of seeing these amazing veterans wearing these things to feed themselves a grape or spoon full of cereal...were, simply, astounding. Dean's entire presentation made me question the way we fund and do science in the United States. If every researcher was presented with real-world needs, deadlines, and high expectations to drive useful, usable results, we would advance the basic science and the impact so much faster.
· Rick Satava gave a whirlwind prediction of "what's next?" for the frontiers of medicine. But first, he began with something I think was even more important, though not as sexy as cool videos, demos, and images of high tech gadgets of the future. He began with a compelling critique of the scientific method. He reminded us that the scientific method needs to be kept in its place--that it is a human creation at a moment in time in history--and that we need to innovate our methods of doing science as we progress. He suggested that we're overdoing the use of "randomized clinical trials" as the means to answer a lot of our questions. I really agree with this. Much of the work on home health solutions Intel is working on are being treated, scientifically and financially, as if they are drugs being tested in drug trials. There's an unquestioned assumption that the proof required for the viability and efficacy of these new kinds of technologies should be driven by the same old scientific methods and randomized controlled trials we've been doing for decades now. We need to innovate the scientific methods and measurables, as much as the technologies themselves.
· Sanjay Gupta shared powerful images and stories from his time on the front lines reporting in Iraq and Afghanistan, as well as more recently around H1N1. The most memorable moment was his description of having the army team come running to ask him to step out of his reporter role to do brain surgery on a wounded solider, and all he could find was a Black & Decker drill used to put their sand tents together to do the surgery. Wow! (The solder lived and is doing quite well now.)
· Dave Gallo & Billy Lange on the closing day showed first ever videos from robot submarines sent down to the depths of the ocean where they discovered hundreds of new life forms in places that scientists were convinced no life could survive. The camera would pan to these underwater "lakes" of toxic chemicals a couple of miles beneath sea level--with pressures unimaginable--and as the biologists would say "nothing could possibly live here," you'd see strange fish, sponges, crabs, sea spiders, and many un-namable creatures frolicking and swimming around down there. Which is to say: we don't know nearly as much as we think we know...even when all the "experts" claim that we do. Message to me: keep on questioning, keep on challenging, keep on searching. And remember that at one point the experts were absolutely convinced that the world is flat!
So why have I spent two blogs on TED MED when most people have probably never heard of it? No, I'm not getting kickbacks from the conference organizers or anything like that, but in full disclosure, Intel was a sponsor. It's because the conference challenged me, made me think, made me question what I know and what I assume about healthcare, medicine, the mind, and the body. Some of that questioning would be a good thing for all of us to take with us into our debates about healthcare reform. And some of the systemic thinking in this conference--from breakthrough ways to do diagnostics, grow organs, or personalize treatment to important reminders to drive behavior change, heal holistically, and look at the body and mind as an ecosystem that needs to be in balance--needs to become woven into the public debate about healthcare reform. After this week, even more than before, I am convinced that healthcare reform is doomed if we persist only in reforming the insurance system. There is so much more to be done...so much more to be talked about...than the public option. And many of the minds and stories in that conference room this week should be brought onto the national stage to help us transform how we treat our policies, ourselves, our minds, and our diseases. If only the whole country had the luxury and time for such a provocative and important dinner party.
posted by Eric Dishman
on October 28, 2009
I'm sitting in the historic Hotel Del Coronado in San Diego at the TED MED conference (www.tedmed.com) reflecting back on the event so far. TED MED, the brainchild of Richard Saul Wurman and currently being reinvigorated by Marc Hodosh of X-prize fame, is legendary for bringing together some of the most innovative, thoughtful pioneers of healthcare technology, media, and entertainment into one big four-day "dinner party" to learn from one another and mix people up from different disciplines and industries to solve big problems in healthcare. It has been an intellectual, social, and visual smorgasbord so far--one that has left me with a mix of emotions.
On the one hand, I have seen some amazing presentations and technologies--the learnings per second at TED MED are very high. There has been a lot of discussion of personal genomics (spit on a chip and get your genetic disposition to a range of diseases and drug therapies) and many speakers showing science-fiction like breakthroughs in tissue regeneration (replace your damaged organs with synthetically grown versions) and personalized medicine (using your own stem cells to develop catered, custom cures just for you). I won't pretend to understand all of these technically or medically, but there are cool demos and compelling visions and visualizations of cells, tissues, organs, and systems in 3D scans that we couldn't have imagined even 15 years ago. And, as always, the relationships and connections with amazing people here is the real payoff.
On the other hand, so much of what is being shown still feels to me to be reactive medicine, not proactive healthcare. It is still the "mainframe" healthcare model of hospital-based acute care that glorifies the medical experts, technologies, and institutions. While there is a lot of talk about prevention in this auditorium, most of the examples are about miraculous (and presumably expensive) technologies for repairing damage already done by disease or injury. Of all the conferences and communities, I would expect the TED MED folks to be thinking very differently about how and where healthcare delivery occurs, but even these pioneers, for the most part, are embracing the medical model of care and intervention in a mostly unquestioned way. There seems to be some small battle for the soul of what healthcare really is about, but the reigning champion is still "medicine," as perhaps symbolized by the anchoring word "MED" in the rhyming title of the conference. TED HEALTH anyone?
I suppose this is an important reminder that the medical model--the mainframe mentality--is well entrenched in our culture and will be hard to move beyond. Our curriculums, our conceptions, our R&D programs, our venture capital, our reimbursement models, our care infrastructure, and our healthcare policies are dominated by an assumption that healthcare is about medical experts fixing problems with miraculous, breakthrough, highly-engineered technologies used in a hospital or clinic. You can see this way of thinking manifest in our television dramas (there must be five new TV shows this year about hospitals or surgeons or trauma units!) that herald the high-tech and hero-ize the high priests of healthcare who perform medical miracles (and get involved in steamy love affairs on the way) each night at 8:00pm EST, 7:00 central and mountain.
Nonetheless, I am heartened by the amount of innovation, creativity, and compassion in the room at TED MED. Here are some key moments for me:
· Tony Atala showed heart stem cells beating in a petri dish. Amazing polymer scaffolding used to build synthetic muscles and blood vessels, baked in an oven like device, and then implanted in patients. Described an inkjet printer they have filled with cells, instead of ink, to "print" a synthetic bladder or kidney. Wow!
· One of my favorite moments was when Damien Bates passed around plastic containers in the audience that were filled with live skin replacement tissue they had synthesized. Wow, and yuck.
· Jack Lord from Navigenics gave a great talk about personalized genetic testing, and hidden in his talk was a comment that "the ritual of going to the doctor hasn't changed" along with our rituals of going to church. Reminds me of how long and hard it is to change culture...and that remaking our rituals of care is the real challenge.
· John Abele gave an interesting talk about collaboration. Apparently, the medical dictionary doesn't have the word "collaboration" in it, which to me shows just how challenging our healthcare reform effort around "coordinated care" is going be. We have to change the incentive structure to require collaboration--it's a shame we need laws to mandate collaboration, but we do. As John put it, "managing the divas is really important in healthcare." I loved his idea of handing out squirt guns at meetings to let people shoot anyone who is being a diva or pontificator. Watch out Intel colleagues--we're going to need bibs!
· David Agus gave one of my favorite talks, starting with the sobering fact that cancer death rates haven't changed in 50 years, while so many other diseases have made much more progress in that period. I was thrilled with his comments that we need to stop referring to cancers by what organs that have invaded and to, instead, focus on a cancer vocabulary based on how the mechanisms by which different cancers emerge and propagate. He reminded us of something that is so core to the work we are doing at Intel around remote patient monitoring in the home: "We go to the doctor once a year, which is crazy," he said, "we don't measure things dynamically." He also pushed for controlling cancer, instead of spending so much money describing it.
· Vic Strecher was one of the few people, refreshingly, who focused on changing health behaviors--an area he has done pioneering work on at the Center for Health Communications Research at the University of Michigan. Much cool work on how to tailor messaging to patients to help change and sustain behavior, and a lot of focus on "digital health coaching" which we work on at Intel and Oregon Health & Science University. This is definitely work to pay attention to.
· Martha Stewart was one of the few people to, importantly, give voice to the need to focus much more on family caregiving and care for seniors, which has been a surprisingly absent topic given the rise of "consumer healthcare" and the age wave. Somehow the conference has talked more about the gear and gadgets than the army of family members and friends who need to use those tools to care for their own loved ones. Stewart's Center for Living is really focused on finding new models of long term care, and she is soon to put out a book on caregiving which I think will bring great visibility to caregiving issues.
· Goldie Hawn gave what to me was a mesmerizing talk about working with neuroscientists to build up an "optimistic" education curriculum for kids--it is called the 'Mind Up' program--that teaches them the cognitive and life skills for better managing self reflection, relationships, and emotional resilience. They shared data about how this approach to education improved the emotional and social intelligence of the kids, which then, not surprisingly, boosted math and English skills as well. Hawn was amazingly knowledgeable, passionate, and articulate about the subject.
· Ezekiel Emanuel, an oncologist by training and brother to White House Chief of Staff, Rahm Emanuel, flew in to talk to the audience but, disappointingly, said he couldn't talk about healthcare reform. (It's kind of like bringing Michael Jordan in but saying he can't talk about basketball.) I enjoyed his critique of medical school (1. loads of memorization forced on us just seemed crazy; 2. incredibly hierarchy of medicine treated the professor as god even if they were wrong), and his frustration with healthcare being driven by tradition ("that's how we've always done it") instead of data. Not surprisingly, my favorite moment was when he mentioned my call to action to the audience to drive 50% of care out of institutions and into the home in 10 years. He said he didn't know if we could make it that far that quickly, but that the goal is worthwhile and a lot of care can and should be done at home.
· David Pogue from the New York Times gave a hilarious view of how the i-Phone could save your life, showing but a few of the apps for patients and providers out of the thousands that have emerged on the flexible, swiss-army-knife type platform that the i-Phone has become. He even sat at the piano singing a song to the tune of a Brittney Spears hit about the topic. Cracked me up. He was very entertaining, but also the disruptive implications to the things shown in his talk have not yet been internalized by the medical establishment. Times, they are a changin'!
That's all for now. Good night.
posted by Eric Dishman
on October 27, 2009
I am sitting on a plane on the way to the TED MED conference (which I plan to blog about here later in the week), scanning the USA Today, trying not to catch the flu from the woman who is clearly very ill just a row behind me. Two above-the-fold headlines caught my eye: "Pushing Hospitals to Their Limit" and "Reid to Advance Opt-Out 'Public Option.'" I saw the cable channels on the airport TVs looping feverishly on the same topic...abuzz with Senator Reid's promise that the Senate version of the healthcare reform bill will contain a "public option" but with an "opt out" mechanism for states. Whatever that means. And then there is the elusive "trigger" option that is getting air time again. Somehow that is supposed to comfort me.
You can almost see relief in the faces of the TV reporters that the public option controversy is back (or that they managed to bring it back) for a few more polarizing news cycles. Polls are apparently showing that the majority of Americans favor a public option. I've certainly seen most of my circle of friends and family on Facebook celebrating the idea. But I am confused how everyone can be so confident about a public option. I'm worried that we're being fed oversimplified, emotional bullet points in lieu of detailed proposals for how exactly this program would work. I've been working on these issues for two years now--have read all five of the Congressional bills and dozens of amendments in full--and still feel like I barely comprehend.
I have avoided talking about insurance reform in this blog for three reasons. First and foremost, I am an not an expert on this complex topic. Second, the healthcare debate has become so bogged down in the public option controversy that I didn't want to give even more time, energy, and attention to it. Third, this issue is so emotional and extreme for many people that I don't want anyone to mistakenly assume that my opinions represent any kind of official Intel position. Because they don't. What I am about to say--as with all things in this blog--are my own opinions. But since I can't seem to get the world to focus on other important reform issues, I will try to address this big elephant in my little blogosphere.
Don't get me wrong. I am in favor of everyone having access to quality healthcare--morally, economically, and from the standpoint of American competitiveness--and the idea of a public option is appealing to me. The reason I remain skeptical is because too little has been said about the implementation of a public option. The fact that the term "public option" is almost always in quotes when I read it--or modified with the words 'so-called' in front of it--is a red flag suggesting that there is no common or clear definition. Everyone seems to be quoting someone else's definition. In fact, I've been trying to understand well over half a dozen different versions of a "so-called public option" from Congressional members, and there are significant differences among them. So if no one can define the term consistently, how can so many people be "for" it or "against" it, and how can we be in such vehement debate over what is kind of, sort of, notionally, a new and important concept?
We may all be simply investing our best hopes or worst fears into the ambiguity of the "public option" concept--which is fast becoming the new litmus test for belonging or not belonging to a so-called "political party." People are also using the terms "government paid" and "government run" ambiguously and interchangeably, but those are very different phrases. Would the government both pay for and run some huge new insurance program? Or simply pay for it while some other entity--perhaps even the private market--runs it? Would we have to create an entire new government department from scratch to run the public option? Or would this be housed in the Department of Health & Human Services, already the largest part of the federal budget? Some lawmakers are now calling the public option "Medicare Part E" for "Medicare for Everyone"--so does this mean Medicare, one of the largest, most painfully slow, un-innovative government bureaucracies in existence, would become much bigger and slower or the prototype for solving all of our healthcare problems? Really?
I know there are lots of plausible answers to the kinds of questions I asked above...but what is the proposed answer actually being voted upon in the end? That's the version of the public option that I want to evaluate before making up my mind. But getting that level of detail has been difficult because so much of the negotiation in Congress about the public option has been anything but public. Oh, I've already complained about too much media attention on the topic, but that's only been surface level analysis. Our elected leaders have been holding their cards so close to their chests in closed-door committee meetings that many Senators and House members themselves have expressed public frustration that they aren't being given access to the details of these plans. We need more information on the "so-called public option" to be informed citizens.
It comes down to this for me: we need a hybrid insurance system that maintains fair competition and checks & balances between Big Government and Big Business to pay for--and run--our health plans. I believe that a government-only or a business-only system would hurt us all...that the tension between the two is what can produce a system that can be both universally accessible and continuously innovative.
We already have a Big Government system called Medicare--the largest insurer in the nation--that has its strengths and weaknesses but it is hardly a utopian cure-all for covering the uninsured or bringing down healthcare costs. It's as easy to drum up anger and horror stories about Medicare as it is about those "big, evil insurance corporations." Ask a lot of folks who are nearing the magic 65-year-old mark if Medicare is everything they want it to be. You will get an ear full about how complicated and confusing the system is, how it doesn't cover a lot of the things their private plan did when they were working full time, how they had to give up their doctor of twenty years because he or she didn't accept Medicare any longer, and how they have been denied services and free choice. As Medicare sets the (slow) pace of innovation and many of the (under) reimbursement policies/amounts for the private insurance marketplace, it needs much reform and rethinking itself before we use it either to run--or as a template for--the public option. But Medicare is also a literal life saver for millions and millions of people--and there are great programs and people in the system who do amazing things in spite of problems and abuses that inevitably occur.
So, too, we already have a Big Business system with the private and employer-driven insurance markets that consist of big and small, for-profit and not-for-profit, organizations that, in their collective, form another huge, confusing, and frustrating bureaucracy for everyone from clinicians to consumers to navigate. There is no doubt the time has come for reform of this system as well. The profit motive--especially with short sighted quarter by quarter thinking instead of long term ROI analysis--means abuses can and do happen. I don't like big bonuses for insurance company executives, either, and the games that some of them play to deny coverage for pre-existing or emergent conditions are unforgivably horrible. But the private insurance system is also a literal life saver for millions and millions of people--and there are great programs and people in the system who do amazing things in spite of problems and abuses that inevitably occur.
So whatever form an additional "public option" takes, if it ends up happening at all, it should strive to maintain a healthy tension between the stabilizing force of the social safety net that a government run system provides with the innovating force of the services competition that a market-run system provides. I'm looking for a hybrid insurance system that does four things:
1) Covers everyone and every condition
2) Deals with costs by reinventing how care is delivered, delegated, and paid for
3) Drives checks and balances between market power and government power
4) And promotes fair competition and innovation within and between the two
Both systems need adequate oversight/regulation and more focus on prevention. And they both must radically transform where care is delivered (the home whenever possible), who takes responsibility for health (patients themselves in partnership with professional and informal caregivers), how clinicians practice medicine (via coordinated care teams, with a medical home champion overseeing all care with common sense scrutiny), and how clinicians are paid and incentivized (based upon quality outcomes instead of quantity of visits, procedures, or tests given).
So there. I've done it. I've uttered the "PO" words in this blog. And I've come to the conclusion that I can't come to a conclusion yet. We need more details. We need to be more questioning. We need to strive for balance in all things. And we need to be able to move on beyond the "public option" controversy to start to deal with that other headline making my newspaper today: finding ways to stop pushing hospitals to their limits. Now that's something I can really hold forth about. I want to give the public another option: the option of getting health care at home.
posted by Eric Dishman
on October 16, 2009
Anyone working on healthcare reform should spend some time observing how a great long term care provider does their job. Long term care providers already think and act in ways that the rest of the healthcare system needs to adopt in a post-reform world. But I suspect the wisdom of long term care is not being brought to bear in the debates on healthcare reform. As our national attention span always gravitates to hospital and acute care settings when we think "healthcare," long term care is rarely given a seat at the strategy table, is often relegated to an "afterthought" discussion, and is even dismissed by many as "not real healthcare." This is especially sad and ironic given that one of the biggest issues for healthcare reform in terms of the cost/quality issue is how to care for seniors differently and better in the midst of the age wave and needed changes to Medicare.
In my job, I spend a lot of time with long term care providers of all kinds. Sometimes doing formal fieldwork in assisted living facilities and CCRCs. Sometimes working on policy issues around Medicare and Medicaid. Sometimes just calling providers up to learn from them about their needs and the needs of seniors and families. Today, I had the pleasure of speaking to--and learning from--the leadership conference of the Oregon Alliance of Senior & Health Services (http://www.oashs.org/), a group of not-for-profit long term care and senior service providers in my home state. These are the people who serve on the front lines of caring for our parents and grandparents when we can no longer manage that care ourselves--often with little pay or appreciation or respect--but with lots of quality and compassion and commitment. (In fact, I am writing this in the car on the way home from the conference...but don't worry...Ashley is doing the driving!)
And here is why I told them that the rest of the healthcare continuum should be paying more attention to how they, as long term care providers, view the world:
1) Quality First: The majority of long term care providers operate from a principled and heartfelt passion of delivering quality care for the seniors they love. No one goes into this business (and most of them don't like to think of it as a business) to get rich, but because they are enriched by serving seniors. This industry has many of its roots in faith-based missions, where quality and compassion supersede ROI and the business of care. I'm not claiming some utopia wherein these providers don't struggle with hard financial and business issues every day, but they know how to strive and drive for quality because it is foundational in their orientation to care.
2) Holistic Orientation: Long term care providers have to care for all of the life needs of their elder residents--sometimes for decades for an individual. From addressing basic needs like housing and nutrition to healthcare needs like medications and disease management and mental health to high level needs like social engagement, entertainment, education, and spirituality for their residents, long term care providers already think and act in holistic ways that the rest of the healthcare system is struggling to deal with. The current medical home movement and the push for someone to act as a primary care "champion" for patients across all the specialists they see is something that long term care providers have been doing naturally for decades. This holistic orientation is a strategic advantage for them in a post-reform world.
3) Continuum Thinking: You can see many sectors in healthcare starting to realize that they must diversify their services and revenue streams in order to survive--that they need to serve more parts of the continuum of care with their clinical and campus assets. Again, long term care is ahead of the rest of the pack--in fact, we have them to thank for the notion of a "continuum of care" as those providers came to realize that they needed to diversify their services from just nursing homes to many other "flavors" of care: assisted living, adult day and foster care, independent living, continuing care retirement centers, and more. Long term care has already diversified its knowledge and service delivery capacity, much as many other healthcare sectors will need to do in a world that pays more for quality and outcomes instead of just the number of face-to-face visits.
4) Care Coordination: One of the hottest topics in healthcare reform--and a core tenant of the Obama administration for reform--is that we have to do a better job on the coordination of care. This relates to #2 above. Long term care providers already routinely practice as coordinated care teams by virtue of the holistic care they provide. In fact, they can't operate without care coordination. Other parts of healthcare would do well to see how long term care does this so successfully--as well as learn from the mistakes that long term care has made--as they try to coordinate care across locations, departments, and needs for a resident whose needs change dramatically over the years.
5) Value over Volume: Perhaps the most radical part of the Senate and House bills in consideration is the shift of payment for healthcare from the volume of face-to-face visits to so-called "bundled payments" or "value over volume" or "quality over quantity." While these payment paradigms may be troubling and new to physician groups or nurses or hospitals, this is already "old hat" for long term care providers who are most often paid in "bundles" (small bundles, if we are honest with ourselves) and then have to figure out how to manage quality care that isn't based on # of visits but on outcomes.
6) Incorporating Family and Friends: The long term care community--again, by virtue of the kind of care it delivers--has long found ways to incorporate family members and informal caregivers into the mix of their services. They realize that it if they are to be successful in their mission of quality care, they have to "recruit" this informal care workforce into the care team. Families come into their facilities expecting to know what is going on--and, since those families are often paying out of pocket for some or all of these care services, they demand "transparency" and "quality" at every turn.
7) Home Orientation: Lastly, and it should be no surprise to anyone who has read much of what I have posted on this blog, I want to celebrate the fact that long term care providers have a "home" orientation in their care. It is their job to create a home for their residents--whether in an independent living apartment or a skilled nursing facility. And many pioneers in long term care are already exploring how to use technologies to deliver their care services virtually and to the traditional homes of their residents. These providers "get it" that the future of healthcare in America is to move care capacity, services, and expertise into the community and into the home--not to leave all of that "locked up" in a campus that someone has to travel or move to. This is not to say that long term care facilities will or should go away--only that they will add even more nodes to the continuum of care in which they serve.
. . . . . . . . . . . . . . . .
Long term care today is very different than it was even 10 years ago. It is an industry that began reforming itself because of its quest for quality, its heritage in faith based compassion, and its need to adapt to the demands of changing demographics. And they are in the midst of reforming themselves again as they contemplate what it means to serve Baby Boomers, who will likely be a very different kind of "senior" than those of the past. But I believe long term care providers still live under a false, antiquated stigma of "nursing home" horror stories that are fodder for sensational news sound bites but are the rare exception, not the norm. In many ways, our cultural imagination and assumptions about long term care have not caught up with the realities of what is really offered today.
I don't mean to suggest that long term care providers don't have problems, don't make mistakes, or that they have all of the answers for healthcare reform. And in full disclosure: I work side by side with many long term care organizations from non-profit boards I sit on to my commitment to CAST (www.agingtech.org) and its parent, the American Association of Homes and Services for the Aging (www.aahsa.org). But the reason I choose to spend my time with these long term care folks--aside from the fact that they are wonderful, fun, compassionate people--is that they offer a glimpse of what healthcare reform must ultimately accomplish: better quality care, at lower cost, with holistic, coordinated care in the home becoming the norm. We should not relegate long term care to an afterthought in our national strategy for healthcare reform. We should learn from the wisdom of those who care for our elders. They--and the seniors they serve--are at the heart of our grand challenge to reinvent care as we know it.
posted by Eric Dishman
on October 12, 2009
Ah, here we go again: more lobbing of scary statistics into the healthcare debate and more lobbying of the American people through sensationalizing headlines. We've got all the makings of another high political drama in front of us: Republicans Versus Democrats, Insurance Companies Versus Everyday People, Good Versus Evil. If only life were so simple. I've been somewhat surprised by more than 100 people emailing me today asking some version of: "Will that study everyone's talking about kill the healthcare reform bill?" To answer simply: I don't think so, and I certainly hope not. And I believe that, like all of the other manufactured controversies provided for our viewing pleasure, this too shall pass.
That study everyone's talking about--or at least that the media is using as a means to turn otherwise boring policy debates into the latest conflict of the American Partisan Wars reality TV show--is a report put out by America's Health Insurance Plans (AHIP) that was prepared by PricewaterhouseCoopers. I just read the whole thing. No, I didn't understand it all. And, no, the world didn't end. But I got the gist of it.
On the one hand, the timing of this report from AHIP is suspicious on the eve of the Senate finance vote. On the other hand, there are also some very valid concerns and issues in the report about the weak individual mandate in the Senate finance bill that would likely lead many people to game the system. There is a very real risk of many folks just paying the small fine for not being insured until they get really sick, and then at the last minute, buying into insurance only when they need it. This flies in the face of the whole purpose of insurance, messes up the risk pool and economics, and is unfair to everyone else who plays by the rules.
It's not the report that bothers me so much as the reporting of the report by the media and politicians who are using it to elevate the national blood pressure, but not the level of discourse and understanding of these complex issues. I've seen headline after headline claiming that families would face "dire" and "dangerous" rising healthcare premiums. This is the argument being used as an emotional cudgel by many Republican Senators to beat back healthcare reform. But the report shows an average of $400 per family per year higher costs because of the legislation, assuming you believe their numbers, which, while challenging for some, is hardly potentially bankrupting for the masses. Still, many Democratic Senators are using this report to play on the too-easy anti-insurance-company sentiment that most Americans already have. Come on, this is just too easy of a target--vilifying insurance companies as all bad and greedy is hardly fair, accurate, or productive.
But it's the war language that appears in these articles and political speeches--"Opens Fire" and "Fire Back" and "Defends" and "Battles Lines" and even "Go To War"--that concerns me the most. This language just ratchets up the emotions and partisan fighting that keeps us from finding consensus and common sense. It's no wonder that a few people are erupting at town halls when we're living in a media soup of extremist rhetoric and emotion-laden language that makes us feel as if we are at war with one another. Can we declare "peace" and start acting as a country instead of a war between the parties? Is it possible to move healthcare reform forward without pitting citizen against citizen, party against party, industry against individual, and playing to our basest fears and emotions?
So on the eve of the Senate finance committee vote, I am trying to cut through the emotional ploys and war mongering mindset that surrounds us. And I am trying to keep the following three things in mind:
1) Read and Think For Ourselves: The partisan political climate is so toxic in Washington right now that you have to read everything with some suspicion. Many Republicans seem only to want to kill healthcare reform--and anything else that might make President Obama and the Dems look good--at any cost. Many Democrats seem only to want to pass a healthcare reform bill--literally at any cost, financially--just so they can declare "mission accomplished" and victory over the GOP. I'm new to this whole politics thing, so I don't know whether the current partisanship is worse than usual or about par for the course. But regardless, it's a shameful waste of human energy, intellect, and time. Each party now acts in perpetual "election battle mode" with polling, pundits, and political calculus driving decisions instead of finding consensus and common sense ideas that are good for the whole country. So...be wary...and beware what you read and hear...since the truth is most often somewhere between two hyped up extremes. We have to try to find, read, and interpret these reports and bills for ourselves, instead of relying upon pundits and politicians to tell us how to feel. Perhaps the high drama of politics is best treated as "reality TV"--entertaining fictional conflicts, if you are into that kind of thing, or else just change the channel.
2) Costs Will Likely Rise: It's hard to imagine that healthcare costs won't rise for most individuals and institutions, at least for the next several years. I don't see how you add all or many of the uninsured to the system and continue to deal with the economic impacts of the age wave without healthcare costs continuing to rise. These bills, if successful, will help to "bend the cost curve," as they say in Washington--which is to say, over time they will help reduce the rate at which healthcare costs go up. But the costs will still go up, and it's unlikely that costs will actually go down (they almost never do). It's unlikely we can achieve meaningful reform without many individuals and institutions having to pay more in the near term (and perhaps the long term). The ROI for healthcare reform will be measured in decades, not quarters, and will only begin to impact the national bottom line when we've truly adopted more preventive care, payment reform for quality over quantity, and more personal responsibility for health and wellness in our culture. These are long term investments with hopefully long term gains....which isn't very satisfactory for our instant gratification culture.
3) This Too Shall Pass: Today's brouhaha (what a fun word to write!) about the AHIP report is just another variation on a theme that has played out throughout this healthcare reform debate. This controversy, like all the others, shall pass. As the Senate finance committee votes tomorrow...and as the five versions of healthcare reform bills in Congress start to get mashed together over the next few weeks...there will be many more distractions planted and emotional buttons pushed. They, too, shall pass. And I believe that, in the end, so too, shall some version of healthcare reform pass. Even though it is hard to realize in the midst of the war mongering rhetoric that pits us against one another--that makes this reform effort feel like a battle--there is far more commonality and consensus underneath all of this hype. After all, we're all mortal, we're all aging, and we're all in need of quality healthcare. Since we, too, shall pass, it would behoove us to spend our energies leaving something meaningful behind--like a quality healthcare system--for those who come after us.
