Winning the War for Independence: The Independence at Home Act

posted by Eric Dishman on November 03, 2009

TED MED conclusion: Juxtaposition & Systemic Thinking at the Dinner Party

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.

Questioning the Public and the Options: Balancing Big Government & Big Business

posted by Eric Dishman on October 27, 2009

I am sitting on a plane on the way to the TEDMED 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.

NOTE:  ERIC DISHMAN'S 'HOME BLOG' PAGE HAS MOVED TO:  blogs.intel.com/healthcare. 

FEDERAL CLIMATE LEGISLATION SHOULD PROTECT AMERICAN COMPETITIVENESS AND REWARD PAST CLIMATE LEADERSHIP

posted by Stephen Harper on October 26, 2009

Earlier this summer, the House of Representatives passed the American Clean Energy and Security (ACES) Act, HR 2454, a massive bill addressing energy efficiency, green energy, and climate change, the latter through a cap-and-trade proposal. The Senate currently is considering S 1733, the American Clean Energy Jobs and American Power Act (ACEJAPA), which is mostly focused on cap-and-trade. Earlier the Senate Energy and Natural Resources Committee marked up a separate energy bill.

Intel views climate change as an important environmental and social challenge and we support development of a Federal program to respond to that challenge. As part of that response, however, we believe Congress should bear in mind two important principles: First, in deciding how cap-and-trade allowances are to be allocated among industries and programs, attention should be paid to using a significant quantity of “free” allowances to help protect US industries that are subject to significant international competition and therefore might suffer a competitive disadvantage as their US costs increase under a cap and trade program while their foreign competitors face no similar climate programs or increased costs. The bills focus mostly on industries that are energy-intensive or greenhouse gas-intensive, even if they are not very trade-intensive. By contrast, industries like semiconductors that are less energy- or greenhouse gas-intensive but very trade exposed are not eligible for allowance allocations. As the second-leading export sector in the US, the semiconductor industry is very trade-exposed. Our competitors in Asia and Europe do not face the type of climate regulations and increased costs that a Federal cap-and-trade program will impose on the US semiconductor sector. That competitive disadvantage needs to be addressed by the Senate by establishing trade exposure as a standalone criterion for allowance allocations.

Both the House and Senate bills sensibly include provisions for crediting with allowances companies that have shown prior leadership by reducing their climate emissions in advance of any regulatory requirement. Intel has spent approximately $100 million over the last decade reducing our climate emissions as part of a program between the semiconductor industry and the USEPA. Other US semiconductor companies have made significant reductions as well. The current credit for early action proposals fail in two respects. They both provide only a very small amount of allowances for crediting early action and both have very narrow criteria for qualifying for allowances. The final legislation needs to provide a bigger “pot” of allowances for this purposes and the eligibility criteria need to be broadened to encompass programs like our industry has with USEPA.

The need for a US – European Union Innovation Dialogue

posted by Christoph Luykx on October 26, 2009

The leaders of the European Union and the U.S. agreed in April 2007 to establish a Transatlantic Framework for Advancing Transatlantic Integration (the Framework) between the U.S. and the European Union. At the same time they established the Transatlantic Economic Council (TEC) to oversee these efforts and to accelerate progress and guiding work between the annual U.S. – EU summits.

The fourth meeting of the TEC will take place tomorrow, October 27th in Washington D.C. against the backdrop of a year which has seen tremendous change for both the United States and Europe. The U.S. experienced a change in political party, with a new President with an ambitious domestic agenda. Likewise, The European Union saw the election of a new European Parliament, the Irish approval of the Lisbon Treaty, and soon a new team of Commissioners under its re-elected President Barroso.

This parallel change occurring on both sides of the Atlantic presents tremendous opportunities as well as challenges for Transatlantic cooperation. And with the increasing importance of the BRIC countries, the need for such cooperation becomes even more urgent. Innovation is one area that is crucial for both the U.S. and Europe and our combined dealings with emerging economies. The Obama administration has repeatedly emphasized the importance of science, technology and innovation for the U.S. economy. It also looks likely that the new European Commission will have a specific European Commissioner dedicated to Innovation.

Given the fact that we are at an important inflection point, Intel has been very supportive of a renewed Transatlantic Innovation agenda. This would mean a restructuring of the different innovation topics under the TEC’s Framework. Such an Innovation agenda, based on a clear ownership structure, should focus on horizontal and vertical - technology specific – innovation issues, giving renewed impetus to the Transatlantic Innovation partnership.

To provide a forum for such a discussion, Intel also advocated for the creation of a Transatlantic Innovation Dialogue (TID). This would be based on the understanding that innovation is increasingly global and the challenges to promote and protect it need to be addressed holistically and globally. It looks likely that such an Innovation Dialogue will be discussed during the next TEC meeting. If approved, a cooperative effort between government and private sector stakeholders should address questions on the Dialogue’s concrete goals and governance structure.

On the goals, we think such a dialogue could focus on the exchange of experiences and best practices on science, technology, and innovation. The discussion could;

(i) identify potential synergies between different private-government innovation initiatives; (ii) examine how government policies can most effectively support (or impair) the private sector in creating innovation; and (iii) evaluate how other factors -- such as availability of venture capital, university curricula, and open markets -- contribute to an innovative climate.

Concerning the governance structure, it is of fundamental importance to the success of such a Dialogue for it to be founded on Public and Private sector cooperation. Intel therefore endorses both parties to engage in an open dialogue with all stakeholders to advance our common goals.

Intel is convinced that this dialogue could make great strides in promoting continued U.S. and EU joint leadership in science and technology and we look forward in participating in this debate and advancing our shared objectives.

Intel Whitepaper: Investing in Sustainable Broadband Adoption

posted by Margie Dickman on October 20, 2009

Intel just published a brief whitepaper titled "Investing in Sustainable Broadband Adoption": Investing in Sustainable Broadband Adoption_FINAL.pdf The paper discusses the significant broadband adoption gap in America: 96% of U.S. households have a broadband network available to them, but only 63% of those households have opted to subscribe to broadband service. Clearly, a big adoption gap.

A disproportionate number of non-adopters are low-income households and those living in rural areas. The main reasons that these Americans cite for non-adoption are the perceived lack of relevance and awareness of broadband, and the cost of acquiring broadband equipment (PCs) and broadband service. The paper explores a proposed public-private solution to close this vast adoption gap by utilizing stimulus funds for a PC-broadband bundle program targeted to low-income and other unconnected households.

The proposed program focuses on first-time residential broadband users by reducing the cost of both elements of a connected PC: the upfront equipment cost (of a full featured notebook or desktop) and the initial subscription cost for broadband service -- supported by community-based digital literacy training. Intel believes that this type of strategic public-private partnership, supported by local community involvement, will help bridge the digital divide in the U.S. and, consequently, help boost our nation's economy and competitiveness over the long-term.

What Healthcare Reform Should Learn From Long Term Care

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.

On Hype and Healthcare Reform: This Too Shall Pass

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.

Comments are welcome.  please post to: http://blogs.intel.com/healthcare/ 

Women, Boomers, and Growing a Careforce Through Healthcare Reform

posted by Eric Dishman on October 08, 2009

I’m beginning to believe that the best way to achieve true and lasting healthcare reform is to just get out of the way and let Baby Boomer women revolutionize healthcare. Baby Boomers as a cohort have been change agents for redefining the family, education, and work life, so why not healthcare as well? Boomer aged women are already—and will increasingly be—the majority on the front lines of formal and informal care. I certainly don’t mean to denigrate the role of men in healthcare or to perpetuate some kind of bio-destiny argument that women are “naturally” supposed to be the caretakers in our society. But I do think our overwhelmingly male Congress would do well to better understand the role of—and listen more to—women, who will likely be the most impacted by these health reform policies.

A quick story. About 9 years ago, during my first attempt to get Intel to see the social need and business opportunity for innovating technologies for personal and proactive healthcare, I was struggling to make much headway. The demographic and economic numbers were startling to some of the executives I approached, and the logic of my arguments made sense to them. But they didn’t seem to “get it” in their bones that there is a fundamental need for caregiving and personal health technologies at home. In one particular strategic discussion with a key Vice President who was skeptical and blocking my request for seed funding for a personal health lab, I showed several early concepts of caregiver assistance technologies, particularly for families dealing with Alzheimer’s.

After my demo, he said, “It’s kind of cool, but I just don’t see why anyone would want this.” It was clear I was going to be denied funding, and before I knew it, I just blurted out: “Can you get your wife on the conference call?” The room was filled completely with men—all were engineers and executives—and they stared at me as if I had leprosy. “Seriously, call your wife, let me explain the concept, and if she doesn’t think this is compelling, then I’ll stop pushing for it.” He went along with the gag, and fortunately for me, his wife answered the call, listened to me explain the idea, and loved it. In fact, I couldn’t have paid her for better comments as she said to her husband in front of the entire room: “Wow, honey, this is the first technology I’ve ever heard you talk about from your years of work there that I actually need…I could use that now for taking care of your mother….when can I try it out?” I won several executive champions that day as they went home and discussed what had happened with their wives.

I don’t believe members of Congress or the technology industry are being intentionally sexist or blatantly dismissive of caregiving as “women’s work.” But we have to admit that this work—done primarily by women—is often invisible to politicians and tech executives, who by and large, are men who simply don’t have the lived experience of caregiving to feel the need for new technologies, policies, and support for caregivers. Yes, I’ve met men who are exceptions (I work with someone who is an amazing partner with his wife as they care for their special needs daughter). But I’ve met many, many more husbands who aren’t even aware of the amount of time, money, and sometimes suffering that their wives are doing to care for their aging parents.

So healthcare reform needs to orient to the fact that women are the primary careforce for making healthcare work smoothly across the continuum of care. In our Intel clinic studies, nurses prove to be the seemingly tireless orchestrators of the day-to-day healthcare experience for almost everyone—they are the glue that holds the healthcare system together. Most research on the topic confirms that around 94% of nurses are women—in most every part of the world—and most of those are “boomer” age or older. In our home studies, women most often serve as the primary health managers, information keepers, caregivers, and advocates in the family, whether or not children are present. There are many studies and statistics that show these gendered trends to be the norm (see the Family Caregiver Alliance summary, the National Family Caregivers Association summary, and the Kaiser Family Foundation Women’s Health Policy page).

Congress needs to “get it” in their bones that we need a reform plan for training, sustaining, and growing a “careforce” of women (and men) that is ready to deliver 21^st century care in some new ways. Healthcare reform without workforce reform—and without broader planning for developing a diverse, flexible careforce of paid professionals, new kinds of care workers, volunteers, and informal caregivers—won’t solve the cost/quality/access problems we all face. Simply put, there won’t be enough traditional nurses and doctors to meet the demands of the uninsured and the age wave using our institution-and-professional-centric system. We need something else.

As Clayton Christensen shows in his great book, The Innovator’s Prescription, we need, among other things, to use disruptive technologies to skillshift—that is, move skills and expertise from higher trained professionals to less trained professionals to families and patients themselves—whenever safe and effective to do so. So much attention in the healthcare reform debate has focused on clinicians while glossing over how to better educate and empower consumers. AARP’s caregiving study points out that more than 34 million Americans are providing informal (but often full time) care at this very moment—to the tally of $375B worth of care if we had to hire professionals to deliver it instead. Again, most of these are women, and few are given the support, respect, and tools to do those informal caregiving jobs. We need to be more conscious in our reform strategy about how to skill-shift many of the things that doctors and nurses do to this huge informal careforce.

So what are we doing in healthcare reform to support, sustain, and enhance the abilities of this often invisible, informal careforce to deliver better quality care at reduced financial and emotional costs? How can we further offload the expensive, institutional care settings and professionals by training and skill-shifting to families, friends, and patients themselves who have to become trusted partners on care coordination teams? How are we retraining medical professionals to use new technologies and build new relationships with this informal careforce to achieve better outcomes for more patients? In short, who will make up the careforce of the 21^st century that anticipates the age wave and caregiving crisis we face?

Outside of some discussion of how to accelerate and give more incentives to students to go to medical or nursing school, especially in primary and geriatric care, there has been too little discussion of these kinds of questions by Congress and the media. President Obama is under attack this week for supposedly being callous and carefree about the unemployment crisis in America (see the NYT op ed by Bob Herbert). Healthcare reform offers enormous opportunity (and there is certainly enormous need) to put people to work. Let’s solve one problem—stimulating the job market and the economy—by solving another: reforming healthcare. Perhaps if we could spend as much time as a nation debating ideas to develop this new careforce—and as much energy figuring out how to grow new jobs for the new healthcare system—as we are giving to Jon and Kate, town hall crazies, and Letterman’s love life, we might well find a way out of this healthcare mess, stimulate the economy, and have better healthcare for all. And maybe we would be able get this done just in time for the Baby Boomers to play a transformative role once again in our society, as they demand, create, and live out new notions of what retirement, health, and being a “patient” really mean.

Next week I’ll offer my top six ideas/answers to the careforce questions I posed in this entry. I want to do some more homework and thinking before I put them out here. And I’d love to hear your creative ideas on this topic here on the blog, if you are up for some homework yourself. 

Perspectives on Healthcare Reform from A Mountain Top

posted by Eric Dishman on October 06, 2009

Sometimes (okay, most of the time) mountains help me see things from a different perspective. I just got back from a week in the beautiful Wallowa mountains in eastern Oregon—an awe inspiring place if there ever was one. The small cabin we stayed in had no email or cell phone coverage or newspapers or headlines. Or blogs. It was a relief to turn off that stream of stress for a week and to slow down to the pace of Mother Nature.

For a brief moment, I almost didn’t make it to the mountains. I called my colleague in our D.C. office about 10 days ago in a panic: “I’m going to cancel my vacation and fly to D.C. instead! This is it, this is the week the Senate Finance bill gets debated, this is our one chance to fix healthcare…I should be in D.C.!”  Wisely, my colleague told me to “calm down” and go on to the mountains because things never move that fast in politics.

As my wife and I sat in a cafe in the small town of Joseph, Oregon last week for breakfast, our waitress, Rose, probably in her early 60s and moving through space with what I can only assume was arthritis by the way she handled the serving tray, unknowingly served me up an epiphany. As I sat admiring the myriad of ways deer, wolves, and elk can be depicted in a painting (this cafe is the place to be if you are looking for any artwork on hunting!), I couldn’t help but hear the conversation between Rose and the folks at one of her regular tables who were on their way to go bow hunting.

“How’s your husband?” asked one of the regulars.

“Jim? Oh, he’s not doing so well. He’s sitting home all bandaged up. And I’ve had to start waiting tables again since he got hurt,” came Rose’s reply. She wasn’t resentful, just resolved to the situation.

“What happened?”

“He doesn’t have a damned thing to do with himself since he got furloughed at the plant. They keep saying he will go back to full time hours soon, but there’s no sign of it. He’s restless—he can’t sit still—he hasn’t been this ‘free’ to do what he wants since he was 14 years old. So he’s been out doing extra chainsaw work before the winter comes to make money—and just do something with his hands.”

The regular (and I) saw where this was going. “Uh oh, did something happen to him?”

“Yes, he split open his knee cap with the chain saw.” About six nearby tables winced in unison as we all tried to pretend we weren’t listening in. Rose continued: “Thank god he wasn’t alone, cause he’s been out there cutting alone at times. But a friend was with him and helped him get back to the truck and to the house. I tried to stop the bleeding and bandage it all up. It didn’t seem that deep. And he didn’t want to go to the doctor cause we don’t have insurance right now while he is part time.”  

She promptly filled our water glasses (with trembling hands that had me ready to dive for a napkin), grabbed a side of bacon for the table next to us, turned on the swamp cooler as it was already heating up in the café, and then sat down at the table of regulars to finish her story. She and her husband Jim had waited for four miserable days trying to get his bleeding to stop and his terrible pain to abate, but it was finally too much for them. She drove him to the tiny urgent care clinic in the town of Enterprise nearby, but the nurse there saw the wound and infection and moaning, feverish, almost delirious patient before her and said they needed to go to La Grande or maybe all the way to Boise.

Rose then drove her husband’s truck (her first time using stick shift) to carry him over the mountains and border to the hospital in Boise because she was worried about the cost of having an ambulance come get him. Long story short: Jim had major surgery, has medications, is in rehab, and they are working out a payment plan with the hospital through a government assistance program. And Rose has been forced back into the diner to help with family finances.

Not surprisingly, Rose then turned to the topic of healthcare reform: “I hope those bastards in Washington just fix this whole damned healthcare system. Just fix it! Cause it’s broken. We don’t need a government takeover, no socialism, but they should just scrap the whole thing and start over. And they better fix it—they better get it right this time. We just need insurance so my family doesn’t get set back for 10 years because of one stupid accident out in the woods.”

And with that, Rose rose…and turned from her regular audience, who were nodding and proclaiming their approval of her wise words, to make another round with the water pitcher.

. . . . . . . . . . . . . . . . . . . . . . . . . . .

As I write this memory of Rose and the restaurant and the pantheon of policy issues that came up in that five minute encounter (the impact of the recession, lack of insurance for part time workers, deferring care which just makes the patient and costs even worse, access to healthcare in rural areas, perceptions about government takeovers and socialism while relying upon the government for survival), I am sitting in a waiting room back in Portland for my own doctor’s appointment. While I’ve been here for an hour waiting, I’m trying not to lose my patience. And I’m trying to remember that I should be thankful that I have a job, coverage, and economic means…that I am not having to wait tables or cut down trees just to pay for one healthcare system encounter…and that I can escape to a vacation to hike in the mountains without one moment of concern about whether or not I can get the care I need should I trip and break my knee while out there.

As I muse on this, one of the nurses who knows me well just came up, somewhat laughing and somewhat serious, and said: “What are you doing here? You’re supposed to be in Washington fixing this broken healthcare system!” She asked me what was happening with all the reform bills and wanted to know if nurses would finally get some relief out of all this “government talk.” She told me what was going on with her daughter at school. And then, just as she turned to walk back to her work, eerily, she ended with almost the exact words Rose had said: “Just make sure they get it right this time.”

As I think more about these episodes—and my own panicked response about postponing my vacation to be in Washington instead—I think we could all benefit from “calming down” and resetting our expectations. We have come to treat healthcare reform itself as some kind of godsend miracle drug to cure the diseased healthcare system. We have built up some pretty high expectations that somehow, some way, Congress will wave a magic wand and fix everything with one stroke of the Presidential pen.

My time in the mountains helped me to see that healthcare can’t be “fixed” or even “figured out” all in one moment, one bill, or one idea. Yes, there is urgency to begin this reform effort now given the precarious economics of healthcare costs, the demographic pressures of the age wave, and the moral imperative to be a healthier nation for all. But healthcare reform is not something we will finish anytime soon, if ever. There are no miracle pills or bills that will suddenly make everything alright. We have to move beyond a simplistic “fix it” mentality for healthcare reform that assumes someone else—the politicians or the doctors—has the responsibility to fix things and to “get it right this time” and to do so immediately. If it is to be successful, healthcare reform will be a slower-paced and ongoing activity—and responsibility—for each of us to tackle for decades to come. We don’t have to get it right. We just have to get it started. And we have to be committed to a long journey of continuous improvement. If we do, then and only then, will we end up moving mountains.

Comments are welcome.  please post to: http://blogs.intel.com/healthcare/