So here are the questions I posed some time ago. What are we doing in healthcare reform to support, sustain, and enhance the abilities of the often invisible, informal careforce—especially women, who as wives, daughters, daughters-in-law, friends, and neighbors, serve on the front lines of care—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 to build new relationships with this informal careforce to achieve better outcomes for more patients? Who will make up the careforce of the 21^st century that anticipates the age wave and caregiving crisis we face?

Here are five ideas that begin to address these big questions:

1) Proactive Patients: We as patients have to become more knowledgeable, responsible, empowered, and proactive about our own healthcare. We cannot sustain our current passive, entitled patient paradigm—what I think of as the Humpty Dumpty syndrome—where we wait until we’re sick or injured and then run to the clinic or hospital to be put back together again by the experts with the expectation of “any means necessary” and “every test available” and “any cost required” to make us better again. We need to catalyze an industry of self-care technologies and services that put some of the onus of health back on patients, to grow the use of Personal Health Records (PHRs) and wellness applications that help people achieve their goals, and to push for cost transparency of tests and procedures so that we as consumers can know the ROI and outcomes of what we’re putting our bodies (and health plans) through. We need to majorly rethink and revamp those dreaded junior high school health classes to make them useful in instilling a foundation of good habits for healthy living while we are young. Health literacy, like all languages, is probably best learned at a young age…so let’s figure out the curriculum to mint hundreds of thousands proactive patients who become an important, unpaid part of the careforce of the future.

2) More Nurses and Doctors: Frankly, we need more physicians and nurses to meet the needs of the age wave, especially those trained in geriatric medicine and primary care. There have been numerous Congressional hearings on this topic, and the problem is well understood, but the solutions have not been forthcoming. First, we need to strive to retain the people who are already working in the healthcare industry. We are burning out our workforce of clinicians with bureaucracy and paperwork and somehow have to get trained medical professionals focused on bedside care and patient needs again. Healthcare reform needs to drive Care Flexibility, where we diversify the locations and models of care to allow physicians and nurses the flexibility to engage with patients in the clinic, in the home, and virtually via electronic means, depending on the need and their best professional judgment. Second, we need to accelerate new students going into healthcare fields. If healthcare reform is able to achieve a “quality over quantity” payment paradigm, this will help pull more folks back into healthcare fields, who have been reluctant to join—or have left—because of today’s “factory line” care paradigm that leaves no one—neither patients nor clinicians—satisfied. Congress needs to implement many of the student loan and debt relief programs for medical and nursing school programs they have reviewed over the years. Perhaps it is time to create “AmeriCorps for Care” or the “Care Corps” for incentivizing new students to go into these fields with service to their country in “trouble spots” or “gap areas” of healthcare to pay back their medical school debts.

3) Empowered Informal Caregivers: Informal caregivers—the family and friends who do the lion’s share of care in America—are key to developing a sustainable, quality healthcare system for all. No matter how proactive we make patients themselves, no matter how much preventive care we do, no matter how many new doctors and nurses we train, it is not likely we can “catch up” with the age wave. We have to train, sustain, and reward informal caregivers to be fundamental participants on Care Coordination teams going forward. Too often today, the medical mainframe treats the family and friends as a “nuisance” who have to be “dealt with” instead of a “resource” who should be “empowered” to offload the formal healthcare system. We need to explore tax credits or other kinds of financial assistance for people who are delivering significant informal care today. We need to explore special mechanisms whereby family caregivers can maintain affordable health insurance for themselves, if they are focused to go part-time or quit their job to care for a loved one. We must develop community health and other kinds of education programs for informal caregivers that explicitly skill-shift some of the chronic care duties that nurses do to these friends and family members who will be on the front lines of care—at the bedside at home—more than anyone else.

4) Retirees and Volunteers: We have an enormous opportunity to build new volunteer programs that help trained volunteers deliver care support for complete strangers who live in their neighborhoods—or even thousands of miles away via telehealth technologies. Imagine tapping into the national pool of retirees who are already trained in healthcare, either as retired doctors or nurses, who are a largely untapped resource in America. Many of these professionals would like to go back to work part-time, especially if they could work out of their homes and/or have flexible hours. We have the technological capability to put many of those retirees back to work, either as volunteers or part-time employees, to meet care needs in the community. And we need new ideas and programs that instruct and empower retirees who have no formal medical training to learn enough of chronic care management to help frail seniors and other co-morbid patients to thrive in their own homes. Again, I like the idea of a “Care Corps” to help train these volunteers to provide in-home and virtual care for others. Think of this as “Neighborhood Watch” with some telehealth technologies combined with Facebook and Google Maps where you can volunteer—and get a tax deduction for your time—to use a PHR dashboard to help care remotely for 10 seniors who live in your neighborhood. Or I am reminded of the great exploratory program that Dr. Arthur Garson, Provost of the University of Virginia, is doing to train “grandparent” age citizens to do basic chronic care management for other seniors in their community. My point is that there are probably millions of retiring Baby Boomers who are ready to “give back” in whatever ways they can; we need to tap into this disruptive demography with disruptive technologies that provide them innovative ways to do that kind of volunteer work.

5) New Kinds of Virtual Care Providers: We cannot achieve universal coverage and quality care for all Americans if we continue to make an in-clinic or in-hospital visit the default care location for every kind of health encounter. There are enormous opportunities to use telehealth technologies to shift the locus of care—perhaps even as much as 50% of the care that is done in institutions today—to the home and community. But to achieve such an audacious goal, we have to invent some entirely new categories of healthcare workers that we may not have even conceptualized yet. We need new curriculums, new credentialing mechanisms, and new national licensure rules to formally train a workforce of telehealth nurses and telehealth physicians who know how to deliver great quality virtual care for a wide range of care needs. But we also need to invent some entirely new kinds of non-clinical jobs, think of these as “Care Coaches,” who are trained in a mix of social work, clinical informatics, IT (information technologies), and nursing skills to offload clinical staff with the many quality-of-life and non-urgent needs and services that seniors and other chronic patients have on a daily basis. Today we’re stuck in a “clinical mentality” that tries to preserve power and authority in highly trained (and sometimes but not always highly paid) professionals; we need to open up our thinking about the new care models that are occur in the home and community and then figure out what staffing paradigms and training can deliver upon those models.

It’s unclear to me whether or not the federal government can even generate new jobs quickly without just hiring more people to work in government (see Time’s article that makes this point quite well). I suspect government’s role in job creation is in longer term stimulation—in creating the conditions in which new innovations and industries in the private sector can thrive. But it is clear to me that the President and Congress need to tackle Global Aging—our other inconvenient truth—and “careforce creation” initiatives with the same focus and intensity that they have brought to Global Warming and “green jobs” initiatives. If done right, healthcare reform ought to generate new industries and jobs, especially when we add millions of formerly uninsured people to the system.

I well realize that change can be frightening, that skill-shifting aspects of care from physicians to nurses to family members can be threatening to many people. Yes, we’ve seen many battles over the years between doctors and nurses on who gets to prescribe medications…or conflicts between nurses and CNAs about who can provide which level of patient care in which care setting. Yes, there are risks anytime we change best practices, retrain staff, or bring novices onto the care coordination team. Yes, there is some danger that we will create rare cases of fraud and abuse as we shift care to the home and community. But the bigger threats are that we fail to prepare a careforce to meet the needs of 21^st century healthcare…and that we miss the opportunity to grow new jobs and industries that put America at the forefront of a new healthcare paradigm needed not just here at home but across the world.

The notion that “healthcare reform is dead” is wishful thinking by some who believe that repeating the phrase often enough will make it so. (And perhaps it will…the echo chamber has worked before to defeat both logic and truth!) And the notion begins to feel almost inevitable thanks to the ever-escalating rhetoric from pundits who need to generate a provocative headline or sound-byte to be heard above the noise of their peers, who are proclaiming the same doom-and-gloom scenarios over on the next news channel or blog site. In our modern, shock-and-awe world, the more provocative and extreme the claim, the better.

Yes, Brown’s victory should be a wakeup call for Democrats, the White House, and arguably all politicians about the frustration flashpoint that voters are reaching due to the recession, the fear we have of change—especially about something as personal as healthcare, and the continuum from distrust to disgust that the majority of Americans hold towards a highly polarized Congress. But we’re ready to scrap much-needed reform of the largest sector of our economy because of a “January surprise” in a special election for a single Senator? We’re once again prepared to have our healthcare held hostage by the whims of a single Senator or to avoid bringing bills forward out of fear of a filibuster?

This is nonsense. This is scary. This is wrong.

Healthcare reform is, in the vernacular of the day, too big—and too big of an issue—to fail. To allow politics-as-usual to derail and destroy healthcare reform as a national priority is as foolish as us walking away from the fight against terrorism. Congress and the White House both know full well that we can’t afford not to do healthcare reform—that it is a vital “national interest.” That Medicare insolvency is a real and increasingly imminent threat. That we’ve not designed a care delivery system to withstand the pressures of the age wave. That the cost of treating the uninsured in emergency rooms is unsustainable. That the rise of obesity and chronic disease is wiping out investment dollars that we could use for other parts of our economy. That Americans want, need, and expect to be covered by our insurance even when we have preexisting conditions. And that we can’t continue to be a globally competitive country without reforming healthcare.

I’ve spent the past year working specifically on these healthcare reform bills, as someone new to advocacy and naïve about “beltway behavior.” Other than a few, rare exceptions, I have to be honest that I have been discouraged by what I have witnessed.

Opponents, armed with the echo chamber of talk radio and blogs, have used despicable fear tactics to frighten Americans away from the facts in these bills. They have decided that making the President fail on healthcare reform is their best election 2010 strategy, even threatening and silencing members of their own party who actually wanted to negotiate and compromise on a real reform bill. They’ve waged a campaign of misinformation and emotional manipulation.

Proponents, armed with the hubris of leading both houses of Congress and the Presidency, have shut out real debate and stifled meaningful bipartisan negotiation with healthcare reform, thus setting the tone of hostility early on. They have decided that “healthcare reform at any cost” is their best strategy, and have deployed their own fear tactics that needlessly vilified insurance companies while silencing the more moderate parts of their own party. They have failed to explain to the American people the content and logic of their proposals and squandered away the public approval—that they had at the start of the process—for reforming healthcare.  

The White House, meanwhile, has sat on the sidelines of the healthcare reform debate for far too long out of fear of repeating the perceived “interventionist” mistakes of President Clinton. President Obama needs to be the Communicator-In-Chief to explain to the American people why these reform measures are necessary and why they will work. He now can step in to drive—and insist upon—a truly bipartisan “campaign” for healthcare reform, instead of allowing the nation to obsess more about the political process for passing the bill than the main points that were in it. And he must make the moral and competitive case that healthcare reform is crucial for our stature and status as a global leader and standards bearer for Democracy.

And finally, we as citizens have let ourselves be “entertained” by the political fray instead of being “informed” and “insistent” about healthcare reforms that the majority of us desperately need. We have somehow come to expect, even relish, the spectacle of the crazies—of every ideological stripe—taking center stage in our national debate that has become more like an ongoing “reality show” than an authentic attempt to derive real solutions for our country. We’ve tolerated, even rewarded, mediocrity from our national leaders. We’ve too easily believed the internet rumor, the talk radio commentator, or the water cooler conversation without doing our homework to really research and understand these complex healthcare issues. And we’ve failed to mobilize ourselves, the now-silent-again majority of Americans who chanted “yes we can” during the Presidential election but haven’t followed through on our commitments to real change.

I refuse to accept the view that “this is just the way it is” when it comes to Washington. That it’s just “human nature” or “politics as usual.” Those are just cynical cop-outs. We can all expect—and do—better.  

Healthcare reform is too big to fail. We must demand that our government leaders actually lead and get real healthcare reform done this year. Let real debate occur. Stop living in fear of a filibuster—let it, and the consequences of wasting the public’s time and money with silly political games, occur under the glaring spotlight of the media and the blogosphere. If the current bill is politically impossible to achieve in its entirety, then let’s go with the “a la carte” approach instead of the smorgasbord. Let’s, for example, put forth the bill focused specifically on ending the denial of coverage for preexisting conditions. Or the bill that brings the uninsured into the fold of quality coverage. Then we’ll see just how many members of Congress decide to vote against these more popular reforms in an election year.

Or most radical of all: let’s have the President call together a mix of members (including the silenced moderates) from both parties to start again with real bipartisan negotiation and to put the country—not the November elections—first. Back in his speech to Congress in the fall, the President said that there is bipartisan agreement on a high percentage of the proposals. If this is true, focus on those as the foundation of healthcare reform that can pass this year. Save the disagreements and the controversies for later.

We have seen how successful bipartisan legislation can be at times of national crisis – terrorist attacks, natural disasters.  Let’s ask Congress to take that same approach to the economic crisis we surely face as a country if the largest part of that economy—healthcare—is left with an unsustainable status quo and potential collapse. We already have the intelligence about when, where, and how this healthcare crisis will occur. We can still do something about it. Healthcare reform is too big, too important to fail…we must refuse to be too small, too self-important to let it succeed. For our own good.

This time of year all the news shows have their “year in review” segments: a fast-edited cacophony of the year’s celebrity scandals, political headlines, media controversies, and, of course, a few new gadgets thrown in all to signify (in their opinion) what was important the prior year. And there is even more chatter when we turn the calendar page to a new decade. Far too many news cycles have already been spent on what to call the decade of 2000 to 2010, with many calling them the “aught” years, the “nameless decade,” or even the “lost decade”—the “naught” years—with the sense that the stock market crash, housing crash, and recession have left us with no gains over the past 10 years.

I don’t know what to call the last decade—and I think it’s ridiculous to think of that time as useless just because our financial wealth didn’t grow—but, regardless, it’s time to look forward. It’s time to move forward. My new decade’s resolution is to do everything in my power to make the next ten years be the decade of care innovation—in particular, to move care into the home and community. If healthcare reform is about anything other than insurance reform (please!), it has to be about care delivery reform. We have to transform how we conceive of care, whose responsibility it is, when we intervene, who is trained to deliver care, and where and how it is practiced. It’s not just a matter of writing a check differently for healthcare—it’s a matter of doing health differently with the money we’ve got.

The good news is that there are many elements in these bills—that rarely make the headlines—that open the door to a decade of care innovation. Covering tens of millions more Americans who were previously un- or under-insured will in itself force innovation as the current system has to find creative ways to deliver more services to more people but without significant increases in money or staff. Very few health plans really know how to be an effective “accountable care organization,” but already a small few of the “old plans” are aggressively reinventing themselves to try be at the forefront of that change. “Care coordination” is going to be novel for many nurse and physician practices—they will have to innovate how they do care on a daily basis. Payment reform—through “bundled payments” and “preventive care incentives”—will create new market dynamics that reward and demand new ways of delivering care that few of us can see or understand at this point. And with care innovation programs and comparative effectiveness studies coming from almost every government agency—the CMS Innovation Center, the Office of the National Coordinator, the Department of Health & Human Services, the National Institutes of Health—it is clear that the next decade, if successful, will begin the transformation of a healthcare system that has changed very little over the past 150 years.

The bad news is that neither Congress nor the White House have managed to capture the public’s imagination about the upside of healthcare reform—about the promise of a decade of care innovation. I’ve said many times that government leaders have missed a real opportunity to excite and ignite the country about reinventing our healthcare system with new industries, jobs, technologies, and care models. (Perhaps we should call this reform debate the “lost debate” or the “naught debate.”) They’ve focused so much on headline-grabbing controversies (the public option, abortion, Cadillac plans), the sausage-making process of legislation (filibusters, late night Christmas eve votes, ping pong strategies, reconciliation) in a climate of hyper-partisan self-preservation that the majority of the public as a whole has soured on the idea of healthcare reform in the polls, even though almost every individual yearns for many of the major elements in the bills.

It’s not too late. Congress and the White House can still set out a bold, innovative vision for where healthcare reform will take us. In fact, they probably need to as they try to get this bill finished soon, possibly even before the State of the Union address by President Obama in the coming weeks. I’ll offer the same advice to the President that I tried—but utterly failed through every friend, colleague, and channel I could find in D.C.—to get to him back in September when he gave his healthcare speech to Congress.

The President should make a New Decade Resolution, declaring 2010 to 2020 the decade of care innovation. In fact, he should set out an audacious, going-to-the-moon goal of moving 50% of care that is done today in institutions such as hospitals, clinics, and nursing homes to the home and community by 2020. Instead of investing in more high-tech infrastructure to “fix” us in a medical institution once we’ve already become diseased or injured, we should be investing in infrastructure that helps us to prevent disease and injury, to be more proactive about our own health and wellness, to shift diagnostic capacities into the home and community, and to enlist family and friends in care coordination to offload those overburdened institutional systems and settings.

Having a bold 2020 vision that uses American innovation to shift care to the home and community—and responsibility for wellness to the patient and their care network—will go a long way towards getting the American public excited about the reforms we need to make. Imagine if 10 years from now, those news retrospectives could be looking back at this decade as the time in which we truly gave every American great healthcare, in which we allowed people to age gracefully in their own homes instead of institutions, in which we turned the tide on chronic disease by focusing on prevention and behavior change, in which we personalized medicine to individuals, and in which we invented entirely new kinds of care models, care workers, and locations of care to diversify services for the wide range of health and wellness needs that we, as humans, have always had.

And as with most resolutions, while we may not achieve every aspect of every commitment we make to ourselves, it is far better to have a positive vision and a discernible direction to go in…than to remain mired in the medical morass and the unsustainable status quo that we find ourselves in during this historical moment. And who knows, perhaps in a decade committed to real care innovation, we may surprise ourselves and exceed all expectations.

I’m reminded of Leslie and her love of that story only days after her funeral. She just succumbed to cancer after having fought it back miraculously about fifteen years ago. We’ve not been in touch with one another for a while, but Leslie and I could pick up a conversation that was three years old as if we had just met for milkshakes or Moo Shu three days before. Her death—or, in fact, the way she lived—has re-reminded me of the need for all of us to live our lives as if there is no tomorrow. Leslie lived a full life as a compassionate truth-to-power teller—someone who would never hesitate to speak her mind with facts and evidence to support her beliefs, but nor would she hesitate to listen and learn from others. She was always the consummate teacher and student, always—even before the cancer first appeared—living her best and most authentic life possible.

While we were grad students in Austin, Texas, Leslie and I discovered our mutual passion for patient advocacy. We both spend a lot of time (okay, the past tense for her ..spent…which is hard for me to accept or get used to) with cancer patients who are facing devastating news, enormous suffering, and the fear of death—often for the first times in their lives. The majority of people we help go through a “personality transplant” once faced with the scarlet letter “C” emblazoned upon their consciousness as the official “Cancer” diagnosis is handed down. Once the initial shock and depression wanes, most become more friendly, more compassionate, and more truthful….less patient, less polite, and less tolerant of BS.  Faced with the possibility of cancer ready to shoot you at any and every minute of your life, most patients begin to live life more fully—more “real” as most of them put it.

“Bill” was one such patient that Leslie and I worked with. His “BD” (before diagnosis) life showed him to be self-absorbed, selfish, and concerned only about advancing his career. He was so political in his every move that he spent most of his life calculating the costs and benefits of saying or doing certain things at work. Even in his first days “AD” (after diagnosis), Leslie and I had taken Bill out for frozen yogurt in an effort to get him to face the realities of his illness, but he spent three hours telling us his complex plan to hide his illness from his boss because he was fearful of losing his chance at a promotion. Bill was so concerned about building his power base and reputation at work that he was often cruel and vindictive with anyone who got in his way.

But as the chemo and radiation began to take their inexorable toll, stripping away not only his hair but also his ego, Bill faced the fact for the first time that he might not survive. He began to undo the alienation he had created between himself and his wife, daughters, co-workers, and friends. He apologized to many of them. He rediscovered his passion for guitar (he was quite good). He actually became much better at his job at work, earning his promotion rather than manipulating it. And his sense of humor—which apparently had been the defining feature of his character so many decades before—returned. He lived three amazing years which, while full of medical hell and suffering, were full of life, truth, and his pursuits of real happiness. Soon before his death, while in hospice care at his home, Bill told me and Leslie one rainy afternoon, “Wow, thank God the cancer gave me the courage to be the real me again. Better late than never!”

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

So what do Leslie, Bill, and these experiences with patient advocacy have to do with healthcare reform? Well, after these many months—and especially these past few weeks as the partisan rancor has ratcheted up again in the midst of the House bill passing and the Senate debate starting—I have felt increasingly that a good politician is hard to find. No, I’m not claiming that there aren’t any good people in politics or that all politicians are bad or evil. But I worry that we’ve created a political system that makes it almost impossible for good people to do good things while they are in office.

I’ve had the opportunity to share the stage recently on panels and presentations with former Congressional members like Tom Daschle, Bob Dole, and Newt Gingrich, each of whom spoke of the freedom they felt once they left office. “I can be the real me again,” says one of them. “Ah, the freedom to speak freely for the first time in decades,” says another, to the laughter of an audience of reporters and healthcare executives. Still another admits, “I may be able to change the world more by having left the Congress than I could when I was in it.” And they suddenly have a sense of humor again, a playful and empathetic respect for one another on stage, even if they have powerful ideological differences. They remind me of Bill and all those cancer patients that Leslie and I worked with—suddenly mortal, human, honest, and real again.

Have we, as a society, created a situation where politicians can no longer give their best ideas, honest opinions, and most compelling evidence?

These past 18 months working on healthcare reform, I have seen first-hand so many politicians bound by “partyability”, “scoreability,” “soundbiteability,” and “electability.” Instead of putting forth their best possible ideas, they put forth what is acceptable to their Party, fearing that the Party will put a well-funded, well-publicized competitor against them in the next race if they don’t tow the line. They put forth bills that are “scorable”—that can survive the bizarre scrutiny of the Congressional Budget Office—instead of what they feel is right for the country. They avoid tackling or explaining complex issues and stick to short, simple slogans that can come across well in a six second sound-bite on the news. And, of course, the next election begins for them the day after the previous election’s victory party, with polls, focus groups, fund raisers, and “public opinion” data to shape one’s every action and utterance. It’s a wonder that anyone runs for office anymore.

I have found myself wondering if our country would be far better off if we could each go through a “mortality moment” earlier in our lives—a cancer diagnosis, an accident, or something that forces us to face the imminence and inevitability of death. It’s tragic to me to see patients, politicians, or anyone discover what’s really important to them only in a moment of crisis just before their peril...or so late in the life that they no longer have the energy to set themselves on a different path...or well after they’ve left behind a position of power where they could have really changed the world. O’Connor’s famous short story is a profound reminder that all of us must somehow find the courage—and be given the opportunity—to be our real selves every day, not just at the last critical hour.

Maybe I am living in a fictional world to think that we can all live our lives with more authenticity. Many will think me naïve to ask policy makers, of all people, to be more open, compassionate, and real—aware of, but not overwhelmed by, the inevitability of death. Living life to its best and fullest, instead of just avoiding death. What mountains Congress—and we—could move if we lived with such everyday courage!

A good friend is hard to find, and losing one is harder still. But Leslie’s example challenges us all to remember to live life with authenticity…as if there is no next election, as if there is no legacy beyond what we have accomplished up to this very moment, as if there is no tomorrow.

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 1/10^th 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 65^th 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!

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

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.

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. 

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.