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.

I am sitting on a plane on the way to the TED MED conference (which I plan to blog about here later in the week), scanning the USA Today, trying not to catch the flu from the woman who is clearly very ill just a row behind me. Two above-the-fold headlines caught my eye: "Pushing Hospitals to Their Limit" and "Reid to Advance Opt-Out 'Public Option.'" I saw the cable channels on the airport TVs looping feverishly on the same topic...abuzz with Senator Reid's promise that the Senate version of the healthcare reform bill will contain a "public option" but with an "opt out" mechanism for states. Whatever that means. And then there is the elusive "trigger" option that is getting air time again. Somehow that is supposed to comfort me.

 

 

 

You can almost see relief in the faces of the TV reporters that the public option controversy is back (or that they managed to bring it back) for a few more polarizing news cycles. Polls are apparently showing that the majority of Americans favor a public option. I've certainly seen most of my circle of friends and family on Facebook celebrating the idea. But I am confused how everyone can be so confident about a public option. I'm worried that we're being fed oversimplified, emotional bullet points in lieu of detailed proposals for how exactly this program would work. I've been working on these issues for two years now--have read all five of the Congressional bills and dozens of amendments in full--and still feel like I barely comprehend.

 

 

 

I have avoided talking about insurance reform in this blog for three reasons. First and foremost, I am an not an expert on this complex topic. Second, the healthcare debate has become so bogged down in the public option controversy that I didn't want to give even more time, energy, and attention to it. Third, this issue is so emotional and extreme for many people that I don't want anyone to mistakenly assume that my opinions represent any kind of official Intel position. Because they don't. What I am about to say--as with all things in this blog--are my own opinions. But since I can't seem to get the world to focus on other important reform issues, I will try to address this big elephant in my little blogosphere.

 

 

 

Don't get me wrong. I am in favor of everyone having access to quality healthcare--morally, economically, and from the standpoint of American competitiveness--and the idea of a public option is appealing to me. The reason I remain skeptical is because too little has been said about the implementation of a public option. The fact that the term "public option" is almost always in quotes when I read it--or modified with the words 'so-called' in front of it--is a red flag suggesting that there is no common or clear definition. Everyone seems to be quoting someone else's definition. In fact, I've been trying to understand well over half a dozen different versions of a "so-called public option" from Congressional members, and there are significant differences among them. So if no one can define the term consistently, how can so many people be "for" it or "against" it, and how can we be in such vehement debate over what is kind of, sort of, notionally, a new and important concept?

 

 

 

We may all be simply investing our best hopes or worst fears into the ambiguity of the "public option" concept--which is fast becoming the new litmus test for belonging or not belonging to a so-called "political party." People are also using the terms "government paid" and "government run" ambiguously and interchangeably, but those are very different phrases. Would the government both pay for and run some huge new insurance program? Or simply pay for it while some other entity--perhaps even the private market--runs it?  Would we have to create an entire new government department from scratch to run the public option? Or would this be housed in the Department of Health & Human Services, already the largest part of the federal budget? Some lawmakers are now calling the public option "Medicare Part E" for "Medicare for Everyone"--so does this mean Medicare, one of the largest, most painfully slow, un-innovative government bureaucracies in existence, would become much bigger and slower or the prototype for solving all of our healthcare problems? Really?

 

 

 

I know there are lots of plausible answers to the kinds of questions I asked above...but what is the proposed answer actually being voted upon in the end? That's the version of the public option that I want to evaluate before making up my mind. But getting that level of detail has been difficult because so much of the negotiation in Congress about the public option has been anything but public. Oh, I've already complained about too much media attention on the topic, but that's only been surface level analysis. Our elected leaders have been holding their cards so close to their chests in closed-door committee meetings that many Senators and House members themselves have expressed public frustration that they aren't being given access to the details of these plans. We need more information on the "so-called public option" to be informed citizens.

 

 

 

It comes down to this for me: we need a hybrid insurance system that maintains fair competition and checks & balances between Big Government and Big Business to pay for--and run--our health plans. I believe that a government-only or a business-only system would hurt us all...that the tension between the two is what can produce a system that can be both universally accessible and continuously innovative.

 

 

 

We already have a Big Government system called Medicare--the largest insurer in the nation--that has its strengths and weaknesses but it is hardly a utopian cure-all for covering the uninsured or bringing down healthcare costs. It's as easy to drum up anger and horror stories about Medicare as it is about those "big, evil insurance corporations." Ask a lot of folks who are nearing the magic 65-year-old mark if Medicare is everything they want it to be. You will get an ear full about how complicated and confusing the system is, how it doesn't cover a lot of the things their private plan did when they were working full time, how they had to give up their doctor of twenty years because he or she didn't accept Medicare any longer, and how they have been denied services and free choice. As Medicare sets the (slow) pace of innovation and many of the (under) reimbursement policies/amounts for the private insurance marketplace, it needs much reform and rethinking itself before we use it either to run--or as a template for--the public option. But Medicare is also a literal life saver for millions and millions of people--and there are great programs and people in the system who do amazing things in spite of problems and abuses that inevitably occur.

 

 

 

So, too, we already have a Big Business system with the private and employer-driven insurance markets that consist of big and small, for-profit and not-for-profit, organizations that, in their collective, form another huge, confusing, and frustrating bureaucracy for everyone from clinicians to consumers to navigate. There is no doubt the time has come for reform of this system as well. The profit motive--especially with short sighted quarter by quarter thinking instead of long term ROI analysis--means abuses can and do happen. I don't like big bonuses for insurance company executives, either, and the games that some of them play to deny coverage for pre-existing or emergent conditions are unforgivably horrible. But the private insurance system is also a literal life saver for millions and millions of people--and there are great programs and people in the system who do amazing things in spite of problems and abuses that inevitably occur.

 

 

 

So whatever form an additional "public option" takes, if it ends up happening at all, it should strive to maintain a healthy tension between the stabilizing force of the social safety net that a government run system provides with the innovating force of the services competition that a market-run system provides. I'm looking for a hybrid insurance system that does four things:

 

 

 

1) Covers everyone and every condition

 

2) Deals with costs by reinventing how care is delivered, delegated, and paid for

 

3) Drives checks and balances between market power and government power

 

4) And promotes fair competition and innovation within and between the two

 

 

 

Both systems need adequate oversight/regulation and more focus on prevention. And they both must radically transform where care is delivered (the home whenever possible), who takes responsibility for health (patients themselves in partnership with professional and informal caregivers), how clinicians practice medicine (via coordinated care teams, with a medical home champion overseeing all care with common sense scrutiny), and how clinicians are paid and incentivized (based upon quality outcomes instead of quantity of visits, procedures, or tests given).

 

 

 

So there. I've done it. I've uttered the "PO" words in this blog. And I've come to the conclusion that I can't come to a conclusion yet. We need more details. We need to be more questioning. We need to strive for balance in all things. And we need to be able to move on beyond the "public option" controversy to start to deal with that other headline making my newspaper today: finding ways to stop pushing hospitals to their limits. Now that's something I can really hold forth about.  I want to give the public another option: the option of getting health care at home.

I'm sitting in the historic Hotel Del Coronado in San Diego at the TED MED conference (www.tedmed.com) reflecting back on the event so far. TED MED, the brainchild of Richard Saul Wurman and currently being reinvigorated by Marc Hodosh of X-prize fame, is legendary for bringing together some of the most innovative, thoughtful pioneers of healthcare technology, media, and entertainment into one big four-day "dinner party" to learn from one another and mix people up from different disciplines and industries to solve big problems in healthcare. It has been an intellectual, social, and visual smorgasbord so far--one that has left me with a mix of emotions.

 

 

 

On the one hand, I have seen some amazing presentations and technologies--the learnings per second at TED MED are very high. There has been a lot of discussion of personal genomics (spit on a chip and get your genetic disposition to a range of diseases and drug therapies) and many speakers showing science-fiction like breakthroughs in tissue regeneration (replace your damaged organs with synthetically grown versions) and personalized medicine (using your own stem cells to develop catered, custom cures just for you). I won't pretend to understand all of these technically or medically, but there are cool demos and compelling visions and visualizations of cells, tissues, organs, and systems in 3D scans that we couldn't have imagined even 15 years ago. And, as always, the relationships and connections with amazing people here is the real payoff.

 

 

 

On the other hand, so much of what is being shown still feels to me to be reactive medicine, not proactive healthcare. It is still the "mainframe" healthcare model of hospital-based acute care that glorifies the medical experts, technologies, and institutions. While there is a lot of talk about prevention in this auditorium, most of the examples are about miraculous (and presumably expensive) technologies for repairing damage already done by disease or injury. Of all the conferences and communities, I would expect the TED MED folks to be thinking very differently about how and where healthcare delivery occurs, but even these pioneers, for the most part, are embracing the medical model of care and intervention in a mostly unquestioned way. There seems to be some small battle for the soul of what healthcare really is about, but the reigning champion is still "medicine," as perhaps symbolized by the anchoring word "MED" in the rhyming title of the conference. TED HEALTH anyone?

 

 

 

I suppose this is an important reminder that the medical model--the mainframe mentality--is well entrenched in our culture and will be hard to move beyond. Our curriculums, our conceptions, our R&D programs, our venture capital, our reimbursement models, our care infrastructure, and our healthcare policies are dominated by an assumption that healthcare is about medical experts fixing problems with miraculous, breakthrough, highly-engineered technologies used in a hospital or clinic. You can see this way of thinking manifest in our television dramas (there must be five new TV shows this year about hospitals or surgeons or trauma units!) that herald the high-tech and hero-ize the high priests of healthcare who perform medical miracles (and get involved in steamy love affairs on the way) each night at 8:00pm EST, 7:00 central and mountain.

 

 

 

Nonetheless, I am heartened by the amount of innovation, creativity, and compassion in the room at TED MED. Here are some key moments for me:

 

 

 

· Tony Atala showed heart stem cells beating in a petri dish. Amazing polymer scaffolding used to build synthetic muscles and blood vessels, baked in an oven like device, and then implanted in patients. Described an inkjet printer they have filled with cells, instead of ink, to "print" a synthetic bladder or kidney. Wow!

 

· One of my favorite moments was when Damien Bates passed around plastic containers in the audience that were filled with live skin replacement tissue they had synthesized. Wow, and yuck.

 

· Jack Lord from Navigenics gave a great talk about personalized genetic testing, and hidden in his talk was a comment that "the ritual of going to the doctor hasn't changed" along with our rituals of going to church. Reminds me of how long and hard it is to change culture...and that remaking our rituals of care is the real challenge.

 

· John Abele gave an interesting talk about collaboration. Apparently, the medical dictionary doesn't have the word "collaboration" in it, which to me shows just how challenging our healthcare reform effort around "coordinated care" is going be. We have to change the incentive structure to require collaboration--it's a shame we need laws to mandate collaboration, but we do. As John put it, "managing the divas is really important in healthcare." I loved his idea of handing out squirt guns at meetings to let people shoot anyone who is being a diva or pontificator. Watch out Intel colleagues--we're going to need bibs!

 

· David Agus gave one of my favorite talks, starting with the sobering fact that cancer death rates haven't changed in 50 years, while so many other diseases have made much more progress in that period. I was thrilled with his comments that we need to stop referring to cancers by what organs that have invaded and to, instead, focus on a cancer vocabulary based on how the mechanisms by which different cancers emerge and propagate. He reminded us of something that is so core to the work we are doing at Intel around remote patient monitoring in the home: "We go to the doctor once a year, which is crazy," he said, "we don't measure things dynamically." He also pushed for controlling cancer, instead of spending so much money describing it.

 

· Vic Strecher was one of the few people, refreshingly, who focused on changing health behaviors--an area he has done pioneering work on at the Center for Health Communications Research at the University of Michigan. Much cool work on how to tailor messaging to patients to help change and sustain behavior, and a lot of focus on "digital health coaching" which we work on at Intel and Oregon Health & Science University. This is definitely work to pay attention to.

 

· Martha Stewart was one of the few people to, importantly, give voice to the need to focus much more on family caregiving and care for seniors, which has been a surprisingly absent topic given the rise of "consumer healthcare" and the age wave. Somehow the conference has talked more about the gear and gadgets than the army of family members and friends who need to use those tools to care for their own loved ones. Stewart's Center for Living is really focused on finding new models of long term care, and she is soon to put out a book on caregiving which I think will bring great visibility to caregiving issues.

 

· Goldie Hawn gave what to me was a mesmerizing talk about working with neuroscientists to build up an "optimistic" education curriculum for kids--it is called the 'Mind Up' program--that teaches them the cognitive and life skills for better managing self reflection, relationships, and emotional resilience. They shared data about how this approach to education improved the emotional and social intelligence of the kids, which then, not surprisingly, boosted math and English skills as well. Hawn was amazingly knowledgeable, passionate, and articulate about the subject.

 

· Ezekiel Emanuel, an oncologist by training and brother to White House Chief of Staff, Rahm Emanuel, flew in to talk to the audience but, disappointingly, said he couldn't talk about healthcare reform. (It's kind of like bringing Michael Jordan in but saying he can't talk about basketball.) I enjoyed his critique of medical school (1. loads of memorization forced on us just seemed crazy; 2. incredibly hierarchy of medicine treated the professor as god even if they were wrong), and his frustration with healthcare being driven by tradition ("that's how we've always done it") instead of data. Not surprisingly, my favorite moment was when he mentioned my call to action to the audience to drive 50% of care out of institutions and into the home in 10 years. He said he didn't know if we could make it that far that quickly, but that the goal is worthwhile and a lot of care can and should be done at home.

 

· David Pogue from the New York Times gave a hilarious view of how the i-Phone could save your life, showing but a few of the apps for patients and providers out of the thousands that have emerged on the flexible, swiss-army-knife type platform that the i-Phone has become. He even sat at the piano singing a song to the tune of a Brittney Spears hit about the topic. Cracked me up. He was very entertaining, but also the disruptive implications to the things shown in his talk have not yet been internalized by the medical establishment. Times, they are a changin'!

 

 

 

 

 

That's all for now. Good night.

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.

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 Senatorsto 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.

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 21st 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 21st 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.

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.

I get a lot of electronic newsletters and emails that go right into the virtual trash, but today's Communications Daily (Volume 29, Number 178) had a headline that made me literally jump for joy: "TELEMEDICINE KEY to meeting president's goals on health care reform, federal CTO tells FCC workshop." This refers to an excellent presentation about telehealth given at an FCC meeting yesterday by the President's Chief Technology Officer, Aneesh Chopra, who is quoted as saying: "We cannot move forward in advancing our nation's healthcare reform goals without the appropriate use of technology in health care and telemedicine is a key component." Citing the government's $150 billion investment in R&D in this country, he goes on to say: "Rest assured healthcare IT will include telemedicine....We are going to apply all levers to drive innovation in this space."

 

 

 

After more than 7 years, hundreds of meetings on Capitol Hill, Congressional testimony, vision videos, and more briefing papers about the need for home health and telehealth innovation in America than I want to remember, I have to tell you that I have at times been on the verge of giving up this fight. But not today. Rarely have we had a high-placed government official get the telehealth/personal health vision, let alone speak so clearly and publicly about the need for it. But Aneesh Chopra gets it. He has made it clear that our notion of "healthcare IT" cannot stop at the hospital room door--technology needs to reach out to the community and all the way to the home if we want to transform our healthcare system.

 

 

 

I have seen him speak several times--in D.C. and in Silicon Valley--and he clearly understands that we can use technology to drive new care models for prevention, early detection, disease management, independent living, and appropriate virtual care for people in their own homes. And he gets that the global age wave presents new economic growth opportunities for America in these areas, if we better coordinate our R&D machinery to focus on personal health at home. I would go so far as to say that he offers our best hope of bringing visibility, priority, and action for the personal health technology movement.

 

 

 

I have written many times about the need for innovation as a core part of healthcare reform (see Space Race and Investing in Sustainable Aging and Continuous Innovation), so I won't repeat all of that here. On this day in which the Senate Finance bill is making its rounds (I am feeling positive so far--am on page 91 out of 220), it is inspiring to see some simple, straightforward comments from our nation's CTO about the importance of innovation and technology for healthcare reform. There is no scenario in which we will magically create enough doctors and nurses to meet the demands of the age wave and of covering the uninsured through in-clinic visits for every healthcare need. We can't just focus on payment and insurance reform in these bills; we have to focus on how we deliver care differently no matter who pays for it. Innovation is key to that.

 

 

 

We need to develop new home-based technologies that offload our busy and expensive clinical settings, and help families and patients themselves to be more proactive about their own care. Whether you call it "telemedicine" or "telehealth" or "personal health" or "home health technology," the intent is the same: enable new care models that reach outside of the traditional bricks-and-mortar institutions and distribute healthcare across time and place as computing and communications have done for every other industry. The United States has a history of being an innovation leader, and there is no reason we shouldn't be the leader of telehealth as well. Now if we can get Congress to hear--and act upon--that message from our nation's first Chief Technology Officer, we can turn healthcare reform into a positive, global growth opportunity for the country...while getting our own healthcare house in order...by moving care to the home.

I've had lightning strike me twice. Okay, metaphorically speaking.

 

 

 

The first time was about 15 years ago in Utah when I was invited to be the "patient representative" on a hospital committee who had won a huge grant from a foundation. Little did they know what they were getting themselves into by inviting me in! The committee was a diverse group of two doctors, a nurse, a hospital administrator, a social worker, an architect, a receptionist, and a few others. And me. We met almost every Wednesday afternoon for a year (though I remember feeling like it was seven years, in dog time or something). Our task: to come up with and prioritize proposals for the hospital CEO on how to spend several hundred thousand dollars on something that would "empower patients and make their hospital experience much better."

 

 

 

For the first few months, we brainstormed well over 100 ideas in some detail which the architect cartooned out for us on paper while I wrote the descriptions in text on my laptop: A scholarship fund to pay for local hotel rooms for families with children in the ICU...An outdoor garden with sculpture, benches, and fountains...Rebuilding the cafeteria and food service (I can attest that this should be a priority, but it didn't seem a good use of that particular bucket of money!)...Buying artwork and new paint for the patient rooms to make them less dreary....Getting laptops for the doctors (it was their idea!)...Hiring a hospitalist to help coordinate care for people...Installing a new tracking technology to locate patients in the hospital...And many, many, many, oh so many more.

 

 

 

You would think we had been deciding the fate of the entire planet. These sessions were endlessly contentious. There were times I was relieved we were already in a hospital in case one of us passed out from boredom or shot someone else on the committee just to make them shut up. I tried for months to get us to develop a matrix of criteria for rating each idea (I guess it was inevitable that I would end up at Intel one day), but no. We'd just argue each idea out and move on to the next one only after people's rage or passion had finally been beaten out of them. Six months later...we finally got to a top twenty list with a two-page description for each one. Two more months...a top five list with a detailed budget...but no consensus. So we brought in the CEO to settle the hung jury.

 

 

 

I don't have the energy to replay that high drama here, though the memory of it is etched in me forever, especially the CEO's hawk-beak nose, squeaky voice, and propensity to flip his comb-over wisp of hair whenever he was nervous. (And he was nervous a lot in these contentious meetings.) There were four of the five ideas I could be happy with, but the fifth was just terrible: they wanted to improve the waiting rooms with more space, nicer chairs, internet access, and larger television sets. I called this the "couch potato" proposal (which no one else appreciated for some reason). Somehow we got down to couch potato and the public garden, the latter of which I was sure would win.

 

 

 

I made an impassioned plea against the waiting room couch potato plan. "If you build bigger and better waiting rooms, you'll just increase the wait times even more! Every doctor and nurse and scheduler in this hospital will think to themselves how nice and home-like the waiting rooms are, so why hurry things along? How are patients going to be empowered by being asked to wait even more than they already do? In fact, let's spend the money to get rid of all the waiting rooms...just close them and use the space for something else. That way you'll force yourselves to define an entirely new workflow that doesn't rely on making people wait!"

 

 

 

Complete and utter silence.

 

 

 

I think they seriously considered having me admitted to the psych unit. Then, the CEO flipped his hair back from left to right, and they voted overwhelmingly to go with the garden, which I should note was basically destroyed after the first winter snows wiped out the fountains and many of the sculptures. (I kid you not: it is now the designated outside smoking area!) There was one silver lining: about a year later, the architect from the committee phoned me up to meet her for lunch. It ends up she had sketched an entire plan for a hospital without waiting rooms (except for the ER) and had thought through what kinds of communications systems and cultural practices would have to happen to make it work. I was overjoyed.

 

 

 

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

 

 

 

The second lightning strike was about 6 years ago when I was, once again, put onto a panel of advisors for an Oregon hospital who had decided to build a mega parking lot due to traffic problems on their huge campus. They wanted "patient input" before spending the millions of dollars on the project. It was another bureaucratic drama about rainwater and climate impact, but not nearly as long or interesting as the Utah couch potato experience. Still, a similar unexamined assumption was at the heart of that decision: that spending money on making it easier to be at the hospital is the best use of healthcare resources. No one seemed even prepared to ask: what is the opportunity cost of building a new parking lot over other projects the hospital could have invested in?

 

 

 

Once the land had been acquired and the construction started on the garage, there was no stopping the parking lot juggernaut. While it went more than three times over the initial budget, they put up happy signs of "progress" that adorned the entire hillside as the structure slowly took shape. Massive investments of time, energy, imagination, and money were used to create that gleaming, shining monument to mobility. And what was the result? The hospital administrator confirmed my experience as a patient there. He admitted to me privately that it only increased the parking nightmare on the campus as now more patients come to the hospital because they, ostensibly, have plenty of parking! (And the cost for maintaining and staffing the parking deck has been five times what they anticipated.)

 

 

 

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

 

 

 

Maybe it is time to stop building not only waiting rooms or parking lots...but also hospitals. Maybe the 5,708 hospitals currently registered in the United States is more than enough for the next 100 years. So should we declare a moratorium on any future hospital building until we can prove that we really need them? I know, I know...call the psych ward for Dishman again. But if we're so worried about the high costs of hospitals, then let's stop making it so easy for people to go to them. And let's force ourselves to use the ones we have more efficiently and more appropriately. This requires focusing hospitals on emergencies, surgeries, and urgent care instead of the chronic disease management factories and walk-in clinics for the uninsured (who have nowhere else to go) that many hospitals have become.

 

 

 

If we're going to really do transformational healthcare reform in America, then we need to be ready to rethink things down to the buildings and foundations for care. If we continue to build more and more expensive hospitals, then we will use them. Humans will creatively jump through any hoop to use and justify what we have already decided to build. We're perfectly ready to invest time, energy, thought, and even more money to justify our prior decisions and investments, even if they were bad ones. And we will continue to build the things we already know about, understand, and have plans for...because imagining new kinds of care models--and the facilities to support them--is hard.

 

 

 

My hospital friends tell me that the rule-of-thumb for building a new hospital is $1M per bed, so a 500-bed building requires $500M in initial funding. What else could we do with half a billion dollars that would improve the health and wellness of our community? What if we used that money to clean up a local water supply? Or to fund preventive care and screening for everyone in the community? Or what if it was used to build broadband infrastructure and a call center that could help 200,000 people each year care for themselves better from their own homes? What if it was used to help combat obesity by making personal trainers available to everyone in town for free? What would be the return for spending that money to drive better prenatal care or parent education about nutrition for their children?

 

 

 

Crazy ideas--Dishman must have really been hit by lightning. But it is even crazier to continue down an endless path of building hospitals (and waiting rooms and parking lots) at any cost without exploring alternatives to how we might achieve great health for more people. At a minimum, I think we have to begin to rethink what a hospital is. It doesn't have to be just a physical place--a medical megaplex with mega parking lots and wondrous waiting rooms--but it could become a more holistic care services provider in the community for a wide range of needs beyond emergencies or surgeries. Certainly many hospitals have a trusted brand in their local communities that could allow them to extend far beyond a bricks-and-mortar mission with new services into the home.

 

 

 

Parking lots and waiting rooms, perhaps even the notion of a hospital itself, may be antiquated affordances of a failed medical mission--of a quantity-obsessed, reactive, clinic-centric paradigm that is unaffordable and unsustainable in the midst of a global age wave. We have the potential to reinvent these care buildings and practices to do care a different way and in different locations, if we can just declare a moratorium on unquestioningly continuing with our old ways of thinking. Let's ask more provocative questions, and see where those crazy answers may take us.

My fingers are disintegrating as I type, as if the words leaving me are taking me with them. Oh. It's just dry skin. My hands are raw, dry, almost bloody. With the threat of H1N1 all around (there are signs everywhere at the airport ticket counter about covering one's mouth when coughing), I've been washing my hands or using hand gel every fifteen minutes for my entire Washington week. This town is all about handshakes, business cards, and cramped quarters in elevators. It is contagion central, and I have the urge to disinfect everything around me.

 

 

 

I'm sitting in the Reagan International Airport with a lot of time on my scratchy hands. I got here really early to check in because it is Sept 11th and here I am in a Washington, D.C. airport of all places. I was afraid there might be extra security to deal with. CNN is scrolling and looping its inexorable bad news on the TV monitor up above me. The headline just came by "Another Terrorist Attack: Vigilance or Lucky?"...and they played an old sound-byte of President Bush saying that terrorism was a "ticking time bomb set to go off."

 

 

 

Then they had an interview with an expert about the imminent H1N1 epidemic.

 

 

 

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

 

 

 

Rewind to about 40 minutes earlier. I was checking out of the Residence Inn, hunting for a cab which is impossible to find on a D.C. morning like this one when it is pouring rain. The hotel staff tells me there's a "special hotel cab" (translation: you'll pay some exorbitant fee since it is not one of the regular city cabs) with another guest who is already going to Reagan, so I can ride with him. We pile me and my luggage into a Secret Service looking SUV, and I offer a friendly but I-don't-really-want-to-engage-in-conversation-at-this-time-of-morning "hello."

 

 

 

The man's blue jeans and Dallas Cowboys sweatshirt are streaked with rainwater, but he is cheerful: "Good morning. Where are you from?" he asks.

 

 

 

"Portland," comes my groggy response.

 

 

 

"Maine or the other one?" he inquires.

 

 

 

"The other one--Oregon," I offer, hoping to close off the pleasantries.

 

 

 

"Never been there. I'm from Texas. A little border town. Been working on healthcare stuff this week. Got nothing else to do since I lost my job back in June." He is now drying his clothes and bag off with some Burger King napkins.

 

 

 

He has hit my weak-spot topic, and I am impressed that someone who has lost their job would spend money in a time like that to come all the way to Washington to work on an issue they believe in. So I go for it: "Oh...very sorry to hear about your job. It's a scary economy. But it's great for you to volunteer your time here. I've been working on healthcare reform, too. Trying to get them to focus on moving healthcare to the home with the help of technologies."

 

 

 

His face is reddening: "I've been here all week on illegal aliens. We've got to stop this thing. I see it. I live in a border town, so I know it. We're in another war--these Mexicans drug lords are getting crazy on the border with lots of big time weapons. I was stationed in Iraq--I've seen this and lived this before--and now we've got a bona fide insurgence happening right here at home from Mexico." His neck muscles are bulging out as he continues: "But we're just inviting them into America and giving them a job, a car, and now health insurance on top of it!"

 

 

 

Oh lord. Surely my face was now reddening, too. I bid to close down the conversation: "Well, Washington is a crazy place, but now it's time to go home, thank god." And I opened up my USA Today as a conversation shield.

 


My bid was denied. He attacked. "We can't let the President get away with giving them our healthcare. We've got to fight that nonsense. His speech was horse ****! That Congressman was right to yell out!"

 

 

 

I wish I had come up with a courageous, eloquent soliloquy that somehow set this man and the world on a different course with his thinking, but I did not. I was actually scared at this point...angry but also afraid that it was plausible for a fist fight to break out in this luxurious cab with my well-muscled border-line travel companion. And I'm not that kind of fighter. So, with a promise to myself that I would never again talk to people in the airport, on the way to the airport, or anywhere near the airport, I said what I could: "Sir, I really disagree with you, but I don't feel well enough to argue with you...could we just get to the airport and get home?"

 

 

 

Miracle of miracles, he said: "Oh. Okay. Yes. Sorry."

 

 

 

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

 

 

 

So here I am, safely arrived to wait for my (now delayed) flight, trying to ignore the scrolling headlines. I wasn't even going to blog about any of this until I just heard that quote on TV: "ticking time bomb waiting to go off." Ah, the perpetual imminence of threat, magnified by the television ticker.

 

 

 

I don't think of myself as a fearful person, but as I think back on it, this short beginning of a day has already been filled with a convergence of little and large fears: terrorist attacks, H1N1, losing a job, war in Iraq, illegal aliens, drugs lords, guns, and fighting with a perfect stranger.

 

 

 

The terrible images of 9/11 were already in my head well before the news started shocking me with them again this morning on the anniversary. Even a month ago when my assistant printed out this trip reservation and I first realized that I would be flying out of D.C. on Sept 11th, I said to her: "Gosh, I'm not sure I really want to do that." If I am really honest with myself, my heart missed several beats this morning at the upstairs check-in when I saw a foreign man with a head covering of some kind. And there was even that little moment of hyper scrutiny when I scanned the foreign face of my cab driver, who was also sniffling and sounded congested. Terrorist? H1N1? I actually tried to steer my roll aboard so that he would never handle my luggage in case he was sick, and out came the hand gel as soon as I got into the airport!

 

 

 

All week I've been asking myself over and over how "people" could be so fearful as to believe that death squads for seniors are coming...that healthcare reform is somehow the Red Scare all over again...that the President actually wants to let illegal immigrants take over our country...or that he has hidden, sinister motives to take away our healthcare benefits? How can people believe these crazy things--how can they be so afraid? But...oh my god...this backdrop of fear is actually inside me, too. I'm not consciously worrying all the time or dwelling on these feelings, but I'm acting upon them in quick glances, small worries, and micro panics. I'm letting them insidiously color my view of the world.

 

 

 

Is there a poisonous paranoia that many, if not most, of us in America have internalized to varying degrees? Has "threat level orange" become the new normal? Are we somehow transferring our fears for things that seem out of our control--wars, recessions, epidemics, and terrorists--onto things like healthcare reform legislation that we feel that we can control? These questions put me at risk of practicing armchair psychology on a grandiose scale, but it feels important to understand how and why this healthcare debate feels at time as embattled, as escalated, as emotionally intense as an all-out war.

 

 

 

While the President's healthcare speech this week was not what I had asked for in my blog the night before, I am beginning to think it is what was needed. Like President Bush standing on the rubble in New York City after Sept 11th, President Obama needed to calm and assure the nation. But, while urgent and even potentially life-saving to many people, this healthcare reform doesn't warrant outright panic or fear of that magnitude. Hard debate about emotional topics such as public options, malpractice lawsuits, abortion, and covering illegal immigrants need to be had (along with hundreds of far less emotional topics), but let's ratchet down the noise and emotional intensity.

 

 

 

The amount of fear, rage, and rhetoric around healthcare reform seems a bit misplaced and mis-calibrated.  As we reflect on 9/11--on what it means to each of us as individuals and as a nation--maybe we can admit that we have a broader, more pervasive fear problem in the national psyche that is coloring our view of healthcare reform. And that perhaps watching the news is not good for our collective health.

 

 

 

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

 

 

 

I'm on the plane now, looking down at large cities and small towns from above. I like the fuzzy view from up here because the scars, ugliness, and decay in our society blurs or even disappears for a while from this lofty perspective. Even as I know that these words here will be cast by some cynics as naïve and dreamy (I read the hurtful emails, too), I hope and pray we can work on hard problems like healthcare, without needing to recreate the terrifying trauma of Sept 11th in order to make ourselves come together. I'm not asking us to ignore ideological differences or rubber stamp significant legislative changes in healthcare for the sake of a sense of community, but let's not prey on--and escalate--our fears from 9/11 and other cultural traumas in order to achieve political wins at any cost.

 

 

 

I, for one, don't want to live as if there is a "ticking time bomb set to go off." I'd like to detox from this poisonous paranoia. I like the other quote I have seen tickering by on the television this wait-full wistful morning: "We did not come to fear the future. We came here to shape it." Ah, so not all of the news is bad after all.

I just left a meeting at the Capitol with Alice from our D.C. office after a long day of meetings, speeches, and interviews. It was incredibly gracious of the House staffer to meet with us at the late hour, especially as the chaos around the Capitol swarmed with prep for the President's speech to Congress tonight. It was like Fort Knox meets a rock concert around the Capitol with both the security guards and speech guests electrified in anticipation.

 

 

 

I had just checked my Facebook messages to discover that my friend who has been working the system to get me into the President's speech said they had run out of seating in the Gallery, so no luck. I knew it was a long shot (U2 tickets are easier to get), and I appreciated her trying so hard, but I admit that I was disappointed. I begged off of a reception Alice was going to, and rushed into the nearest cab to whisk me away from the chaos.

 

 

 

"Was she a Congress person?," he asked in a thick accent that took me a minute to parse.

 

 

 

"Oh, uh, no...no, that was my colleague from work."

 

 

 

"Are you watching the speech tonight," he asked.

 

 

 

"Oh yes, I wouldn't miss it. I had hoped to go in person, and for a brief moment I thought I might get to just be in the room for it, but it didn't work out," I told him.

 

 

 

"You can come with me if you want. I have a place we're going...some of us changed our shift to be able to see it," he offered.

 

 

 

"Oh, wow, thank you. I probably will just get some takeout and watch from my hotel room," I replied. Though I immediately wished I had said something else.

 

 

 

"Where are you from?" I asked.

 

 

 

"Nigeria."

 

 

 

"Ah, I wondered with your accent."

 

 

 

He laughed and said, "My English is good. I am a citizen now, but can't seem to shake the accent." He turned onto Vermont Street, and I saw some signs that we were coming closer to my hotel.

 

 

 

"I just wrote a letter to President Obama about this country," he told me matter-of-factly. "This was the second one I've sent. They replied to my first one for him."

 

 

 

I told him to drive around my hotel a couple of times because I wanted to hear the story.

 

 

 

He continued: "I told the President that he has to tell the people to stop abusing their freedoms. Like freedom of speech. It is shameful the disrespect these radio talk hosts and all the people showed him and the office of the President. Just no respect. I was embarrassed for America to question his speech to the children. That is just insulting. Disrepectful. Disgusting. Just because your people--our people--have freedom of speech does not mean they should abuse it. They take it for granted. They shamefully use it. Disrepecting the President now means that everyone in the future will think it is okay to disrespect the President."

 

 

 

I told him I agreed, and we each shared some of the silly rumors about the President, his student speech, and the healthcare bill that were going around. He then told me more about the letter.

 

 

 

"It was four paragraphs. Very long paragraphs. Because then I told the President that he should not let people abuse our freedoms--that he lived overseas and should remind everyone that Americans have the luxury of being able to complain about things. But I don't think everyone should talk so much, that they shouldn't be able to criticize everything unless they offer their own ideas. Just because speech is free doesn't mean you have to use it," he said.

 

 

 

We parked in front of my hotel, waving away passengers who were trying to get into my cab. "Keep on driving, I'll pay," I told him. He went on.

 

 

 

"This healthcare debate is important. Why are people being so awful to the President and to what he is trying to do? He is trying to give everyone healthcare--which we should all have anyway. Again...don't yell at the President or each others unless you have something useful to say...an idea to share. That should be the new rule: speak only if you have ideas to offer. You can offer a criticism, but only if you replace it with a better idea of your own."

 

 

 

He then proceeded to tell me--and I do not exaggerate here--incredibly rich details about what his concerns were about the public option (he was worried it would be a big, slow government bureaucracy that would cost too much and lead to long waiting lines) but also his frustrations with "HMOs and big insurance companies who are more concerned about profits than patients." He continued his constant refrain: "don't yell and scream against the President unless you have some better idea to offer."

 

 

 

He had pulled into a side street next to my hotel by this point. And gone was my stress of the busy day, the disappointment from missing the speech in person, the worry that all my advocacy for home-based care was falling on deaf ears. He asked me if I had insurance, and I told him that I do, through my work. I told him how I had often made much of my career choices about where I could get good coverage, and he thought that made good sense.

 

 

 

I asked, "Do you have insurance?"

 

 

 

He came back with no bitterness: "Of course not. That's why I told the President that I love him and what he is doing and to let me know if I could help."

 

 

 

I was incredulous. "You told him that you love him?"

 

 

 

"Yes, of course," came his reply.

 

 

 

"Wow, thank you for sharing your ideas and letter with me. I really appreciate your thoughts here." My words felt inadequate, but they were all I had. The fare came up $8, and I went through 1000 permutations in my mind at that moment about whether or not it would be insulting to give him a big tip, or offer to take him to dinner, or ask him if I could go with him to see the speech, or would a big tip be seem as paternalistic, would it send the message that I assume all cab drivers are idiots and he is a nice exception, would it be insulting, or should I ask to follow up with him in some way, but then again, hey, what crazy cab rider starts asking the driver for his address or phone number....AGGGGHHH!

 

 

 

So I gave him a twenty and said, "Keep the change. You have inspired me with your idea and your letter. Thank you so much for sharing your wisdom with me." It was the best I could come up with.

 

 

 

He gave me a huge smile, and said, "Thank you very much. You Americans who were born here need to remember to value the things you take for granted...like free speech and the ability to even argue safely about things like healthcare reform. Where I am from, we can get killed just for having a different idea, or talking about it. And we can't even begin to imagine the luxuries that people here take for granted. Don't abuse those gifts and the leaders who work to give them to you. Good luck."

 

 

 

A woman rushed into his cab, he pulled away, and I just stood there dumbfounded, inspired, ashamed, and lots of other emotions.

 

 

 

So America, as you watch the speech tonight or listen to the interpreted soundbytes ad nauseum or read blogs abounding...I hope you'll remember a few things. That those of us with the privilege of healthcare coverage only have so much to say on the matter. That those of us who have grown up with the freedom of speech are perhaps abusing it and cheapening it, as we hurl and consume headlines that stir up public sentiments against fictional monsters while the talk show pundits laugh all the way to the bank. That our freedom of speech is not to be squandered or used recklessly or superficially. And that perhaps the most important speeches to hear may not come from Presidents but from the wisdom of the crowds who are around us all of the time, if we would just notice them, and listen.

 

 

 

I've just finished my takeout. I'm sitting outside at the Corner of L and Vermont pilfering WiFi from a nearby cafe. This blog is posted without me even having proofread the darned thing. Because I'm about to rush upstairs to take off my tie and painful shoes. Let's hear what the President has to say and give him, and the office he represents, the respect they deserve.

I just got back from a brisk walk (after yesterday's blog, I at least tried to exhibit some Personal Social Responsibility by getting some exercise!) by the Capitol, the White House, and the National Mall all lit up at night. What a stunning view! I really needed that dose of inspiration to lift me up beyond some of the ugly politics that goes on inside and around those beautiful buildings. If only we could be so lofty and grand in our daily endeavors as those magnificent monuments that bare witness to our higher and more noble abilities.

 

Okay, back down to earth, Eric.

 

There's a lot of talk around town about The Talk. That being, of course, the imminent and eminent speech from the President tomorrow night about healthcare reform. I'm in a hopeful mood after my walk, so let me lay out some things I personally hope to hear:

 

1) That we're "staying the course" to do real healthcare reform, now. We can't defer this issue again to a future Administration. That doesn't mean we can't take more time to do reform right--we shouldn't declare "Mission Accomplished" prematurely--but the President and Congress need to stay committed to moving our country forward with access for all, payment based on quality/value, care coordination, and cost savings.

 

2) That he has not given up on bipartisan compromise. He needs to coax some in Congress to act more like Ted Kennedy did--to reach across the aisle and make real compromise. This bill is too important to ignore Republican ideas, to squeak by with a Democratic majority, or even worse, to use an obscure loophole like reconciliation to close off filibuster and reduce the threshold of votes needed to pass.

 

3) That the commitment to cover everyone remains. It's time to act and be like the economic world power that we are, which means giving every American access to quality healthcare. It is important for our nation morally, economically, and competitively. Almost everyone is for universal coverage (which, I should point out, is different than--and can be achieved without--a "public option" or a "single payor" system). So let's "leave no patient behind" once this healthcare reform work is done.

 

4) That healthcare reform is bigger than deciding a "public option." I am disappointed to see politicians playing chicken with something as important and complex as healthcare reform by reducing it to a fight over the public option. There is far more to get done than just insurance reform, and no matter "who pays," we have to change how we pay and how we deliver care. Congress has chosen to make this issue the battleground, but they can just as well choose not to divide-and-conquer each other and our nation on this issue.

 

5) That government protection and market competition are not mutually exclusive. We seem to be headed towards an "either/or" false dichotomy: either the government runs and pays for all of healthcare or there is a free-market insurance system. I, for one, don't want insurance companies to have free reign to kick me out or make my rates prohibitively expensive if I become seriously ill or have a pre-existing condition. After all, I pay for insurance for exactly those kinds of scary scenarios. There needs to be some reform, regulation, and government oversight of the industry. At the same time, I am not exactly encouraged by Medicare and other existing government-run healthcare programs as being the epitome of fast-paced, ever-improving, service-oriented institutions needed to deliver great care to the whole country. There needs to be a competitive insurance marketplace where private and government options compete on a level playing field. Let's find a middle ground. (See #2...compromise...above.)

 

6) That there will be a focus on the tough problems: chronic disease and seniors. We can't achieve meaningful cost savings without tackling better ways to prevent and treat chronic disease and finding ways to help seniors live longer and healthier from their own homes. The lion's share of costs come from these areas. We need to admit that the age wave is upon us with a flood of chronic and age-related illnesses and injuries, so let's focus on redefining long term care and chronic disease management for the 21st century.

 

7) That we'll tackle moving 1/3rd of care from institutions to homes in ten years. There is no scenario in which we will come up with enough dollars or doctors or nurses to continue to see everyone in face-to-face visits in a clinic or hospital for every healthcare need. We can't afford it today. We can't afford it when the number of seniors doubles. We can't afford it when we add 47 million uninsured to plans. Home based care has to become a part of our national strategy for reform, and "virtual visits" to the home through telehealth technologies need to become as normal in American life for many kinds of care needs as email has become. Use hospitals for what they are good for, but use homes for what they are good for, too.

 

8) That he'll talk about the new responsibilities we'll all need to take ownership of. School students aren't the only ones who need a reminder to take personal responsibility in our society. All of us--as patients, providers, plans, politicians--are going to have to undergo some behavior change if we are to succeed with healthcare reform. This will take some personal sacrifice and some new roles and responsibilities for all of us. Culture change is hard and anxiety producing, but we need to be honest with people about what is expected of us going forward, from taxes to healthier behaviors to family caregiving.

 

9) That continuous innovation will be designed into our reform infrastructure. No one should believe we're going to figure out how to fix our largest sector of the economy that impacts every single person in one session or even one lifetime. We need Medicare, HHS, and other government-run sectors to embrace innovation and innovation methods--and to drive continuous, iterative improvement of our delivery and payments systems. Healthcare reform needs to be an ongoing exercise, not a once-a-generation disruption.

 

10) That care coordination will still be a priority. Regardless of the flavor of the conversation you speak--"care coordination" or "medical home" or "accountable care organization" or "payment bundling" or "care teams"--we need to keep speaking about and enacting models of care that reward the coordination and collaboration of care across specialties and across peoples' multiple healthcare conditions and issues.

 

Okay, enough digital ink spilled on this top 10 list. I'll go to bed with this last thought: we need details. While I know there is only so much detail that can be offered in a televised speech to Congress, we need to see some follow-up documents with more details. The President can't stop at high level principles and compelling personal interest stories. He has surrounded himself with some of the smartest minds on the planet about healthcare and innovation--it's time to see what that brain trust has come up with to solve one of our society's most pressing issues. And it's time to take this conversation to the next level of detail and action.

 

Stay tuned.

This Labor Day, I am on a plane headed back to Washington, D.C., either a glutton for punishment or an eternal optimist about healthcare reform. It's another week of 40 or 50 meetings on Capitol Hill to try to be heard above the "public option" noise which has sadly come to dominate this debate, as if it is the only problem (or solution) worth fighting for. Regardless of how we end up paying for healthcare for everyone, the painful facts remain: we can't afford quality healthcare for all...or grow our economy...or stay globally competitive...without fundamentally changing our healthcare paradigm--and our social contract--for the 21st century.

 

 

 

For the health of our country, we need to get off the entitlement train. From patients to providers to politicians, we have come to live in an era of entitlement. We have become a fast-track "me generation" with super-sized expectations for our lifestyles, services, salaries, profits, power, and appetites. We need the moral equivalent of Corporate Social Responsibility for each of us as individuals--call it Personal Social Responsibility, or "PSR" for short. Sure, I could just call this personal responsibility, something we're all supposed to pay attention to, but capitalizing the phrase and putting "Social" at the center reminds us that we also need to be doing things for the social good, not just for the good of us as individuals.

 

 

 

Reforming healthcare in the midst of a global age wave and economic recession requires a rethinking of who we are as citizens. Defining a new social contract for healthcare means that we need to renegotiate the terms and conditions of what we are signing up for as a member a healthy society. What do we as patients, doctors, workers, corporate leaders, or political leaders need to do differently to achieve true healthcare reform? What would Personal Social Responsibility look like for each of us? Because so little in the debate has talked about PSR or reforming our social contract, I'm going to devote several blogs to this topic over the next couple of weeks. And to start things out, I want to focus on all of us...as patients and consumers of healthcare services.

 

 

 

Over the past twenty years as an advocate for several hundred patients in six different states, I have noticed some disturbing trends. There are multitudes of chronic disease patients like "Margaret" who took a laissez-faire attitude towards her diabetes. She once told me "the doctors can fix anything that goes wrong," so she kept eating junk food almost every meal, forgot to take her insulin, and failed to track her glucose readings. Then there are the "Morris" type of patients. He was a retiree in Texas who was convinced he was the only patient in the universe, who deserved every test and attention that the doctor could give him because, as he oft pointed out, '"I've paid my dues and my co-pay." And then there are those, like "Frances," who epitomize an epidemic of patient passivity. In dealing with her stomach cancer, she dealt with over a dozen specialists across three states, but she never took the first note in an exam room, challenged anything a doctor decided, researched the first treatment being suggested, or even questioned when two different doctors put her on the same medication.

 

 

 

We as patients--as consumers of healthcare services--have to behave better and differently if we are to achieve healthcare reform that covers everyone, improves quality, and holds costs and the deficit at bay. We have become addicted to all-you-can-eat lifestyles with an all-you-can-use sense of entitlement towards healthcare services. We have too often lived up to the name "patient" by waiting around, passively bowing at the feet of the high priests of healthcare, absolved from all personal responsibility and action in our own care. We have treated our bodies like we do our cars--waiting until things break only to have the mechanics "just fix it" but with someone else paying the bulk of the bill no matter how reckless we've been as a driver. This collective lifestyle is unsafe, unhealthy, and unsustainable. So we need to become a different kind of patient.

 

 

 

First, we have to take Personal Social Responsibility for eating better food, exercising regularly, and stopping smoking. Our country simply cannot afford to pay for the largely preventable epidemics of chronic disease that suck dollars into our voracious healthcare system from other important areas like education, infrastructure, science and innovation, and homeland security. Healthy lifestyles have to become almost a patriotic duty--each of us rationing our unhealthy foods and behaviors for the War on Obesity, much as the greatest generation made personal sacrifices to fund military wars of the past. Parents on the frontline have to set baseline behaviors for nutrition and exercise for their children so that these become "second nature"--this is the ultimate act of prevention and patriotism and, quite frankly, love for our children that we can give. And we need to be open to explorations of insurance premiums and other incentives that foster healthier, more responsible behaviors by and for all of us.

 

 

 

Second, as consumers of healthcare, we have to take PSR for paying attention to the value and costs of healthcare services we are using. We are not entitled to an endless smorgasbord of healthcare services at any cost--regardless of who pays for it. Somehow even the wealthiest of us have come to balk at a "$10 copayment." Somehow we've come to expect that treating a cold should cost us the same as a fall down a mountain. Somehow we've come to demand every test or therapy imaginable, even if it has little-to-no proof of improving our health. Healthcare is and always has been "rationed" because resources are never unlimited, but somehow we've turned the "R word" into a litmus test for being a communist. The reality is that one person's wastefulness is another person's potential lifesaving resource. We need transparency of healthcare costs in understandable terms and language so we can evaluate the emotional, economic, and evidence-based tradeoffs of different procedures and medications. And we need to pay as much (or more) attention to the economics of our healthcare services as we do to the house, car, or electronics that we buy.

 

 

 

Third, PSR means we have to become more proactive as patients. Gone are the entitled days of patients simply waiting until we are sick and then showing up at the doctor's office for a dose of wisdom and some prescriptions. We need to be informed patients--researching the illnesses, injuries, and genetic risks we face so that we are a partner with our doctor or nurse in preventing a problem or getting better faster. We need to be empowered patients--taking notes and taking names in our clinical encounters to understand the details of our recovery. We need to be adherent patients--striving to follow what are most often "best practices" offered by our clinicians if we would only stick with the care plan they give. And we need to be demanding patients--being in charge of our care across providers, specialists, and problems we face because no one else can be a better champion for our holistic health than ourselves.

 

 

 

I'm under no illusion that these three things--healthier behaviors on a daily basis, paying attention to the economics of our care, and becoming more proactive patients--are easy. While I am personally pretty good at the third one, numbers one and two are hard for me. I've struggled to stop eating fast food, junk food, and get more exercise to reduce my heart disease risk and better manage my own multiple conditions. And while I've tried to research the comparative costs and effectiveness of drugs and other therapies I am on, it's not an easy task to do. With the hieroglyphic codes that show up on dozens of different bills from a single outpatient visit and the unavailability of what procedures should typically cost, it has proven difficult for me to be economically conscious about my care.

 

 

 

Do I want my employer, insurer, or the government to monitor my lifestyle? No, but at the same time, I realize that just knowing the right thing to do for my health has not been enough to get me to change things adequately. Perhaps hitting my wallet would help me help myself, while also saving the country money. Do I need the government to tell me what choices to make about my care? No, my clinical team and I can figure that out, but I could use policy changes that make cost transparency more standardized and intelligible. Do I think doctors and nurses are ready for empowered, informed, proactive patients? I can tell you from lots of direct experience that the answer is mostly "no." In an age in which they are incentivized to see as many patients in as little time as possible, doctors don't have time for proactive patients like me.

 

 

 

But I do need the government to establish a vision, a social contract, and a set of policies for our new healthcare system that shifts us from personal entitlement to personal responsibility. We can become more proactive and preventive, without spending our every minute thinking about healthcare. We can become healthier, without becoming a nanny state. We can become more personally socially responsible, without becoming a socialist country. And, as I have said before, we can shift the national discussion...to ask not what healthcare reform can do for you...but what you can do for healthcare reform? Or so says the eternal glutton for optimism.

I wasn't even born until 11 years afterwards, but I grew up fully aware of the launch of Sputnik I in 1957, the dog "Laika" sent up by the USSR the next year, and the whole "space race" between the Americans and the Russians. Those historical moments gave us a global--even galactic--perspective and a global competition for innovation. Yes, for many people, it was tinged with an element of fear and potential military catastrophe. But for me as a child through to this very day, it captured my imagination and felt like a collective sense of purpose for where America should be headed. It was that generation's manifest destiny to own the skies, and it generated enormous advances in other fields and industries as a side effect of focusing on those grand challenges.

 

 

 

As we are bogged down in this healthcare reform debate (and for those of you who missed the intended parody of my last blog post, I want to assure you that, while tired of the silly headlines and partisan posturing, I am okay and that it was meant entirely as a humorous critique of our healthcare paradigm!), it occurs to me that the President and Congress have missed an enormous opportunity to show how healthcare reform--what we really ought to call "healthcare innovation" instead--could and should be the context for the equivalent of our next global space race. 

 

 

 

We should be taking a global, competitive perspective towards healthcare reform, realizing that some country is going to develop new infrastructure and industries to deliver care in fundamentally new ways for our swiftly aging planet. Some nation will see this global age wave not only as an economic threat but as an opportunity to generate new technologies, services, and jobs to deliver personal healthcare. Back in the year 2000, there were 600 million people over the age of 60 on our planet. By 2025, in just fifteen more years, the World Health Organization says there will be 1.2 billion...with more than 2 billion by the mid century point. This demographic horizon is where we should be aiming. The United States ought to be at the forefront of innovation to meet the needs of this global age wave.

 

 

 

How do we pay for the uninsured and our voracious healthcare appetite in America? One answer would be to become a global leader of delivering new healthcare services and technologies not only here at home but also to many other parts of the world. Someone is going to use the advances of the Internet, genetic testing, personalized medicine, home diagnostics, health coaching and disease management software, and social networking sites to deliver care differently. Some country is going to tap into the "Boomer Phenomena" to foster and ride a cultural movement of consumer empowerment, self-care, personal responsibility, and patient proactivity with new services that allow people to pilot their own bodies and healthcare experiences from their own homes, laptops, cell phones, and personal health records. The question is: are we in the United States prepared to compete in this global race to deliver personal health care to the planet?

 

 

 

I get to spend some time in Europe when visiting our Technology Research for Independent Living, or TRIL Centre, in Dublin, Ireland (check out www.trilcentre.org). My friends and colleagues there tell me that the European Union is investing with clear intent to develop a 21st century healthcare services infrastructure for themselves (they are ahead of us on the age wave curve so already need advances in aging-in-place and disease management technologies) and for other countries. They have invested more than one billion Euros in independent living technology research. They have made home and community based care an international priority. They are exploring the trans-national licensure of doctors and nurses who could then deliver care to their patients virtually or in locations across Europe. They are in the early stages of training and credentialing new kinds of home care and other "care concierge" workers. They are investing in broadband and other computing infrastructure to the home--even in rural areas--to help people be "e-citizens," which very much includes getting health care at home. So perhaps the United States is already well behind in the "space race" to innovate for global aging?

 

 

 

As the President addresses Congress and the nation next week on healthcare reform, I hope he brings his innovation message forward.  He has reinvested in science and technology research and education. He has hired the nation's first Chief Technology Officer. He has invested in health information technologies and electronic health records as infrastructure for healthcare reform. He has shown how innovation to meet the needs of Global Warming can generate new jobs and industries across America. Now he needs to show how the same results can come from a focus on Global Aging.

 

 

 

  1. President, let Wednesday's speech be your call for a Sputnik launch for healthcare reform...start the next space race...throw down the innovation gauntlet to the American people to make healthcare reform not only a means of healing our sick care system but also a means of generating new jobs, new kinds of healthcare jobs, new technologies, and new services for providing care which could extend globally. Show the American people and the rest of the world that healthcare innovation--for a global marketplace--can be a stimulus to our economy. Let us begin the race that others have already started. It is our generation's challenge to own the future of healthcare--the largest segment of the economy in almost every nation on the planet. Healthcare reform and policies in Washington D.C. should focus on helping us to compete fairly, vigorously, and internationally...and to win.

I have avoided writing here about my new healthcare problem because I thought it would be too self-serving, but I don't feel I can hold this in any longer. I am just really, really tired, overwhelmed, a little scared, sometimes even exhausted. I know, I know...I am an oh-so-popular-big-time healthcare blogger (one person other than my Mom read last week's entry!), and the power players of healthcare reform are just hanging on my every word. So I am supposed to be energized, passionate, and committed to reform. But I am just so fatigued--ready for all of this to be over--ready to change the proverbial channel.

 

 

 

Honestly, I've been ignoring these symptoms for a month or more, but I finally called my doctor's office to try to get an appointment last week when I saw something online about how serious my Reform Fatigue could be. I thought it was just stress, but who knows, could be much more serious than that. After all, Google came up with 198,764,145  possibilities. I'm not that worried, but, then again, it could even be terminal, according to my friend's brother who heard something about this kind of thing while playing golf with a doctor's sister's friend. So I figured I better have it looked into by a professional.

 

 

 

I am relieved to report that Dr. Hurray finally fit me in this morning after I left twelve voice mails for his nurse and faxed over the stack of lab results given to me by the specialist Dr. Hurray had asked me to see before I came to see him again. (I think I left some of the papers in the specialist's waiting room, but how important could those be anyway?) Traffic was just awful this morning going over to the clinic. It was a miracle I got a parking space--some guy in a wheelchair tried to slip his van into the space that I had been waiting on for ten minutes. Sheesh!

 

 

 

The waiting room was a can of smelly sardines with everyone sneezing and coughing in my face. My god, there were sick kids running everywhere acting like 4th graders or something. "I waited a week for this?" I thought to myself. There were eight people in front of me for the check-in, but after ten minutes, I had finally made my way up to the little sign telling me to "Please Wait Here Until Called, Out of Respect for Other Peoples Privacy." (What is it about people not using apostrophes correctly anymore?) More waiting. And I could have shot the idiot in line in front of me who couldn't find his insurance card, had had unprotected sex with a woman he met at a bar last night, and was there to see a doctor about potential STDs. I mean, that is so 1980s. All of us in line were embarrassed for him.

 

 

 

Finally, I got up to the window which the attendant slammed shut in my face, pointing to the pen and notepad to sign in, as I frantically looked around for hand sanitizer. The window swept back open with a grating metal noise, and Darth Receptionist thrust a clip-board in front of me. "I need your insurance card, and fill all of these out, and we'll call your name in a little bit." She retreated behind her glass fortress, closing the drawbridge to lock out me and my band of personal space invaders. I was concerned about the words "a little bit."

 

 

 

I had just filled out the same form last month when I was in for the flu. But I dutifully tried to remember and spell the nine medications I take regularly, the last decade I had had a tetanus shot, and whether it was 1973 or 1974 when I had broken my elbow from that terrible fall off my bicycle when Billy Jones pushed me. Hmmmm...."reason for visit today?"...I wondered what to say. I mean, if I marked anything in the "Mental Health Problem" section, then someone...my wife, my boss, some sneaky blogger, even the CIA...might get the data somehow and jump to the wrong conclusion. I'm not depressed, after all! So I just put down "fatigue" and "shortness of breath" in the blanks provided at the end of the form.

 

 

 

I stepped away from the window, searching for the most solitary seat I could find. It's like scanning across a police lineup looking for the person who is least guilty of being sick. Ah, finally, the back left corner where the light bulb was burned out and the air conditioner blower was setting a new wind tunnel record. "I'd rather be cold and alone than sitting in the sick section," I thought to myself with a sense of satisfied victory. I sat down to wait. About 15 minutes later, this huge woman with Kleenex stuffed in the top of her blouse tried to sit next to me and grab the dog-eared copy of People magazine that was on the table, but I was there first. I frowned and grabbed the magazine (unfortunately, it had Michael Jackson on the cover...from 12 years ago...when he was still alive and looked almost human). Then I hocked up the best tuberculosis-sounding cough I could muster, which drove her into full retreat. My drama degree was paying off.

 

 

 

About 30 minutes meandered by, and I didn't hear when the nurse called "James!" until about the sixth time. I go by "Eric," my middle name, but they just can't seem to get that straight after 10 years of my going to the same clinic. She escorted me back, thrusting the thermometer into my mouth and nudging me up on to the scales to weigh me.  I almost gave a "moo" for effect, but decided I better not tick off the person who might have to give me a shot or blood draw later. "189 pounds!" she disdainedly (that should be a word!) announced to the entire office staff. She didn't seem to care that I was wearing heavy clothes, my Ipod, my cell phone, my wallet, and what must have surely been 18 pounds of change in my pockets. Whatever happened to scientific rigor and accuracy in measurement?

 

 

 

She rustled me into the arctic chill of exam room 5, told me to put on a gown (now she asks me to disrobe, once she has already bungled my burdened weight!), and said, "The doctor will be in, in a few minutes." I knew that wasn't true. I could hear him trying to explain to the poor woman in the next room, who clearly didn't understand much English, what a hemorrhoid was. I took a mental note not to shake his hand. I don't care much for Sports Illustrated (interestingly enough, there was an article in it about bicyclists avoiding hemorrhoids), but hey, Tiger Woods was on the cover, so I read the April 2006 issue to catch up on my current events.

 

 

 

Finally, Dr. Hurray hurried in with "Hello, James, how have you been?"

 

 

 

"Eric," I replied.

 

 

 

"Huh?"

 

 

 

"I go by Eric," I repeated.

 

 

 

"Oh, yes, sorry Eric. What can I do for you today? It says here you are having stomach cramps." He seemed reticent to touch me. (The feeling was mutual.) Come to think of it, I can't remember when Dr. Hurray has actually touched me in the past two years of visits. He just asks me questions and gives me prescriptions, but never actually does an exam.

 

 

 

"No, that's someone else's chart. I came in because I'm a little, well, um, fatigued and have some shortness of breath." He sheepishly put away his papers, scrambled through some other official-looking papers in a chart, and said, "Ah, yes" with confidence that didn't convince me he was really looking at my chart. "Tell me what seems to be the problem. When did you notice the shortness of breath?"

 

 

 

"Should I tell him about the mood swings?" I thought to myself. No, no. Not yet. "Well, I was reading a newspaper at the time...it was the Wall Street Journal...about the trillions of dollars of debt expected over the next decade from the healthcare reform bill."

 

 

 

"I see," he said he saw. "Anything else?"

 

 

 

"Well, I am just really, really, really tired. More so than usual. Just overwhelmed a bit...not really sad or depressed mind you...but moody."

 

 

 

He jotted down a note with a concerned look in his eye. I wished I hadn't said the word "moody." "Tell me more about the moodiness," came his next question. Damn.

 

 

 

"Well, uhm, one minute I am really excited about healthcare reform, then I'm way down about it...though, of course, never actually depressed...and then I am way up again."

 

 

 

"That could be something," he mused. "Any other symptoms?"

 

 

 

"My blood pressure medication usually keeps things pretty stable, but I just find it boiling at times. Like when I was watching the news stories on the death panels. And when I heard talk radio going on about communism while driving home from work the other day."

 

 

 

I thought then, at that moment, he would actually touch me, actually do something, you know, an exam. But he deftly wielded his stethoscope to listen to my breathing without his hand actually making contact with me. It's not like I wanted a bunch of probing, mind you, but I'm thinking this guy is in the wrong profession if he is scared to touch patients.

 

 

 

"Sounds interesting. I'll be right back," he promised as he scurried out of the room like a cockroach running from the hallway light.

 

 

 

About 20 minutes later (I could hear him re-explaining hemorrhoids to exam room 4, promising he would call her at home in a few days to check in on her), he came back in the room with a glossy brochure. "You have Reformania Exhausticitis...it's a new disease...but I'm seeing a lot of it these days. It's nothing to worry about, there's a very harmless new drug you can take that will clear it right up."

 

 

 

"What is it?" I asked.

 

 

 

"It's called Complacencia," he said as he handed me some literature, and I suddenly felt like I was in one of those awkward TV commercials that plays during the six o'clock news.

 

 

 

"Can't I just have an antibiotic? Or is there something else I can do without having to take another pill?" I pressed.

 

 

 

"No," he retaliated, and handed me his scribbled prescription on a piece of paper. "Here, I'll give you some samples to get started. And I'll call you next week just to see how it is going."

 

 

 

Ah, free samples. Music to my ears. I felt like I had won the Pharmacological Lottery. I embraced my swag, reading the pretty, glossy font: "Complacencia: That Little Something to Restore Your Satisfaction with the Status Quo." It went on to explain how the medication could help me stabilize my reform moods, fend off my cravings for real progress and change, and better manage my tolerance for mediocrity.

 

Clutching my prize, I took the first two pills right then and there, and by the time I reached the parking lot, I was ready to get back into the trenches of healthcare reform...hungry for more of the same. Once again, the miracle of modern medicine had shown me its awesome power.

 

 

 

Notice: Complacencia is not for everyone--use only as directed by a physician. May cause drowsiness or excitability, especially in adults who act like children. Some patients report dry mouth, wet mouth, constipation, diarrhea, sadness, happiness, the urge to gamble, the urge to stop gambling, and a propensity to want to just sit around and watch television. Do not use Complacencia if you are an activist, reformist, concerned citizen, or employed in a job where you need to be highly motivated. Ask your doctor about taking Complacencia if you are already taking optimism-reducing medications such as Headlinea, Partisinia, Prodeficitia, or C-spania. Extreme liberals and conservatives should not take Complacencia for more than 30 days without consulting your doctor. Moderates should not take Complacencia, as it can cause an overdose of complacency that can be fatal. Have a nice day.

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