Consulo Indicium 6/18/18

Information for your Consideration…

 A Diversionary Thought:  I Thought I Was Useful – As most of my readers know, I moved into executive and managerial roles some time ago and when I’m asked by those I met the question – “So, where do you practice?” – my usual response is: “On United Airlines!”  I answer that way because for the last 20+ years it seems that the clear majority of my time has been spent on planes traveling across the world.  So, you can imagine my dismay when I recently picked up The New York Times and there was an article titled: “Is There a Doctor on the Plane? Increasingly, Airlines Hope Not”.  I’ve always known that there was a company in the background someplace providing support to the flight attendants and pilots on in-flight medical emergencies.  Evidently, the major company is MedAire, Inc. which provides services to more than 100 airlines – and, by all accounts very high-quality support.  According to their data, only 1.6% of their flights are “diverted” for a landing due to an in-flight medical problem which generally costs about $200,000 – so the emphasis of the airlines is to avoid diversions.  Now the diversion results of MedAire are different than the results of a study reported in a 2013 issue of the New England Journal of Medicine which revealed that there was a medical emergency once in every 604 flights and 7.3% led to diversions.  The study also reported that 0.3% of medical emergencies on planes end in deaths. The dismaying part of the article was the statement that the airlines “hoped” that no physicians were available on the flight in large measure because in-the-air physicians have a much higher propensity for diverting a plane to land.  It got me thinking.  What were my results?  So, I did a quick tally.  Over the last 20 some years, I’ve experienced about 3 – 5 “medical emergencies” with 0 deaths and only 1 diversion – which was for a gent who was having chest pain and all the symptoms of a myocardial infarction.  But the vast majority of my clinical experience has been related to in-flight patients who either drank too much the night before or the hours before a flight or, drank too much during the flight.  These have been interspersed with “real” medical emergencies like acute asthma due to peanut dust in the air, an apparent appendicitis (although I never did get the final diagnosis), a TIA-like presentation and other assorted “real” experiences.  My most challenging was when one of the flight attendants collapsed in the cockpit and I had to work with the crew to extract her from the floor so that they could continue the flight.  We made it…  Anyway, I decided that zero deaths with one diversion is a record that’s not bad.  Hopefully, United will continue to let me fly the (increasingly less) friendly skies. I expect to continue answering the call when I hear, “Is there a doctor on board” or the flight attendant approaches me with a quiet whisper, “Dr. Fickenscher, please come with me right now!”

Politics Before Health Care So That Health Care Trumps Politics – Lancet had a very interesting article several weeks ago entitled, “The world has been warned” by Richard Horton. The essence of the article is that it makes the case for greater involvement by the health care professions in the politics of the day if we are going to be successful in continuing to make the case that investments in health care research and programs make a difference for society.  Our focus tends to be on the more immediate questions related to patient care services with strong advocacy for a proper financing and functioning of the health system. Beyond those core areas of focus, the health professions tend to scatter.  The article makes the case the we need to listen to the advice of the economist, Dambisa Moyo, Ph.D. who argues in her new book Edge of Chaos (2018) that the support for public investments in health programs and services is weakening.  Why?  She argues that it all comes back to sustainable economic growth and development – which is not the first order of concern among most health care professionals.  Without it; however, the ability of governments to provide the necessary funds for health care programs will wane even though demand is rising.  In fact, her central argument is: “politics, and not economics, will be the key driver of human progress and prosperity in years to come”.

In essence, the message is that threats to democracy, factors that diminish economic growth (e.g. growing debt, aging of the populace, natural resource depletion, deepening income disparities and a host of other “economic” considerations are key factors that will be driving the health care debate in future years.  We need to listen.  The point of the article by Horton is that “Taken together, these pathologies are laying foundations for an unprecedented period of government failure, political instability, social fracture, and community unrest.”  You definitely need to read this article and check out Moyo's conclusion that, “liberal democratic capitalism is in retreat”. There are ten prescriptions offered that could help move us back toward a position of stronger support of health care – a core offering of most governments throughout the world.  The ten prescriptions have little to do with health care and everything to do with democratic stability.  Check it out. 

Are We Prepared For Value-Based Care?  Short answer, “No!” A new study of over 900 physician organizations by Black Book, a consulting firm, reveals that physician organizations are increasingly concerned about their readiness for the move toward value-based care.  Independent and physician-led practices represented 72% of the study group. The essence of the findings; however, was that the groups felt that they were not prepared for a move toward value-based payments.  In fact, the study found that 93% of the practices did not have a strategic plan in place "for transforming [to] population health management or value-based care solutions…”  My prediction: The coming decade will be littered with also-ran medical groups that failed to prepare for a tsunami of change that is about to sweep the fiscal structure of our health care delivery models.  The current system is unsustainable from a purely financial perspective.  The Boomers (my generation) will bankrupt the nation if we continue the current course.  Change will be led by the states.  It already is!  Things need to change. 

Secondhand Smoke And Marichiwanna – A new study was recently published online in the journal Pediatrics suggesting that the warnings we’ve made about the use of cigarettes in the home by parents should also now be extended to the use of marijuana in the home.  The assessment of the study was that “an increase in parents smoking pot around their children could undo decades of effort to protect” children from the effects of secondhand smoke. The homes as risk were those where parents already smoke cigarettes.  In those families, the percent of marijuana smokers increased from 11% (2002) to 17% (2015), a notable rise versus those families where cigarette smoking did not exist with an increase of 2% to 4%, respectively.  I mean, after all, smoke is smoke…

Healthy Diets = Big Brains – In a new 10-year study from the Netherlands, it was determined that eating a healthy diet like the Mediterranean diet seems to be associated with larger brain volumes. In fact, the brain matter in these individuals had a higher volume of grey and white matter along with a larger hippocampus.  The study is consistent with my wife’s missive that I need to eat six cups of fruits and/or vegetables every day, less red meat and less fat (i.e. far less bacon).  And, potatoes are not considered a vegetable in her ruling which doesn’t make sense to a farm boy of German heritage unless I decide to become Greek – which she notes is always a good option!  But, I’m learning that I should not argue!  Besides, now I have a reason – a bigger brain.  That and $2.00 will get a Grande dark roast at Starbucks.  But, we do seem to be getting consistent results related to the impact of the Mediterranean diet.  It’s worth adopting in my estimation.

Sovereignty Of The Tribes Indirectly Challenged – The US Department of Health and Human Services is seemingly stumbling into what could become a decade long litigation nightmare as it continues down the track of requiring Native Americans to hold jobs to keep their health care.  The move by HHS directly assaults long held agreements between the US government and the tribes by challenging tribal sovereignty which has been recognized for centuries – not, decades.  The Trump Administration has put forward a proposal stipulating that the tribes are a racial group and not separate governments.  Needless-to-say, the reaction from the tribes and many members of both parties was quick and negative.  In making the preliminary ruling, the feds are passing along the implementation to the states which will no doubt result in a series of inconsistent proposals and approaches toward the tribes.  This is not an arcane legalistic argument.  Rather, it cuts to the core of agreements made between the US government and the tribal nations over the last two hundred some years.  The decision has also split the department where the political appointees have taken a seemingly softer position (i.e. let the states work it out) while the HHS Office of General Counsel have taken a distinctly opposite position (i.e. work requirements apply to everyone and the tribes are not exempt).   So, the question is whether the Trumpee discord will be resolved in the Agency or in the courts?  HHS political leaders have tried to avoid the controversy by suggesting the matter is a local issue that could be resolved as the federal government and states negotiate the parameters of their proposals. But, duly negotiated agreements between sovereign tribes and the US government would be a difficult thing to undo to say nothing of the political fallout.

Here A Tweet, There A Tweet, Everywhere A Tweet, Tweet – It was only a matter of time before academia caught on to the use and impact of Twitter.  In fact, in a recent article, Jason Frank, MD (@drjfrank), a clinician-educator at the Royal College of Physicians and Surgeons of Canada (@RoyalCollege) made a bold statement when he offered this thought: “Within the next decade, you won’t be able to be a successful scholar without having some activity on social media.”  Hmmm…  Dr. Frank’s thinking is that social media is becoming a ubiquitous tool for sharing one’s scholarship, engaging with the public on the findings of research, advocating for change in public policy and in building new social networks.  His contention is that Twitter offers a means for educators, clinicians, and researchers to communicate directly and accelerate information sharing by extending the network from a handful of conference attendees to a worldwide audience of involved researchers.  In fact, the data from a recent Pew Research Center study supports the notion that the use of social media is growing substantially among researchers (See graph below).  While I’m not going to get in the way of this rapidly moving train, I would like to point out that we need to be highly attuned to the unintended consequences of social media use as it relates to public perception and interpretation of information.  My fear is that the nuance of an issue or problem or research finding cannot be effectively conveyed in many – if not most cases – with a string of 140   characters.  So, the question for academia is: what are the ground rules for engaging in the use of social media?  How should this new communication form be integrated into traditional avenues?  And, what types of research needs to be completed to affirm the adopted approach?  It’s clear that social media can have a very positive impact on research and the sharing of research results.  We need to foster its use and support its deployment.  But, let’s also keep a watchful eye on the results…

Percentage of All American Adults and Internet-Using Adults  Using at Least One Social Networking Site

social graph

Source: Pew Research Center surveys, 2005-2006, 2008-2015. No data are available for 2007.

Far be it from me that “Dr. Change” would get in the way of “change”.  At the same time, I’ve strongly advocated for adapting to rather than resisting change, I’ve also always stated a strong belief that it is incumbent upon those of us who are change agents to monitor what we change since the unintended consequences will sneak up on us over time…

Consulo Indicium 5/11/18

Information for your Consideration…

Technology Reading Your Mind – And, you thought it was way out into the future…  Researchers at MIT Media Lab have been working on a wearable device that can read your mind – literally.  The device is like an extended ear piece for a mobile device except that it has an elongated attachment that follows your jawline and attaches to the skin just under the lower lip.  It picks up neuromuscular activity in the face and jaw which are activated by verbalizations.  The result is that this activity has been translated into the specific words, thereby allowing verbalization of your thoughts.  Dubbed the AlterEgo, the device is now at 92% when trained with a limited vocabulary of 20 words.  But, after all – it is only May 2018.  Just think what it will be able to do by Christmas!!

Cost Of Health Care Continues To Increase – It’s not too surprising but a recently released study reveals that the major drivers of high healthcare costs in the USA are essentially higher prices for nearly everything—from physician care to hospital services to diagnostic tests and on to pharmaceuticals to say nothing of the costs associated with administrative complexity. The study was completed by researchers from the Harvard Global Health Institute and the London School of Economics and published in the March 13, 2018 issue of JAMA (Journal of the American Medical Association).  The researchers compared USA health care cost data with 10 other comparable countries (i.e. Australia, Canada, Denmark, France, Germany, Japan, the Netherlands, Sweden, Switzerland, and the United Kingdom) on nearly 100 data points. 

And, the findings?  In no surprise to many of us, the study confirmed that USA health care costs are way higher with worse population health outcomes and less access to care than all of the other wealthy countries. For example, the USA percent of GDP for health care in 2016 was 17.8% and growing.  The next highest was Switzerland at 12.4% to a low of 9.6% for Australia.  In a point of further humiliation, our USA life expectancy was the lowest of the entire group at 78.8 years (range = 80.7-83.9 years); and, the percent of the USA population with health insurance coverage was 90% - again lower than all of the other nations (range: 99%-100% for the remaining 11 nations).  I recommend that you read the study.  It blows away a lot of myths about USA health care.  Folks…I keep saying it: “We’ve got a problem”.  If we continue the current course with the current demographic trends, the entire system is unsustainable.  Health care is Job #1 in America but: 1) not well understood, 2) complex, 3) system-centric rather than consumer-centric; and, 4) disconnected from the average person because of the way health insurance is structured.  Change will happen one way or the other.  Either we lead the change or change will happen to health care.  Either way – it’s moving forward… 

Not That I’m A Bearer Of Bad News, But – Since I’m on a downer today, I thought you should also be aware of that the well-being of USA citizens took a hit in 2017, according to the annual Gallup-Sharecare Well-Being Index results released last month. In fact, 2017 saw the worst decline in well-being in the 10-year history of the survey, marking the worst results since the Great Recession. The top five states in well-being included:

  1. South Dakota (64.10)
  2. Vermont (64.09)
  3. Hawaii (63.39)
  4. Minnesota (63.12)
  5. North Dakota (63.06) – we’ll stop right here :-) 

Something is going right in the Upper Midwest.  Perhaps it’s the winter storms?  Or, the prairie mentality?  Any ideas on why? 

“It’s Not The Money, It’s The Money!” – I’ve used this moniker before which I learned from a close friend and colleague nearly 30 years ago in referencing the problems with the health care system.  So, it wasn’t surprising to learn that 71% of the Medicare Shared Savings Program ACOs recently indicated that were likely to leave the program if forced to take on risk.  The results came from a survey conducted by the National Association of ACOs (NAACOS).  In responding to the survey, the ACOs noted that the three biggest reasons for their decisions were: 1) the risk is too great, 2) ACO and CMS rules are too unpredictable; and, 3) the financial projections are often unreliable. As Clif Gaus, President/CEO of NAACOS, in responding to the results of the survey noted, "It's naïve to think ACOs that aren't ready will be forced into risk in what is ultimately a voluntary program. The more likely outcome will be that many ACOs quit the program, divest their care coordination resources and return to payment models that emphasize volume over value."  Such a result would be a wrong turn at the busy intersection of health care…

Consulo Indicium - 5/1/18

Information for your Consideration…

 Ominous Clouds On The Horizon – As I grew up on the Great Plains, one of the lessons I learned is that when you see a really dark storm on the horizon – it’s important to pay attention.  So, we have one of those metaphorical storms brewing on the American horizon in my estimation.  So, what is it?  In 2020, according to the Congressional Budget Office, the federal deficit will exceed $1 trillion (yes, that’s “T” as in terrible).  The new tax law advanced the increase by a couple of years and over the years 2021 to 2028, the rate of increase in the annual deficit will be 4.9% of GDP or, higher than at any point since World War II.  Even more troubling, the total national debt will reach $33 trillion or 96% of GDP over the next decade.  What are we doing?  What kind of legacy are we leaving our children? Congress and our elected officials (all of them) are simply kicking the can down the road.  In my experience, ominous clouds on the horizon generally cause major – in some cases disastrous – damage and destruction.  Are we headed in that direction?  I think so…

Statistics Worth Noting And, Checking – In 2016, the USA witnessed the highest share of homicides attributable to guns in the last century at 74.5%.  In fact, we’ve seen more gun-related deaths since 1968 (1.58 million) than all of the USA wars combined (1.48 million) according to the according to data compiled from various sources by Snopes – the Fact Checker. Furthermore, the rate of homicide by guns is higher than we have seen at any time since the 1920s at the height of Prohibition – the next highest time period.  It was a time when mobsters were carrying around machine guns and other automatic weapons.  It’s also a time when the National Rifle Association (NRA) became an advocate for stricter gun control.  Hmmmm!! 

Alright, Alright – Let’s Exercise – For many of us, getting our bodies moving with exercise is a challenging daily task or, should I say “chore”.  Well, get the lead out.  There’s a new study that ties your marbles to your muscles.  In a long-term study started in 1968, investigators found that high levels of cardiovascular exercise resulted in a dramatic reduction in dementia for middle-aged women at a level of 88% LESS than those participants who did not exercise regularly!!  The dementia examinations occurred in six separate evaluations over time.  In fact, the study showed that the highly fit women who did develop dementia did so an average of 11 years later than the moderately fit women.  So, while the researchers follow-up with further studies, I recommend that everyone continue to exercise – and, we’ll start with me…

And, in a related consideration, researchers have for many years questioned why our cognitive abilities decline over time.  The consensus has been that part of the reason is that the brain did not create new cells as older cells died off.  Such a model would ultimately result in the loss of nerve connections leading to memory and reasoning loss along with declines in language skills.  But, the researchers at Columbia University have reported that the brain, in fact, makes new nerve cells, especially in the parts of the brain involved in memory.  Specifically, the researchers found that cellular replacement occurred in older and younger people.  However, in the aged brain, the reduction in blood flow for nourishing the new cells was far less than among the younger subjects. This takes us back full circle to the other study mentioned immediately above. So, the mantra (coming from multiple studies) is exercise, exercise, exercise

Congressional Opioid Inaction – There seems to be a lot of inaction, action among the four US House and Senate committees that are considering legislation to address the ongoing opioid epidemic.  The good part is that what some are describing as “the most sweeping proposal” is a draft bipartisan bill winding through the US Senate Education, Labor, and Pensions Committee.  It includes provisions such as accelerating the development of non-addictive alternatives, enhancing existing enforcement efforts of current opioid controls; and, increasing the grant programs to the states that have been hit the hardest by the opioid epidemic.  But, some of these provisions will take time.  For example, Francis Collins, MD, the Director of the National Institutes of Health (NIH) has noted that it will likely take at least five years for a non-addictive for pain medication to become available. 

On the research front, a new study was recently reported in JAMA Psychiatry that treating people in jails and prisons for opioid addiction show some promising results for reducing the incidence of deaths after discharge.  Specifically, the report discussed a program instituted by the Rhode Island Department of Corrections in 2016 and resulted in a 61% decrease in post-incarceration deaths.   In discussing the results of the study, one of the researchers from the Boston Medical Center Grayken Center for Addition and an Adjunct Associate Professor at Brown University – Traci Green, MD offered the following assessment: “This program reaches an extremely vulnerable population at an extremely vulnerable time with the best treatment available for opioid use disorder…Here we have a program that’s shown to work, and it’s absolutely replicable in other places. Not only do we see that a statewide program treating people using medications for addiction treatment is possible and reduces deaths, but also this approach intervenes on the opioid epidemic at its most lethal and socially disrupting point — incarceration — to give hope and heal communities.”  So, onward with the replication

 Obscurity Vs. Transparency – If you have ever tried to traverse the pathways of health insurance or pharmacy benefits managers (PBMs), you know that it is a treacherous course.  The out-of-pocket costs seem (to me, at least) to shift every year.  One of the little known requirements imposed by those health insurance providers and PBMs is that pharmacists are often restricted from informing patients that a certain drug is cheaper if paid for out-of-pocket rather than paying for the drug through their insurance program.  Senators Susan Collins (R-ME) and Claire McCaskill (D-MO) introduced S. 2554 or, the Patient Right to Know Drug Prices Act which removes the “gag clause” imposed by the insurers and PBMs. The increase in transparency is CRITICAL as we move forward towards value-based care delivery.  Without it, consumers will not be empowered and the whole notion of fostering “value” will be crippled.  Kudos to the Senators for taking the lead.  Let’s get behind them and support the legislation. 

 Let’s Get On Board! – Two of my colleagues – John Halamka, M.D., CIO at Beth Israel Deaconess Medical Center (the “other doc who wears all black”) and David Bates, M.D., Senior Vice President for Innovation at Brigham and Women’s Hospital – along with some other colleagues from the British National Health Service and Scotland have called on Congress to allow for the creation of a uniform health identifier.  The ability to move in this direction was banned by Congress due to privacy concerns.  However, as the advocates noted, the ban has fostered an environment that has allowed misidentification and medical errors which could be easily correctable to continue.  We need to get ahead of the curve here (finally) and move in this direction.  The article from the NEJM Catalyst made the following point:  “When accurate information is attached to the right patient, data access is timelier for clinical, administrative, quality improvement and research purposes; inappropriate care, redundant tests and medical errors are reduced; and health information exchange becomes easier—within organizations as well as between.  Identifiers are also beneficial for patient mobility, allowing information to be linked to patients and following them as they move.”  Let’s get behind them. There is growing and strong support in the medical community for moving in this direction.  Write your Congressional delegation!

Consulo Indicium 12/12/17

Information for your Consideration...
Another Cup Of Joe, Please - You can imagine how excited I was when I read that a group of researchers reported that caffeine can block some of the effects of UV radiation.  First, a little education.  UVA or, ultraviolet A (long wave) rays tend to penetrate the skin quite deeply and affect the dermis or, the layer below the epidermis.  These are the types of waves that case the skin to become wrinkled and aged.  UVB or, ultraviolet B (short wave) rays generally only end up penetrating the epidermis or top layer of the skin and are known to be the major factor in the cause of skin cancers.  So, what does this have to do with coffee?  A new study was reported in the International Journal of Cancer that found the regular consumption of coffee could significantly lower men's risk of skin cancer.  The researchers claim that drinking coffee could, in fact, have one major health benefit for men. The researchers studied over 500,000 people to uncover the link between a standard old cup of Joe and skin cancer!  And, the results were not just by a small margin.  In fact, the men who drank caffeinated coffee were 70% less like to develop melanoma (one of the most lethal forms of skin cancer).  Now, that is protection!!  What is not well understood is why?  Women and decaffeinated coffee drinkers did not have the same reduction in risk.  The contributions of coffee to health are quite remarkable.  Not only has it now been shown to reduce skin cancer in some people (i.e. men), it also has been found to help your body burn off its fat layer, reduce the symptoms of Parkinson's disease, keep your brain healthier for longer and reduce the risk of developing Type 2 diabetes.  Now this doesn't mean you can stop using the sunscreen.  It does mean that a double shot latte with 100+ SPF sunscreen fosters an extremely low chance of skin cancer.  So, don't worry about your coffee intake.  Just apply sunscreen...
The Coming Age of Robotic Medicine - I've been a big proponent on the use of artificial intelligence and machine learning as a core capability for enhancing health care delivery.  In fact, I've dubbed the use of these technologies as "clinically augmented intelligence" on the notion that the technology will assist clinicians in making decisions better, faster, more efficiently.  And, I still hold to that premise.  But, earlier this month, the Chinese medical robot - Xiaoyi or, "little doctor" - accomplished something that some physicians fail to achieve.  The "robot" received a passing score of 456 on the Chinese medical licensing examination where only 360 out of 600 is needed.  The robot uses machine learning to link natural language processing with information derived from medical textbooks, medical records and journal articles.  But, the docs don't have to worry yet.  The robot has only learned to pass the medical examination.  It still can't talk with people, hold their hand, administer medications, perform surgery, do procedures or essentially take care of them.  Aside from that; however, the technology could clearly "augment" the clinician.  It's the type of capability that I predict will be ubiquitous over the next 10 years (or, sooner) in healthcare - just as radiographs, pathology slides and other technical support systems are in place today.  Note that the robot did not get a perfect score.  It fell down when it had to review actual patient cases and integrate information with actual case presentations.  Now that is a real doctor...
Coming In At #5 - Telehealth - The Cleveland Clinic conducts an annual listing of the top innovation for the year.  The Top 10 Medical Innovations for 2018 touted telehealth as its "#5" on the list noting that there are now 7 million regular users of telehealth services - a 19 fold increase from 2013.  In addition, over 19 million users are involved in using remote care management devices.  Furthermore, several recent surveys have shown that the overwhelming number of health care delivery organizations are involved in developing telehealth programs.  Coupling the users with the remote devices with the providers of health care seems to be a logical next step.  In fact, it is an area that is replete with possibilities for further development. 
 
Failing By Falling - According to the Centers for Disease Control and Prevention, the contribution of falls to the demise of our elder citizens is one of the biggest overlooked problems in health care.  Falls are one of those incidents that affect one in three older adults each year - or, a $31 billion dollar cost problem for our nation's Medicare program! In 2014 - the latest year for which good data is currently available - there were more than 2.8 million people over the age of 65 whose falls were treated in emergency rooms across the nation.  Of those elders, 800,000 were hospitalized and 27,000 died from the falls.  In fact (scary statistic), falls are the leading cause of death among adults over 65 and the death rate has been increasing over the prior decade.  Now for the policy impact.  In 2014, the elders represented about 14% of the USA population or 46 million people.  By 2030, the number of elders will grow to more than 20% over the age of 65. So, the financial and social impact of falls will balloon over the coming decade.  Why?  It relates to balance and mobility.  Researchers at the Institute for Aging Research have been studying the issue and how to foster prevention for more than 30 years.  They recently reported on a new finding that - on the face of it - makes a lot of sense.  Tai chi is being used in a study by the Institute in an effort to enhance balance and improve mobility among elders.  What they have discovered is that in addition to improving balance, flexibility, and mental agility, the exercise program involved in Tai chi also reduces the incidence of falls.  The researchers have noted that adherence to the programs enhances the elder's muscular control, coordination, equilibrium, and also improves brain function. The idea of using Tai chi to deal with a major, major problem seems simple.  And, it is!!  It's so simple and it's easy.  So, I'm on it... 
 
Getting The Right Care At The Right Time - Since I'm blogging about elders, let me point to another study by The Commonwealth Fund.  They recently reported out their annual International Health Policy Survey which compares the experiences of elders across various countries including Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the USA.  The survey is now in its 20th year.  The disturbing results from the USA respondents were that 23% of the USA elders cited costs as the reason for not seeking care with a physician when they were sick, for not filling a prescription or skipping a dose, or for not obtaining a recommended test or medical treatment. In France, Norway, Sweden, and the United Kingdom that figure fell to 5% or less.  Another contributing factor was that one in four USA elders (22%) spent more than $2,000 in out-of-pocket expenses for health care last year versus only 10% in all of the remaining countries except for the Swiss.  In Switzerland, 31% of the seniors reported spending more than $2000 in health care expenditures.  

Consulo Indicium - 4/2/18

Information for your Consideration…

The Pace Of Blogging – For many of us – who are news junkies – one of the first things we do in the morning is turn on the news. Over coffee and breakfast, we ponder all of the changes that have occurred overnight and the Tweet storms on the horizon to gain a better view on the lay of the land.  But, it’s difficult.  The change of direction, the requirements for fact-checking on many items, the incomprehensible blizzard of changes in staffing are all distractors to the many issues facing America.  As my readers know, “health care” is at the top of my list as an issue that needs resolution.  It also needs consistency of policy over time.  It needs leadership with integrity.  It needs bipartisan solutions.  And, for these reasons – I’m sending a “special” blog because of the recent changes at the Veterans Administration.  As always, your thoughts and perspectives are valued.  Send them to This email address is being protected from spambots. You need JavaScript enabled to view it..  They will be read, reviewed and appreciated.  Now…on to the reason for the special blog…

The Discontinuity Of Continuity – At the outset, let me say that this note is out-of-character for me.  In fact, it’s a first!  I don’t usually comment on people changing positions or moving from or to various roles.  I view those types of changes as the inevitable outcome of what happens in modern day corporations.  However, the decision by President Trump to fire US Veterans Affairs Secretary David Shulkin, MD deserves some commentary. 

There are a couple of items you should be aware of before reading my thoughts.  First, I’ve known David for nearly 25 years.  We “grew up” together in the world of health care systems as Chief Medical Officers for various care delivery organizations.  As part of that club, we got to see one another’s warts, scars and traumas as we all moved from working as clinicians to becoming administrators and then, working diligently to become leaders – a process that most of us continue to work on to this day. 

Second, David is a person who is driven by facts and data.  One of the reasons the VA has turned the corner in recent years is because of the measured philosophy he has brought to the agency.  When push comes to shove, an approach to solving problems where “just the facts, Ma’am” is the dominant model creates an environment of accountability – and, transparency – that is difficult to argue against. 

Third, on a good day, taking on the challenge of remodeling the VA is a gargantuan task.  On a bad day, it can seem impossible.  Change is difficult but in an organization like the VA – it requires a degree of perseverance that is inestimable.  Yet, David has slowly but surely moved the chess pieces forward in an effort to provide veterans with the health care they deserve. 

Finally, any person looking at the capabilities of the VA and those of other health care systems would easily come to the conclusion that forming some type of alliance between this large, cumbersome bureaucracy and local health care delivery organizations would make sense.  But, there is clearly not a cookie cutter model and anyone that goes down that road will likely be doomed to failure.  The potential integration and/or collaboration with local providers is a move that requires the careful consideration of the types of services available locally to support not just the run-of-the-mill medical problems of veterans but also the unique veteran disabilities whether physical or mental.  It also makes sense to have some defined proof points recognizing that the initial models will likely be variable and not deployed on a uniform basis across the entire nation.  Such was the approach of Dr. Shulkin…

While Dr. Shulkin’s departure will no doubt be absorbed – just as the departure of most leaders in government or private industry – his methodical movement toward “solving the problem” will likely result in a backward slide within the VA.  It is unfortunate.  When one considers the data, it’s obvious that progress was once again occurring within the VA after a 10+ year hiatus.  Efforts were being made to enhance quality; initiatives, to enhance service; and, projects, to increase access.  And, at the end of the day – increasing the quality/service/access triad is one of the important requirements for “making health care better” (my personal mantra for why I get up in the morning for nearly 40 years).   

So, what should be done about the VA?  Here are a couple of steps that require serious consideration and which the next Secretary should put on the table as part of the requirement for taking the job.  It’s probably not a complete list and – more importantly – is a list that is devised as an “observer” of the VA rather than as “consultant” or “employee” or “advisor” to the VA.  These are purely my high-level thoughts in considering how our nation can best honor its commitments to veterans and also drive efficiency and effectiveness in a large, bureaucratic organization.  The thoughts include:

  1. Initiate a Revised Structure for the VA – Congress should seriously consider re-establishing the VA as a separate “Public-Private Partnership” (P3) corporation. One of the issues that Dr. Shulkin mentioned in his departure interviews was for Congress to address how the problem of the “revolving door of leaders” at the VA can be resolved.  Political appointees to leadership positions is the last thing that is needed to solve the problems.  In a large organization that is complex and spans the entire nation – consistent, focused and reliable leadership is essential.  It will require a strong, diverse team that moves in concert philosophically and managerially to solve problems.  Large, diverse corporations require such leadership to be successful.  There are good examples that serve our nation well.  Two examples come immediately to mind.  In the shipping industry, our nation’s ports are mostly managed by P3 arrangements – and, quite successfully.  Having open, high quality operations at the ports has been a cornerstone of our successful economy for many years.  A second example is the increasing use of P3 approaches for managing our nation’s transportation infrastructure.  Whether it is roads, bridges or interstate highways – such an approach has been successful.  It’s not easy and the approach of shipping is different than transportation so, again, there are no cookie cutter models.  On the international level, we’ve seen the use of P3 arrangements for managing “public” health care systems and organizations in the United Kingdom, for example.  So, the idea has merit, it is being used internationally and, it should be considered.
  2. Establish a Functional Governance Model – While the P3 model is a potential solution, the requirements for making it work – in my estimation – will never be met if Congress serves as the “Board of Directors.” I don’t care whether it is a Democrat or Republican Board that is in control. Congressional governance will only continue to exacerbate the ongoing problems of the VA.  Rather, appropriate “oversight” should be put in place that represents true governance – like a large health care system.  The delivery of quality, reliable, cost-effective health care for veterans is not a political process.  It requires a governance oversight that can resolve the very significant problems faced in providing care to veterans.  If I were a Czar and able to make the changes, the Board of Directors would be something like: 3 veterans, 3 health system leaders, 3 “open” positions; and, 3 Congressional appointees.  The positions would be staggered and be for 6 – 9 years in duration.  They would be required to provide a report to Congress every year.  I’m sure there are other parameters but this is a good starter kit.
  3. Deploy Tele-Technology – The VA has actually been one of the leaders in exploring the use of tele-technologies for enhancing the ability of the agency to delivery services. In particular, the use of VA systems has been shown to be very effective in delivering care to rural areas and to those veterans with mental health issues such as PTSD.  What’s needed; however, is for Congress to support a national infrastructure plan for enhancing the digital capacity of all geographic areas across the USA on a ubiquitous basis.  The fact of the matter is that many rural areas – which are large swaths of the nation – have inadequate digital capacity for supporting the types of communication required for effective telecare. 
  4. Continue the Focus on Service – One of the areas Dr. Shulkin emphasized was enhancing the service capability of the VA. This is a cultural phenomenon and does not simply occur because of declarations.  The efforts that he initiated should be continued and expanded. And, in my experience, culture starts at the very top with leaders.  So, continuing that focus from the Office of the Secretary will be crucial or it will hit the dustbin of talked about strategies that never become reality.
  5. Continue the Drive for Transparency – When problems are hidden or covered over, they are unseen. Dr. Shulkin has really pushed the “transparency” agenda which has been very good for the VA.  The ideas and efforts need to be continued.  Continued use of metrics and comparisons to private health care providers should also be expanded.  Let’s hope that this effort does not slide into oblivion with the passing to a new leadership team…

Let me offer a final comment on Rear Admiral Ronny Jackson, MD who has been named by President Trump to replace Former Secretary Shulkin.  Dr. Jackson has a strong medical pedigree.  He is a graduate of the Uniformed Services University of the Health Sciences, a graduate of an Emergency Medicine program and a Fellow with the Beth Israel Deaconess Medical Center Disaster Medicine program.  Plus…he has lots of military medals and awards.  But, does that prepare him for the role?  While there is every indication that Dr. Jackson is an outstanding clinician – that does not necessarily provide the grounding for leading large, complex organizations – despite the support he is receiving from various sectors.

I will never forget when I took on my first role as a Senior Vice President and Chief Medical Officer.  This was after nearly 10 years of some managerial experience in leading smaller groups of 10 – 20 people.  Early in the experience, I remember an issue coming forward where I decided I needed to take action.  I reached for the metaphorical handle on the decision lever and pulled it with bravado and action.  Nothing happened.  This is what happens in large, complex organizations.  Change does not happen by pulling on the metaphorical handle.  Rather it comes through providing a vision, through being the type of leader you want others to be and, by setting a direction and encouraging your followers to step up and refine the ideas.  I question whether Dr. Jackson is ready for the challenges of the VA.  All the training and skills of an outstanding clinician do not solve the problems of management and leadership. 

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