Readings To Consider - 11/14/19

Books and Articles worth a Review…

Six Degrees: Our Future on a Hotter Planet – If you haven’t read Mark Lynas’ book on global warming, it’s time to check it out.  At 358 pages, it provides a degree by degree analysis of global climate change.  Written in 2007, some might consider it a bit dated but from my read the scientific data described in the book is or has become a reality.  By the time you get to four degrees of warming, you’ll be more than nervous which is where we are headed.  As I keep pointing out to friends and colleagues, the lobsters of Maine have already moved 150 miles further north over the last 15+ years.  They seem smarter than we are or, they’ve decided to become Canadians.  Perhaps it’s both?  Check it out.


The Occasional Perspective, 11/14/19

Random Considerations from a Global Rover… 

On Being American – I’ve just returned from a 3+ week trip to Greece and Egypt.  It was a mix of business and leisure with family and friends.  As you can imagine, tensions were a bit high when we arrived due to the recent announcement by President Trump to pull-out the American troops out of Syria.  It made a region of the country noted for a degree of instability – compared to USA, Canada and European nations – even a bit more on edge than normal. What was particularly noteworthy for us was the relative calm among the team members that shepherded us from place to place.  Another noteworthy point was the intensity – in terms of numbers – of soldiers, security stations and the like designed to offer up a safe and secure environment.  But, what was really striking was the response of the guards when they saw our passports and recognized us for what we were – American tourists.  In most cases we were simply waved through even if the buzzer went off because 99 times out of 100 it was a cellphone, a battery, a metal object we had in our pocket or some other innoxious piece that posited no potential harm to anyone.  The guards would smile and wave us through.  We were “American”.  That’s a distinction – in my estimation – that our nation has been earned for its citizens over the last couple of hundred years.  The American people are a freedom loving, friendly and engaging lot of people.  Our reputation precedes us.  It took just over 200 years to develop a persona like that…let’s not dissipate it in a few short years by not adhering to our word or standing by those we deem to be our friends.  There’s a lot to be said for earned admiration.  And, the only power we – the American people – have over the many issues facing our nation is the opportunity to vote our conscience.  As we enter the season of electoral politics in the coming year we need to ask ourselves what it takes to continue being waved through because we are an American! 

The State of the States – Are you having the same experiences I’m having?  Does it seem like there is more than just a little unrest happening all over the world?  There are the Yellow Jackets in France; the Chilean street protests where citizens were apoplectic about a hike in the cost of public transportation which ended in lootings and fires; and, the ouster of President Evo Morales of Bolivia because of cheating on the election by him and his party with a move to exile in Mexico.  But, it’s not just these few isolated examples.  We’ve been hearing about the protests in Hong Kong for several months now.  London has the Brexit protests which have regularly frozen central London in recent weeks.  It seems to that no nation, no political party nor any individual is immune from the rage of citizens.  Even Russia has had street protests in recent weeks. It seems to be the tenor of the times.  And, in fact, it is…

Unlike the days of yore where organizing required lots of asynchronous phone calls and outreach by organizers, in today’s world – protests can evolve quickly and spontaneously through social media and other forums where “the people” gather.  The technology is the enabler.  The embers creating the firestorms are the embers of pent-up frustration by “the people” with their governments...with lack of transparency…with lack of integrity…with dishonesty.  Some – perhaps many – of these concerns are legitimate and others are still to be proven. We have entered what I refer to as the “Yellow Journalism” stage of media much like the period following the US Civil War when there were no standards, no principles of journalism, and little ability to effectively evaluate the information spread by the various media.  Which information was believed at the time depended upon which source was trusted!  We’re in a similar boat.  There are media of all stripes and flavors.  Pick your favorite corner, go that source consistently and listen to the echo chamber. 

But as a “listener” to all sorts of media – I for one intend to stick with using my own judgement by reading and listening to a “spectrum” of media sources.  In fact, that would be a good model for all of us. I urge you to consider checking out All Sides News which provides an unbiased evaluation of the media across the spectrum from right to left.  For me, I’m sticking to a cross section.  My regular sources are: CNN News, The New York Times News & Opinions, NPR News, The Wall Street Journal News & Opinions, BBC News – and, of course, Maine Public Radio! Now, the downside is that I have little knowledge of what’s on television – except news, of course.  I visited my brother last week and watched “Modern Family” for the very first time.  So, perhaps I’m not as balanced as I should be?  Think about it.  It’s our duty to listen to all perspectives – but, listen carefully.  America depends on it…

Medicare For All: An Analysis – My intent over the last month has been to provide my readers with an analysis of the Medicare For All (MFA) proposals put forward by Senators Elizabeth Warren (D-MA) and Bernie Sanders (D-VT) as part of their presidential campaigns.  However, in fairness to all – I have not yet been able to make it through all of the various analysis so that I could weigh in appropriately.  My hope is to complete the readings and the assessment by the time of my next blog – shortly before Christmas.  It’s a very important topic and deserves special attention.  “Health care” is the #1 top of mind topic for most American citizens.  It is #1 in our household as well and it’s not just because we happen to be physicians.  Thanks for waiting…

The Occasional Perspective, 10/18/19

Books and Articles worth a Review… 

Cracks In Our Foundation – Every day seems to bring yet another revelation, breaking news announcement or press release that precipitates a collective, “What?” from the American public.  What we need to realize is that our national soap opera is far more than a “national” discussion.  The world is watching.  Having just returned from a trip abroad, the first question from friends and colleagues is: “What are you folks thinking?”  When I traveled the world in my prior life as an international consultant, the USA was always held up as a “leader” across all fronts – political, social, linguistic, economic.  Now, our reputation is increasingly tarnished at best. 

There are so many debacles in the ongoing saga we are facing that the cracks in our foundation should cause us some concern.  We are distracted by the daily news and not focused on the essential elements that have made for a strong nation.  It seems to me that we have some VERY big challenges on the horizon that get pushed to the background by the chatter and finger pointing among our left and right perspectives.  I found it truly a tenor of the times to hear the debate about whether Ellen DeGeneres should be having a good, laughable conversation with our former President, George W. Bush.  Ellen has done remarkable things for our society by coming out as a proud lesbian and – while I was not a fan of Bush during his Presidency – I admire the fact that he has the ability to converse with a diverse crowd of people, including his close relationship with Michelle Obama and others whose political perspectives he does not embrace – or, at least, did not embrace historically. 

Long story, short – we need more dialogue and discussion among left and right.  Such discussions are the very foundation upon which societal problems have been historically resolved.  So, what are the problems? 

  • As you can imagine, first on my list of priorities is health care. It’s a biggie! As a consumer of nearly 20% of our nation’s GDP, so goes health care – so goes the rest of the nation.  And, “Houston, we’ve got a problem!”  I won’t harp on it but, the state of health care and the costs and quality of the product are a BIG issue for the USA.  We need to solve that problem.  So, what else? 
  • Next on my list – and, actually, first on the list – is climate change. Yet, we’ve walked away from any leadership on the issue for the world.  Why?  Because science has been pushed off the table.  In the current Administration, data and science have been relegated to the back burner.  Yet, the science and data are glaring if not scary.  WE ALL NEED TO GET INVOLVED IN THIS ISSUE NOW! 
  • Third on my list of concerns is our educational framework. The very fabric of our universities is being challenged by a new virtual world that is disintermediating our knowledge factories. 
  • Fourth, our economy is very much increasingly intertwined with the global community. Rather than building walls and engaging in wars that essentially provide “temporary” protection, we need to collaborate.  The USA is no longer the sole economic engine in the world. Being an effective partner is now far more important if we want to be a leader.
  • And, Fifth on the list is infrastructure. One of our failures as a nation over the last couple of decades has been to apply insufficient resources towards upgrading our bridges, water and sewer systems, highways, roads and all of the other elements that we frequently just take for granted.  With the advent of the Great Recession (and, even before that), we’ve failed to keep up and breakdowns in core infrastructure are no longer exceptions but seemingly weekly – if not daily – occurrences. On top of that, we’ve failed to invest properly in developing our digital infrastructure such that vast swaths of the nation have insufficient, little or in many cases no digital access.  How can the virtual world survive if the infrastructure is not present?  The divide between the rural and the central urban areas is growing.  We can’t allow that to continue.  We are one country and core capabilities need to be a part of promise our governments make.  So, there is physical and digital infrastructure to consider…

The list could be longer but five priorities – it seems to me – is a long enough list.  But, before we can solve these priority problems, we need to engage in a lot more dialogue.  We need to do what Ellen DeGeneres and Former President George W. Bush did last week – laugh a little with the other side!  In my experience, the big problems of the day were never solved by retreating to our corners.  They have always been solved as a society when we reached accommodation and engaged in the middle.  It’s called democracy.  It may be a bit slower than dictatorial models but it eventually solves problems.  It’s what our nation was built on.  It’s what the world has come to expect.  Let’s focus on dealing with the cracks in our foundation so that we can move on to the priorities we face in house.  

The Occasional Perspective…

The accumulation of readings percolates some thoughts on how to proceed…

The Fairness Doctrine and Medicare for All – I had the privilege this past week of attending a conference where Michael Smerconish served as a speaker.  Over the last several years, he’s one of the pundits that I’ve listened to on cable news more and more as the shrillness of the debates among the partisans have become ever more sharp.  In fact, the one thing I love the most is that there is no “speaking over one another” in discussions or debates on the Smerconish Show.  So, why do I bring this up in a health care blog?  It’s because looming on the horizon is one of the most important debates we will be considering for the next several generations – Medicare for All!  Now, full disclosure: while I’m a recently eligible Medicare recipient, I’m still with my private health plan due to the benefits provided by my wife.  Here are my issues:

  • Medicare is an absolutely crucial benefit that our society decided back on July 30, 1965 to make health insurance available for the entire USA population over the age of 65.
  • Before Medicare, nearly 50% of the elderly populace did not have health insurance coverage. With the advent of Medicare, universal access to health care for the elderly and disabled was provided – something we as a society should take strong pride in supporting.
  • Medicare has been shown to clearly make a major difference in the availability of comprehensive (i.e. across the board), quality (i.e. with defined measures) services (i.e. access). Prior to the implementation of Medicare, the elderly frequently did not obtain services or services were delayed inappropriately. 
  • Study after study has shown that Medicare is efficient from an administrative standpoint with an overall growth in costs far lower than other insurance options. This allows Medicare payment rates to be much lower than traditional insurance products.  So, the question we need to ask ourselves is whether or not the efficiencies created outweigh the reduced societal costs.  What will happen to those programs, services and institutions that rely upon the balance of traditional insurance against Medicare to maintain survival – for example, rural hospitals?  These questions have not been adequately addressed.
  • In a report of the Medicare Trustees who provide oversight to the program, the Trustees have indicated that the hospital insurance coverage provided by Medicare will remain solvent only through 2026 – in other words, only 7 years away. At that point, the revenue-to-cost ratio drops to 89% and gradually declines to 78% through 2043.  The addition of another 140+ million to the rolls overnight (NOTE: the Sanders/Warren plan calls for a four year implementation schedule) is likely to tip the proverbial wagon over!
  • Medicare For All – is a catchy title but the underlying approach to payment is the Achilles heel. What do I mean?  Well, the current system is based on a traditional fee-for-service (FFS) model where the incentives for providers are in “doing things” (not inappropriate things but, things nonetheless) to people rather than emphasizing a “keeping them healthy” strategy.  Without a wholesale shift toward “value-based care delivery” my concern is that we engage in a whole lot of “doing” and not enough “healthing” of the populace. THEREFORE, before shifting to a Medicare for All strategy, we need to shift the payment systems to value-based care models or, at least move them heavily in that direction. That’s essentially what Obamacare was beginning to do.  But, that movement is now on hold with the health care systems waiting and watching to see which way the proverbial winds blow. If such a change is not made, the lack of resources to support Medicare will, in fact, bankrupt the nation as the demographics move toward an elderly tsunami which is just starting to gain force across the nation. The health care system is incredibly efficient at finding the money.  So, again, I emphasize that it seems to me that we need to shift the payment model FIRST before shifting the insurance model.
  • A shift toward value-based payment models is not some monolithic approach. There are currently many different approaches including shared savings, bundled payments, shared risk, pay-for-performance (P4P), global capitation, accountable care organizations (ACOs) and provider-sponsored health plans, among other evolving approaches.  BUT, to work – these systems require market readiness in the form of “care management” systems, community-based care, adoption of telehealth and telecare capabilities and a host of other changes which health care systems have been slow to adopt. 
  • So, without a wholesale change in the approach we take toward payment of services we are likely to move in a direction of overwhelming the very fabric of a program that we all (or at least the vast majority of us) believe is an essential underpinning for sustaining the health of the nation.

So, what’s this got to do with The Fairness Doctrine? Smerconish got me to thinking!!  If we don’t have a reasoned debate about “Medicare For All” and other reasonable and responsible solutions for providing access to “health care as a right” – which I firmly believe in – then, we run the risk of going down pathways that are ill-conceived.  As I noted earlier, the name “Medicare For All” is a catchy title but as a health care provider, I can assure you that catchy titles at the end of the day don’t deliver quality care.  Catchy titles don’t solve the issue of an aging demographic that can potentially overwhelm the entire nation.  Catchy titles are for campaigns but the details matter. 

In fact, I would be for a Medicare For All if we had at least a decade of experience in considering, developing and deploying alternative payment models. The single biggest lesson I’ve learned from economies that adopted Medicare for All-like strategies is that the emphasis of the payment systems is on preventive care. In addition, it would be a lot easier to support a Medicare For All strategy if we fully understood and had adopted the right technologies for helping us to deliver better more efficient care.  For example, Medicare for All could be a very smart strategy if machine learning and augmented intelligence were applied to create better protocols, guidelines and diagnostic pathways for delivering more efficient, effective care. 

AND, finally, we come to the most important consideration.  Without an honest, open debate that does not entail each of the corners yelling at one another from across the room, interrupting the presentation of facts or no facts so that we can engage in a conversation about the expected outcomes of the proposals which advocates are espousing – we will not solve the problem.  So, re-instituting the Fairness Doctrine or a facsimile of it in some fashion seems like a reasonable course of action.  We need more reasoned debates.  We need fewer Tweets.  We need dialogue not interruptive displays of one loud voice over another.  We need to think about this – together. The nation depends on it.  Does that sound reasonable?  One last thought.  All of the big challenges of the last century were resolved when we came to bi-partisan consensus on how to move forward.  That may seem old fashioned but working together – in my experience – has always been a good thing!

The Occasional Random Consideration - 5/1/19

Periodic thoughts that percolate forward while traveling about the world…

I’ve just returned from whirlwind visit to five cities in China – Xi’an, Zhuhai, Changsha, Beijing and Shenyang. Before I share some thought about health care in the context of the US-China relationship, I wanted to share a couple of observations: 

  1. The People – If you have the resources, you need to visit China. It is a wonderful country with even more wonderful people.  Unlike the uniformity of presentation and perspective that I originally experienced in 1978, there is massive diversity among the people. When you get them alone you learn about the very diverse thoughts they have which are creating an environment of intellectual diversity. It is evident by the adornment they wear which consists of multiple, bright colors (sometimes with matching hair color) and a variety of T-shirt statements that adorn their outerwear. I won’t repeat those T-shirt statements here. In fact, I’m not sure the Chinese actually know what their English statements on the front & back of their T-shirts are actually saying. Regardless – they are wonderful people. They are open. They are inquisitive.  They (the people) seem to love Americans…
  2. Air Pollution – Unfortunately, it seems that the presence of severe air pollution has become the new normal. Even with rain, the air did not clear in Xi’an.  It’s because of the reliance upon coal and wood-burning sources for heating and cooking.  There is a big national campaign to move toward less polluting resources but the latest report revealed that 337 cities in China had worse pollution this year than in 2018.  Not a good turn of events. When we think of global warming, we need to think international collaboration.
  3. Construction Everywhere – Oh, to be an architect in China at this time in history! The skyline of China in all of the major cities is adorned with high rises that challenge the traditional framework. While there are many, many (shall I say “many” again) high rises that are simple replications for housing – I mean row after row of 20 – 30 story buildings – the unique buildings are the ones that capture your attention.  There are a massive number of iconic buildings that are either under construction or already completed.  In fact, it is hard to take a picture of the skyline in any city without capturing at least a few construction cranes on the horizon.  They have become the national bird.
  4. Economic Development – The economy is clearly booming in China. In the US, we think of the Chinese taking over the manufacturing of all manner of goods.  And, in fact, they have done that in many instances because of their lower labor costs.  However, the “service” industry is the fastest growing component of the Chinese economy. Chinese manufacturing is moving from China to places with less costly production costs like Thailand, Bangladesh, Sri Lanka, major portions of Africa and other places in the world. So, the march of economic development continues its relentless pace.  It is a lesson for us, however.  We clearly need to redouble our efforts at investment in educating our work force for the next generation of economic development.  It will not be in repetitive manufacturing of widgets, vehicles or other similar products.  So, the question for the US is: what and how we deliver a work force prepared for the new economy.  From my perspective, too little debate and discussion has been held on this very important issue.
  5. The Cost of Living – We were told by our guides that the cost of housing in central Beijing is running about $15,000 a square meter. So, a 200 square meter apartment/condominium would run about $3M. It was clearly outside the range of our guides and the average Chinese resident.  The phenomenon is not just a central Beijing issue either.  So, inflationary concerns are top of mind for most Chinese.

Back in 1983, I applied for a Kellogg National Fellowship and was lucky enough to receive one of those coveted Fellowship experiences.  In my application, I noted that I wanted to study Chinese culture and language because I felt that “China will be the next great nation and the nation of the next century.” It’s becoming true.  I would encourage everyone to consider how we can embrace China rather than castigate it as a country.  There is much we can learn from one another.  The challenge for both sides will be in embracing a strategy of mutual respect, cooperation and collaboration. 

Finally, you might ask: Kevin, what’s this got to do with health care?  Everything!!  I believe we are moving toward a much smaller world where interaction, cooperation, collaboration, coopetition, co-learning are becoming the norm.  To survive in such a world means that rather than castigating countries and working to dismantle their efforts, we should be embracing those nations as learned relatives who over time become a part of us.  As the singular most diverse and accepting (even though it does not seem like it at times) country in the world, we have an opportunity to embrace such nations as partners in progress.  We need that because health care is going to continue absorbing more and more costs – despite our best efforts to control costs – due to the aging of our population. This is not just a US issue. It’s an EU issue.  It’s a China issue.  By working together; however, we can solve the problem.  The health care forum can actually serve as the petri dish for multi-national collaboration and development.  Economic development and sustenance is on the periphery of health care but, it’s central to health care.  Think about it…

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