Keep Searching Says the Fat Lady

It was the Big Bang that started it all. Since then, its background microwave radiation lingers in a massive externality of space "without walls" propelled forward in time. Humans individually inhabit this reality. We are born, we live and then we die, navigating along by seeing, hearing, smelling, tasting and feeling. Sometimes we pause and wonder what else could be beyond border zone of consciousness. Is that all there is to it?

The Fat Lady feels our pain. Our conceit is even worse she says, reminding us that our inhabited reality is not as cleanly rational as we think. At a sub-atomic level, our world seems to be made up of probability energy that collapses only when we "look" at it. In the here and now, most of the gravity we experience is unaccounted for by the known mass of galaxies and the search is on for stubbornly undetectable "dark matter." Jump up to the level of stars and light-years and it turns out that space and time are astonishingly "relative." The mathematics that describes it all ultimately doesn't really need time or distance. Rather, they're imperfect tools used by the human brain that impose order on the universe.

Keep searching, says the Fat Lady. Wise Men Melchior, Caspar and Balthazar are good role models this holiday season. Mathematicians with eyes to the sky, their earthbound gifts remind us to be mindful of the limits of our central nervous systems. The scent of frankincense is at the edge of what is seen and known, solid gold contrasts with an ephemeral world construct while myrrh makes us wonder what the "future" is really all about.

More On the "Call for Comments" and Here's One From JD Salinger's Fat Lady

The Disease Management Care Blog has gotten some terrific one sentence 'messages' in response to its "call for comments" to share at an upcoming U.S. medical school lecture. If your submission has not appeared anywhere among the DMCB's vast array of web portals, fear not: it's in there. Your comments are being compiled with others, dropped into PowerPoint and will likely appear in a future DMCB posting.

Comments are still being accepted through early next week. This is your chance to educate, impress and influence a roomful of future doctors. Posts here, email, tweet, Facebook and LinkedIn are all accepted.

By the way, the DMCB is **NOT** going to teach about, let alone mention, "disease management." Rather, the lecture will deal with various approaches to health care financing and risk transfer.

The DMCB is planning to conclude the lecture with a comment that touches on a favorite topic borrowed from J.D. Salinger's literary masterpiece Franny and Zooey. That would be the "Fat Lady," or how contemplation, reverence, submission and service can can light up the universe that lingers just beyond the reach of rational thought. This is the astonishing insight from brother Zooey that pulls the gifted radio star Franny Glass out of her nihilistic funk.

Physicians are especially privileged because they have a leg up on discovering their own personal Fat Lady. She exists in every patient and she calls to us. And she is now telling us that, while diagnosis and treatment are still "Job One," we docs are also being called to apply new skills in reconciling ethics, financing, public health, health literacy, lifestyle issues, socioeconomic status and third party meddling:

Zooey's explanation to Franny:

[I was told] to shine my shoes...I was furious. The studio audience were all morons, the announcer was a moron, the sponsors were morons, and I just damn well wasn't going to shine my shoes for them... I said they couldn't see them anyway, where we sat. He said to shine them anyway. He said to shine them for the Fat Lady. I didn't know what the hell he was talking about, but he [had a] ... look on his face, and so I did it. He never did tell me who the Fat Lady was, but I shined my shoes for the Fat Lady every time I ever went on the air again -- This terribly clear, clear picture of the Fat Lady formed in my mind. I had her sitting on this porch all day, swatting flies, with her radio going full-blast from morning till night. I figured the heat was terrible, and she probably had cancer, and -- I don't know. Anyway, it seemed goddamn clear why [I had to] shine my shoes when I went on the air. It made sense.

And now the Fat Lady is telling physicians that while morons abound, understanding the principles underlying risk transfer and how insurance works is important because will help you get your patients the care that they need. In other words, knowing how and why health care services are financed and what can be done about it at the individual patient level is no longer the job of that lady sitting on that porch.

Here's the DMCB comment: Docs need to shine those shoes.

J.D. Salinger, Franny and Zooey's Fat Lady, Lent and the White House Health Reform Meeting

Since the Disease Management Care Blog has repeatedly belabored J.D. Salinger's Fat Lady, familiar readers may ask why it didn't mark the author's passing on January 27.

It was waiting for the right time. This posting is dedicated to him.

Recall the 'Fat Lady' is that piercing insight achieved by the crisis-addled Franny. Thanks to the counseling of her precocious brother Zooey, her breakthrough helps her deal with a favorite theme of J.D: the modern world's self-absorbed fakery. Franny realizes that her deepest human potential will be met so long as that poor distant woman 'sitting on a porch, listening to the radio' is served - because that Fat Lady really represents something far more wonderful.

Which leads us to the confluence of two other events, one being major and the other relatively minor. One is Lent, the other is Mr. Obama's Feb. 25 go-for-broke Blair House health reform meeting. Lent is that 40-day season before Easter when believers practice self-denial, penitence and seek insight, including thinking about all the other '40's' that are embedded in the Christian calendar. That includes the Jews' 40 years of wandering about in Sinai, as well as Jesus' fasting for 40 days in the desert while being tempted by the devil.

And what temptations they were. The DMCB's amateur interpretation is that Satan's three offers appealed to our most basic human needs: turning stones to bread means freedom from hunger, the 'on-call' availability of angels after leaping off a pinnacle means being immunized against death, and having dominion over all the world's kingdoms means absolute power.

The DMCB isn't suggesting that ashes be passed around or that scripture be read at the Feb. 25 health reform confab, but the Temptation of Christ does have something to teach about the fundamental hard wiring of the human condition. Being "human" means to live by more than bread alone, by being content with some hard facts about our mortality and to being acutely aware of the hazards of concentrated political power. Otherwise, we risk falling far short of meeting our deepest human potential. In order to achieve that, something far greater is necessary.

The DMCB has little doubt that there are honorable people on both sides of the health care debate, that there are critical policy issues at stake and that social justice is in our lifeblood. While some may wonder if the DMCB has turned into some wingnut case full of the Devil Made Me Do It, it thinks the lessons of Lent and the Fat Lady should give pause about the tempting notion of being able to practically cure any threat to our mortality if only we were willing to apply the right kind of enlightened political power.

Franny was a radio entertainer, so she knew something about audiences. When she recognized the Fat Lady was out there, she got her life in order. For the Feb 25 Health Reform meeting, our elected representatives would be well advised to remember the Lenten season and that the Fat Lady is in the audience. It can only help.

The DMCB thinks J.D. would probably approve.

*Since J.D. probably wouldn't permit an unauthorized image of him to be shown, the DMCB decided to portray the prayer (this one's in original Romanian) repeatedly uttered by Franny until Zooey's rescue

Martin Luther King Day and Health Care Disparities - Much Work Remains

Martin Luther King Day is upon us. The Disease Management Care Blog is using this time to reflect on Dr. King's remarkable achievements on behalf of the disenfranchised. Yet, while his civil rights legacy is indeed a cause for celebration, it's also a reminder that, when it comes to healthcare, much work remains to be done:

Of course we know that socioeconomic status and race are linked. The good news is that it's possible to tease that out and discern when barriers to care are predominantly economic and when they are a function of skin color. Sadly, the science confirms that what Dr. King told us decades ago is till true today: we still have a problem. No, make that a really BIG problem.

While we're all looking for reasons to leave no corner of the health care system unexposed to electronic medical or health records, the Department of Health and Human Services has released a long awaited Interim Rule on the 'meaning' of meaningful use for health information technology. The good news is that it includes a requirement that it be used to reduce health care disparities. The bad news is that that particular issue is being treated as a 'quality of care issue,' along with other care domains such as continuity of care, error reduction and research. If Dr. King were alive today, he'd probably wonder about linking fundamental human rights issue to 'quality'; the Disease Management Care Blog would not only agree, it'd also worry about the prognosis of that approach.

Of course, having an electronic health or medical record is not the same as having a workable registry. Despite the little real world knowledge of just how electronic records address disparities, there is this report on how registries can help define the patterns of care associated with race. The first step to doing something is to measure it, and this sure looks like a good first step, assuming this is built into registries and we are prepared to act on it.

Many may not be are aware that managed care insurers have a long legacy of working to reduce disparities among their enrollees. They're making some progress (see here, here and here), but the flight of employers to self-insured plans could possibly undo things. Going forward, the DMCB thinks Rev. King would suggest this deserves greater measurement and scrutiny.

Last but not least, patient centered medical homes and disease management can reduce disparities. In working with many organizations, the Disease Management Care Blog is proud to report that many take that mission very seriously. It just wishes they'd do a better job of taking their data on this and moving it into the public domain.

The Fat Lady is a fan of Reverend King and brings up this quote from the 25th Chapter of Matthew.

.....Come, you who are blessed by my Father; take your inheritance, the kingdom prepared for you since the creation of the world. For I was hungry and you gave me something to eat, I was thirsty and you gave me something to drink, I was a stranger and you invited me in, I needed clothes and you clothed me, I was sick and you looked after me, I was in prison and you came to visit me....I tell you the truth, whatever you did for one of the least of these brothers of mine, you did for me.'

While some readers may think the Bible shouldn't have any role in health care policy and planning, the DMCB knows Reverend King would disagree. Even then, we can still be guided by its powerful insights about the human condition and the way forward.

These 'least' are our equals. The sick await. The work remains. We can do better. And the stakes are high.

A Holiday Reminder

Whatever you may think of Washington DC's road to health reform, the Fat Lady reminds us that we need to put things into perspective. Recall the Fat Lady is the savior in J.D. Salinger's classic Franny and Zooey. Franny is overwrought by the misplaced passions of her time. After considerable struggle and prayer, Franny achieves a newfound insight about what really counts. J.D Salinger wonderfully describes how Franny's anxiety evaporates in the face of knowing What Is Truly Important. She sees the way through and the transcendent Fat Lady is not surprised.

Of course, J.D. Salinger can't take full credit for the metaphor. The Disease Management Care Blog thinks much of the credit goes to an event that occurred 2000 years ago. While Rome was no Washington DC, its citizens were acutely aware of the influence of power, the role of alliances and the struggles that resulted in winners and losers. Little did anyone realize that those temporal ingredients would fade in importance thanks to stunningly new insights on how to deal with the world. All this and much more thanks to a small baby born in a small outpost of the Roman Empire.

The DMCB has been to Washington DC and it's full of statues of dead people. Every one of them did something important and the DMCB thanks every single one of them. It is also thankful to its President and the members of Congress for their efforts on health reform, as well as all the other stuff they're doing. In fact, it wouldn't be surprised if a Senator or two gets recognition with a statue.

However, the Fat Lady doesn't care about that. She is looking deeper at each one of us with a far different measuring stick. This Holiday Season is a good time to pause and be thankful for that gift of insight.

Another Reason Why the Health Reform Town Halls Are Not Failing to Disappoint

The Fat Lady points out that the historical and religious tension between population based care versus one-on-one care may be one ingredient in the health reform Town Hall brouhahas.

Recall it was the ‘Old’ Testament that proscribed certain dietary practices and contact with persons with communicable disease. While the basis of these laws are myriad and include public health as well as holiness, they strike the Disease Management Care Blog as being among the earliest examples of population based care: the care shown by God for a chosen people blessed by a special covenant.

Contrast this community-based hygiene with the 'New' Covenant of Jesus’ ministry in the New Testament. While He certainly personally followed Jewish law, His controversial appeal to his past and present followers seems to have less to do with the collective fate of peoples and more to do with the personal salvation of individuals. To the DMCB’s knowledge, Jesus didn’t come up with a means to diminish the prevalence of leprosy, schizophrenia, blindness or paralytic syndromes. Instead, He cured individuals one at a time. How inefficient. And how wonderful.

Say what you like about the role of the Bible in modern society, the Fat Lady thinks it continues to give great insight into today’s human condition. The insight here is that when it comes to illness, persons don’t want to have the likelihood of future complications from their chronic conditions to be diminished, they want to be cured. That was the health care gold standard uncovered approximately 2000 years ago - and it remains with us today.

Which may be part of the problem underlying the August health reform doldrums and the Town Halls discussed in yesterday’s DMCB posting. After being thoroughly pressured cooked by the dense Boston-based academosphere of D.C. health policy, our elected representatives have emerged from the Capital building spouting opaquely dense terms like ‘access’ and ‘primary care provider’ and ‘bending the curve’ and “preventative.’ They want the public to buy into quality assurance, comparative effectiveness and actuarial predictions.

The Fat Lady says good luck.

Part of the Town Hall dynamic may certainly include political grandstanding, unreasonableness, partisanship, manipulation and public inattention. However, the DMCB also thinks many persons want to hear how the electronic health record, how comparative effectiveness research, how the public plan option, red pills-blue pills, better attention to living wills and subsidies for health insurance will help cure people. Anything less just won’t do, especially if it’s going to cost $1,000,000,000,000.

As an aside, even the Fat Lady understands the difference between miracles and medicine. That being said, one allure of today’s medical-industrial complex is its promise of miraculously ‘curing’ diseases like cancer, heart disease and obesity. In fact, she wonders if the continuing business success of the disease management industry is due to its recognition of the U.S. health care system’s core appeal. They quickly changed course on marketing themselves as the best approach to chronic conditions in the 1990s to re-emphasizing their role as a supportive care strategy in the 2000s.

The Fat Lady, Attending a House of Worship, Disease Management Engagement Rates and the Little Things That Count

The Fat Lady reminds the Disease Management Care Blog that everyone should regularly attend a house of worship. Aside from matters of faith, it’s a good way to regularly put things into perspective while taking a break from worrying about tomorrow’s meetings and deadlines. More importantly, you’ll gain insights about the human condition that are generally ignored by popular culture. Heavy stuff indeed.

Presidents are a good illustration of this. Both Kennedy and Reagan, for example, reached for inspiration from the shining city upon a hill. Abraham Lincoln famously pointed out a house divided against itself cannot stand. Even President Obama has told us it is time to set aside childish things.

Well, the DMCB isn’t immune either. It reached into the Easter Service grab-bag for two insights about its little corner of healthcare.

First off, purchasers of disease management programs have long gnashed their teeth over low contact and engagement levels of all persons in their eligible populations. In its business dealings, the DMCB has tried to point out that increasing recruitment drives up costs, enrolls progressively more disinterested patients and counter-intuitively reduces the return on investment. Perhaps it should also point out that that it was recognized long ago that a message far more important than A1c levels, asthma medication compliance or blood pressure control has also been stymied by ears that do not hear. 100% of all eligible patients will never cooperate with disease management, engage with their patient-centered-medical-home team, log onto their electronic health record, buy health care insurance, take their medicines or see a physician. Since less than 100% engagement was described in important literature well over 2000 years ago, the population-base care industry should work on describing what engagement rates are possible, not ideal.

Secondly, the Gospel of John has an interesting detail about the Tomb and the Resurrection:

“and a linen, that was about his head, not lying with the linen clothes, but wrapped together in a place by itself.”

The DMCB isn’t too sure about the significance of the folded cloth separate from the rest of the rumpled burial linens. It was told by a Methodist preacher that the ancient carpenters used this to signal that their job was done. Even if that is not true, the Fat Lady still likes the special touch in this behemoth of a population-based (and soul saving) intervention. The lesson here is that the little things nurse coaches do to inspire, nudge and motivate their patients are as important as any exquisitely constructed, decision-supported, evidence-based protocol. While we think about populations and billions of dollars we’re preparing to spend on chronic illness, we need to remember that the small details also count in ways measured and unknowable.

A Contrarian Nominee Suggestion for the Secretary of Health and Human Services

The DMCB feels sorry for its fellow bloggers who boned up for Czar Dashcle’s reign by memorizing his blueprint or forwarding the minutes from those holiday home-based healthcare confabs. While y’all were getting ‘engaged,’ the DCMB was involved in other far more rewarding holiday pursuits. The silliness is not done, however, thanks to the speculation fever over the identity of the Obama Administration’s ‘Plan B’ HHS nominee. Examples are here, here and here.

Not wanting to miss all the fun, the ever contrarian Disease Management Care Blog would like to present its own favorite candidate:

Gloria James.

NBA sports fans may recognize the name of the mother of the Cleveland Cavs’ superstar forward LeBron James. She’s something else. She had LeBron at the age of 16 and as a single mom moved from one menial job to another while keeping a roof over her head and her son from disappearing into the street violence of Akron, Ohio’s streets. This is a woman of grit, determination and hard work.

So, why is she qualified you ask? Well, says the DMCB, consider the following:

It's not just her mettle, she’s a mom. That is a huge advantage, not only because of her gender (which remains underrepresented in DC) but because of what the Fat Lady teaches us in this story from the 15th Chapter of Matthew: ‘Have mercy on me,’ said this anonymous mother to Jesus, ‘my daughter is grievously vexed with a devil.’ When rebuffed, she repeated her plea, saying ‘Lord, help me.’

Curious, isn’t it? The child is ill but it is the mom that is personally suffering and is begging for mercy and help for herself. The DMCB finds this story once again demonstrates the Bible’s special insights about the human condition: mothers feel their children’s pain. What’s more, they understand other moms’ pain and they’ll (and in this example, literally) move heaven and earth to fix it. The DMCB asks: wouldn’t this special skill of selflessness for others’ suffering be a refreshing ingredient inside the beltway? Go to ANY home and school association meeting, any school sports game or Sunday school and you’ll find qualified candidates for the job. You’ll find Ms. James.

Speaking of moving heaven and earth, Ms. James would be a tireless and energetic advocate. There is no better demonstration of this than this clip of Ms. James rigorously debating the finer points of NBA officiating with a referee during a Boston-Cleveland game. The DMCB thinks our President and his team of rivals would benefit from having a person like this who won’t be afraid to tell the Big Man the way it is. By the way, Mr. Obama’s love of basketball will only further cement their mutual respect.

Last but not least, Ms. James has allegedly amply demonstrated her preference to not to take advantage of limo rides at the taxpayers’ expense, expressed by kicking out car a window, if necessary, to make her point. No last minute tax issue surprises here: with Ms. James, what you see is what you get.

But she has no background in healthcare policy you reply? Well, it’s not just the DMCB that thinks it’s possible to have too many economist/PhD experts cluttering up the White House. What’s more, just because you are one doesn’t mean you’ll be very successful. Secretary Ms. James can surround herself with her own team of rivals. What’s more, if common sense and hard work don’t allow her to understand what’s being proposed, I think we can count on her to keep our healthcare laws regulations from being gummed up by even more gobbledygook.

But she has no chance you think? Well, she has about as much of a chance of being named as this guy does.

You GO Ms. James!

The Magi and What Their Mathematics Discovered. The Fat Lady is Back

While the role of the Bible in modern American society can be controversial, the Disease Management Care Blog still thinks it’s great literature that gives important insight into the human condition. While it is the nature of popular media to substitute “Happy Holidays” for “Merry Christmas,” Santa for St. Nick and happiness for holiness, the DMCB is reminded by the Fat Lady to look for the lessons from the Season.

That’s why it’s been thinking about the Magi. These are the wise men who made a brief appearance in the second chapter of the Gospel of Matthew. These individuals were probably top learned scientist-astronomers engaged in the full time study of the patterns of the heavens. As the lights circled overhead in precise mathematical patterns, this expert class of professional stargazers constantly sought out new insights and even attempted to link them to human events or predict the future.

The DMCB isn’t too sure that the stargazers of that day are not too dissimilar from today’s vast numbers of professional number crunching pattern watchers. The only difference is that their areas of study are no longer confined to the stars. In addition to breathtaking advances in the physical sciences, modern wise men are gazing at humans and their patterns, likewise seeking to link them to other events and predicting the future.

We’re all familiar with these brainiacs. Facile with incredibly complex mathematics, these data-heads can price risk, assess the strength of statistical associations and assign attribution. Some are better than others. The ones that are really good, really lucky and benefitting from the work of others often go on to make incredibly useful discoveries. Some even win Nobel Prizes. This is the work of turning data into insight and information into inspiration. This is the work of making numbers “sing.”

So who were the greatest mathematicians greatest of all time? The DMCB votes for the Magi. Blessed by the work of generations of predecessors as well as the good fortune of being in the right place at the right time, these brainiacs also applied prodigious (and literal) amounts of leg work in the pursuit of explaining new pattern in the sky. And what a thing they discovered.

Is this an endorsment of mystical numerology? Hardly. But the DMCB finds it interesting that mathematicians feature so prominently in this classic Bible story. Once again, something far greater lies at the center of our logical hard wired dependence on what is seen and what is measurable. The Fat Lady reminds us that this calls to us every Christmas season.

What Angels Teach Us About Announcements from the Disease Management Industry

The season reminds the Disease Management Care Blog that healthcare is more than just outcomes or trend. It’s also about the Fat Lady and not living on bread alone. Consider that Jesus’ life-story was bracketed by angels announcing His birth and resurrection to persons subsisting at the lowest socioeconomic rungs of the day: shepherds and women. I leave it to the reader to interpret the significance of what happened between the angels’ visits. Whatever the conclusion, it should remind our industry to always consider the relevance of our multiple announcements for those struggling at the margins of today’s modern society.

Where's the Fat Lady?

Fans of J.D. Salinger may remember the Catcher in the Rye, but the Disease Management Blog thinks Franny and Zooey was J.D.’s finest work. In it, the college-attending, 1950’s heroine, Franny, becomes disillusioned by her meaningless life. Lacking access to the answers offered by our more modern age, like attending a rave or the joys of body art, she turns to repetitive prayer. It’s up to her elder brother and precocious radio-star Zooey to get her to snap out of it. After giving the reader a literary bus tour of the Upanishads, Zen Buddhism and Christian mysticism, Zooey finally hits pay dirt when he reminds his sister about the Fat Lady. Franny’s anxieties are eclipsed by the satori-provoking metaphor of lifelong service to this least-of-us child of/symbol of God.

Heavy stuff indeed. So what does this have to do with anything? Well, my blog, my posts. But seriously, the Disease Management Blog recently had the pleasure of touring a disease management call center, which was an industrial-strength, football-field sized, white-noised cubicle farm of nurses telephonically “engaging” persons of chronic illness. When I was invited to sit in on an HIPAA compliant “outbound,” the nurse took the time to show me a simple hand-made present and a handwritten thank-you letter sent to her by one of her diabetic patients. While she appreciated the small gift, it was gratitude in that note that was memorable for the two of us. Its value will never be captured in a per diseased member per month transaction.

There are several lessons here. The first is that Franny and Zooey is a good read if you're a JD fan and like that sort of book. It’s an option for that next plane trip. The second is that the sheer scale and complexity of these call centers is remarkable. Don’t turn down an opportunity to see one. Third, the remote coaching telephony from a good nurse to an interested patient is not automatically the Vytorin of health care: it can make a remarkable difference in individual patients’ lives. Fourth, the nurses that work these centers are good. Really good. And finally, while it’s fun to cross swords over what to do about the national cost and quality of chronic illness care, the Fat Lady not only appreciates the disease management nurses. She also writes to us from the center of our healthcare policy debate.