Gladwell, Blogs, Connectors, Mavens, and Ezra Klein as Salesman: The DMCB's Insight About the 51 Vote Majority & Health Care Reform

In its presentation at the Jefferson hosted Population Health and Disease Management Colloquium, the Disease Management Care Blog discussed health communication and social media. Among its many insights was a Gladwellesque view on blogs and their dynamic in 'tipping' policy debates: there are connectors (e.g., the excellent HealthHombre), mavens (e.g., the expert Health Care Policy and Marketplace Review) and then there are the salesmen (what better example than the energetic, enthusiastic and likeable Ezra Klein?).

And speaking of Ezra, what's there not to like? His sharply written posts are a study in the art of communication and new media, he's appeared in that summit of hip popular culture, The Daily Show, he posts vegetarian recipes and regularly sports fashionable amounts of facial hair. And salesman he is. The parliamentarian ruling on the health care bill is good news, the opinion polls on health reform show widespread support for the Democrats, Senator Harry Reid is a civics lesson in political aplomb and geniality, increasing Federal spending to reduce the deficit should be a no-brainer if only opponents would listen to us media elites and, finally, passing health reform on 51 votes is a marvelously grand idea.

That latter point is important and didn't occur to the naive DMCB. If health reform does make it, that may mean that there is a silver lining: a similar bicameral simple majority may be all that will be needed to revamp it. Hmmmm.......

And a DMCB afterthought: The editors at the New England Journal of Medicine could save themselves a lot of work over the faux centrist Health Care Reform Center by simply substituting links to Ezra. That way they could devote more space to a) what they're good at: publishing important cutting edge research and b) thinking how to make the research results understandably accessible to an increasingly savvy and skeptical public

The Health Care Industry Answers the Question Again: Why Did the Chicken Cross the Road?

It's been some time since the Disease Management Care Blog posted industry answers to the age old question. It's that time to ask again .......

"Why did the chicken cross the road?"

Health Insurance Industry: Crossing the road is not a covered benefit and, because we weren't informed about the bird's pre-existing tendency to cross roads, have issued a rescission effective three years prior.

Healthways: We regularly survey thousands of chickens with that question. We think this question can be applied to turkeys and guinea hens.

Lifemasters: Um, the chicken didn't make it across the road.

The PHI Institute: Compared to what?

The Dartmouth Atlas: We looked at regional variation involving the road-crossing patterns of dead chickens and can find no explanation for it. It must be preference sensitive.

Mainstream Media News: Fowl on Foul Road Prowl: Bird Defies Death, Seeks Safety From Evil Insurers!

The DMAA Care Continuum Alliance: If crossing the road was a desired outcome, our members' engagement strategies were responsible for it and that service should be covered by all health insurers and Medicare.

Academic Medical Centers: To find out, we'd like the government to fund large studies that randomly assign a valid sample of chickens to a road, another sample without a road and prospectively measure both groups over many years of comparative effectiveness research.

Medicare: So that we can be billed for it 10,000 times by a suppliers in Florida.

The Senate Confirmed CMS Administrator: blank

Bloggers: We don't know, but we'll be happy to speculate on why - or why not - for days on end.

The DMCB: To avoid having to watch the maudlin blubbering in The Biggest Loser

The DMCB Spouse: You have a ceiling to paint.

getting there the hard way (part 2)

When I left off yesterday, I was stranded at the Detroit airport, standing in a line-up for three hours waiting to re-book my flight to Atlanta. 

A very drunk young guy in front of me spent the whole time hitting on all the younger women in line (I was only brought into the conversation for affirmation, "Isn't she pretty?"). He also showed us the the alligator Crocs he'd bought for his young nephew (whom he called while standing in line. Not sure where his nephew lives but it was well after 10:00pm in Detroit) and asked if the shirt and tie he'd bought matched each other. Under different circumstances, he might have been endearing but I was well and truly done with him by the time we reached the front of the line.

At the 2.5 hour point, the woman behind me in line, who had been reading the Book of Ruth and worrying relentlessly about what would happen next, stepped out of the line and went directly to an agent - who served her and sent her on her way. There were some very disgruntled rumblings about this but I'm surprised to say that no one had a meltdown, or even complained to the staff. I was very impressive by the behaviour of the crowd throughout our frustrating wait.

And there were some folks around to give us perspective, chief among them the 6 year old boy who I did not hear complain even once. There was also a big guy who was sharing some beef jerky with his neighbours. I heard him say. "This is a pain in the ass but it's better than being in Iraq." Seriously. He went on to explain that he'd recently returned from a tour of duty.

It was around this time that I overheard an agent telling folks who had succesfully re-booked that they would be given a voucher for a hotel room, if their layover was due to mechanical failure but not if it was due to weather. When she then asked folks one by one which was the reason they'd missed their flight, I did my best to send them telepathic messages, "Say 'mechanical failure'!" - because, really, if no one is checking, why would you say anything else?

I knew that my own case was ambiguous, since my original delay had been due to weather but languishing on the tarmac in Detroit had sealed my fate - and in Detroit the skies were clear and there was no snow on the ground. I was fully prepared to argue my case when it was my turn to do so, to raise my voice, to threaten a blog post and even to play the cancer card. Basically, I was ready to stoop really low to ensure that my head would rest on a pillow that night.

It was after 11:00 by the time it was my turn.

I approached one of the two agents on duty. He asked me how I was. I took one look at his face and said, "I'm just fine. How are you?"

He replied that he was OK, just frustrated because the computers were now working really slowly, to which I said, "That's OK. I've been really patient until now, I can be patient for a few more minutes."

I thought at that point that the guy was going to burst into tears. He said, "You've been really..." then interrupted himself and concentrated on getting me out of town the next day. It took a while but when I left him I had a ticket on a 7:15 flight to Nashville the next morning, a connection to Atlanta, vouchers for a hotel room (no questions asked) and for breakfast the next morning and the reassurance that my suitcase would meet me in Atlanta the next day.

After getting lost trying to find my way to the hotel shuttles, I called the hotel listed on my voucher to find out how to get there. The voice on the other end of the phone told me they were full and I should go to the Quality Inn. I called the Quality and was told how to find their shuttle.

As I left the airport, I spotted the drunk guy from the airport. He was holding the free phone to hotels looking confused. I silently wished him well but was too tired to stop and see if he needed help.

I boarded the hotel shuttle as instructed, along with a lot of other punchy, exhausted travellers (we were sitting in a circle and someone started singing, "Kumbaya!"). Our first stop was a little Days Inn. I got off to confirm with the driver that he would be stopping at the Quality Inn. 

"You have to go here, Ma'am. The Quality Inn is full and all passengers are being re-routed here."

"But I just spoke to someone at the Quality Inn and she said to come on over." I'm sure I sounded petulant.

"I've been told to take everyone here, Ma'am but I'll call for you." He placed the call while I stood there and I listened as a hysterical voice on the other end of the phone shrieked at him that they were completely full, as she had already told him.

I apologized, thanked the guy profusely and got into yet another lineup in the lobby at the Days Inn. There was one person at the front desk and she was really flustered. She loudly announced that she was not at all sure she was going to be able to acccomodate all of us. As I stood at the back of the line, I felt tears pricking my eyes.

In the end, she did have a bed for me, in a smoking room (incidentally, this is the only time in my life that I have checked into a hotel room without being asked for any form of id or a credit card). I was hungry but also nauseated, so I skipped the restaurant which was filled with smoke (it  had also been a really long time since I'd been in a public place where smoking is permitted). I went up to my room, flopped down on the bed and turned on the TV just in time to watch Joannie Rochette accept her bronze medal.

The alarm went off 4 hours after I'd closed my eyes. I showered, dressed (from now on, I'm carrying clean underwear in my carry-on) and headed down to join a throng of bleary-eyed travellers in the lobby (my "free breakfast" turned out to be a tray of wizened, sugary pastries with a large sign overhead saying "Please do not smoke during breakfast." I was tempted to take a photo but didn't want to linger, out of fear of missing my shuttle).

The hotel clerk, a young man, was on the phone as I checked out, trying frantically to find another hotel shuttle. I gather that there were twice as many people in the lobby as had signed up for the airport shuttle the day before. After a couple of minutes, a shuttle was succesfully located - another instance of someone, who is no doubt paid minimum wage to do a difficult job, pulling out all the stops. I was impressed (and I emailed hotel management to tell them so).

The rest of my trip was uneventful. I sailed through security. Bought a latte and a new paperback book and read my way through my next two flights. I arrived at the hotel in Atlanta 90 minutes before the start of my conference.

I was very happy to be there. And way too relieved to complain when I discovered that my "city view" room looked out on a giant car park.

The Three Legged Stool of Government, Evidence Based Medicine and Markets in Insurance Reform

The Disease Management Care Blog attended a quarterly meeting of its county medical society tonight. Once again, it came away impressed with these physicians' depth of knowledge and sophistication about health reform. Unsurprisingly, one big topic of the night was the on-again, off-again 21% cut in Medicare physician payment rates. My colleagues were well aware of how we got here, understood the difficult politics and voiced their preference that they not go through a huge pay cut. Yet while there was dismay in the room over just how broken the political process is (if the AMA and the President can't deliver, who can?), the DMCB also detected something much deeper going on.

Almost no one seems to disagree that 'insurance' i.e., the pooling of risk, maintaining reserves to adequately transfer risk, maintaining a buffering surplus and covering administrative fees is a bedrock approach to financing health care. The perception of the brokenness is over how three key viewpoints are interacting over deciding how to deal with a strained health insurance system:

Government: With statutes, regulations, policy, enforcement and seeking redress in the courts, government has to balance oversight versus active management of the insurance industry, including the benefit design, underwriting, pricing and payment.

Evidence-Based Medicine (EBM): This says rational science can guide the allocation of resources in mitigating risk, based on a dispassionate understanding of clinical and cost effectiveness. It has its limits however, since much of clinical medicine is not evidence based and the real challenge is to translate what we already know into actual practice.

The Market: It's up to individuals, or blocks of individuals, to decide on the content of the risk transfer, the price they're willing to pay and which insurers they're willing to do business with. That's assuming, however that the market can be made sufficiently transparent and that persons will take as much time to research their insurance choices as they do in selecting a high definition TV screen.

What the DMCB witnessed tonight among the docs was a thoughtful understanding of how all three approaches are simultaneously necessary and complimentary. From time to time, government has to step in (when markets fail and individuals are facing double digit increases), science should always inform what should be covered (coverage of mammography is a no-brainer) and consumers should be able to make informed choices if it's their money (for example, the DMCB has a health savings account and is planning accordingly). The real work of a competent society is to get all three to add up to a functional system of coverage that is greater than the sum of its parts. Each may have an increased role from time to time, but in general, all three have to work together.

Like a three legged stool, over-emphasis of any single approach can be unstable. Government can meddle by mandating unrealistic premiums and bloated benefit designs. EBM can torpedo mammograms for women under age 50 or decide that certains forms of chemotherapy should not be offered. The market has certainly demonstrated an unending ability to screw unsuspecting consumers with products that strain the definition of insurance.

The DMCB personally thinks that a perfect storm of unsustainable demand for more and increasingly expensive health care services is tilting the stool toward an ascendant role of government. While that may be our best hope to fix the health care mess, the DMCB wishes that the current debate did a better job of considering novel ways to use EBM and the market. Maybe that's too boring and doesn't appeal to our media besotted advocates at the extremes of the political specturm. The DMCB says too bad.

The good news is that there is a clutch of physicians in a county medical society who get it. There are undoubtedly others in other groups of professionals, informed citizens and voters in town halls, living rooms and service organizations. That makes the DMCB more optimistic over the long run.

getting there the hard way

At the end last month, I attended the 10th Annual Conference For Young Women Affected By Breast Cancer. The conference was a wonderful experience, the getting there, however, was a traumatic experience.

The kind of experience that made me think that if I never see the inside of an airplane again, it will be too soon.

Please bear with me (or feel free to move on to more interesting places) while I rant. This is my story.

February 25

1-At 8:15am (my flight is at 11:15 and I live fifteen minutes from the airport but I have become paranoid extremely cautious about long lines and security), as I the taxi pulls up, I get a funny feeling in the pit of my stomach. I ask my spouse to check on my flight status. It turns out that it's been cancelled. The cab driver is none too pleased when I send him on his way.

2-Wait on hold for an hour so that I can re-book my flight. It turns out that the big storm in New York has caused many flights to be cancelled (I was scheduled to go via Newark). My new flight will take me via Detroit.

3-Leave for the airport at 1:30pm for a 4:30pm flight. End up waiting for half an hour for ticket agents to finish their break and check me in. I truly don't mind that staff take breaks. It is a little annoying when they are doing so in full view of lined up passengers. Couldn't they go have a coffee or something? Couldn't Delta have other staff cover breaks? Do they all have to go on break at the same time?

4-Clear security and proceed to the bar near my gate. Have a big beer and a sandwich. Given what follows, I end up being very grateful for the sandwich.

5- Settle in at the gate only to learn that my flight has been delayed by an hour. 

6-Board airplane and sit on the tarmac for 40 minutes as the wings are de-iced. I have a good book and lots of time to make my connection, so I'm not remotely worried.

7- Land in Detroit with an hour to spare beofre my flight to Atlanta. The flight attendant asks that all those with less than 25 minutes to make their connections be let off first. We then sit on the tarmac for an hour, growing increasingly anxious, as there is too much of a logjam to get to the gate.

8- Get off the plane after my connecting flight was scheduled to leave but note that the Departures screen indicates that my flight is still boarding. Sprint through two terminals and across the airport.

9- Arrive at my gate out of breath and with my heart pounding, to be told that a) my flight has left and b) there are no more flights to Atlanta that evening. I am directed to another gate to re-book my flight. The agent tells me that he has "no idea" whether I will be offered a hotel for the night. 

10-Try to re-book by scanning my ticket. When that doesn't work, I join a very long line,  in which I stand for three hours.

I've worn myself out just writing this. I'm going to go do something else now. I'll conclude this riveting story tomorrow. Do you have a travel horror story? Want to share it in the comments?

The 100th Cavalcade of Risk Is Up

Coming at you from New Zealand, Chatswood Consulting hosts a marvelous summary of the latest bloggery on risk - all kinds of risk. That means insights on health insurance, re-insurance, home insurance and workman's comp from the best of the net thinkers. Sample this excellent piece of global commentary from the comfort of your PC by simply clicking here. Enjoy!

Advanced Practice Nurses As A Solution to the Crisis in Primary Care

The Disease Management Care Blog welcomes colleague M’Lynda Owens, who is pursuing a PhD in nursing and has extensive experience in the health care industry. She makes an important point: if the market isn’t willing to support primary care and the physicians themselves are walking away from that specialty, why would anyone oppose the expansion of nurses in this field, especially when there is so much science that supports it? Given that point of view, she also offers up some recommendations for health care reform:


This nurse couldn’t help but respond to the provocative comment quoted in the DMCB's recent ‘Selected Quotes’ posting: "When asked about physicians that are reluctant to transform their practices into patient centered medical homes, Gordon Norman offered this astute solution: 'Fine, let the nurses do it.' The silence in the hall was telling."

I've watched the national conversation about health care reform and find the silence surrounding the role of non-physician primary care providers (PCPs) deafening. Advance practice nurses (APRNs) and physician assistants (PAs) have been serving with distinction as PCPs for more than 40 years. Numerous studies (for example here, here, here, here, here and here) have repeatedly demonstrated high clinical quality and patient satisfaction associated with APRNs. In addition to their clinical outcomes, they’re also trained to commit more time talking with and listening to patients during encounters and have an excellent record of patient safety in a wide variety of settings.

APRNs do not want to displace physicians. What they are willing to do is use their training to fill the growing gaps in health care coverage. Physician groups note with alarm that increasing numbers of medical students are not choosing careers in primary care. That may not be necessarily bad. The level of education and skill possessed by specialist physicians for highly acute and complex cases warrants extensive training and should be commensurately rewarded. But someone has to serve in primary care. So if physicians don't want the job, why not let the nurses do it?

As noted above, there is ample science that shows that it doesn't take physician training to manage many of the tasks involved in primary care access, including treating upper respiratory illness, conducting wellness exams, caring for minor trauma, providing institutional care in nursing homes and prisons, following normal pregnancy, treating stable chronic conditions, collaborating with disease management initiatives and addressing the myriad other routine reasons people seek first-contact medical care. In addition, APRNs are paid less than physicians – which helps with cost containment for these types of services. Last but not least, APRNs are willing to serve in rural and economically disadvantaged areas, where reimbursements are low. This is Disease Management 101. Other than the turf battles, why not support letting the nurses practice what they've been trained to do in an evidence-based manner?

To make this happen, the following need to be included right now in health reform:

1. Independent licensure and prescriptive privileges across the 50 States are necessary so that physicians are not statutorily saddled with "supervising" or "collaborating" with APRNs who can competently practice and prescribe medications independently in all but 12 states. An APRN, practicing within her (yes, 95% her) independent licensure, should not be statutorily forced to find a physician willing to take on the oversight of another's practice.

2. Insurers need to reconsider their unwillingness to independently empanel and reimburse APRNs.

3. While the educational roles of pharmaceutical companies are being reexamined, they should drop their reluctance to provide educational support and pharmaceutical samples to APRNs; they are not shadow providers;

4. Pharmacies should honor APRN prescriptions that are not co-signed by a physician.

5. We also need to continue to gather hard data on the safety and efficacy of APRN practice patterns, including their contribution to the care of populations with chronic illness

Why not support the nurses? For the sake of cost containment, access, quality, and disease management, it just makes sense.