The Sky is Falling! Oh.. It’s Just H.R.3590 Saturday, Mar 27 2010 

While in Alabama last week I spent three days working at Huntsville Hospital. I had intense fellowship with a few of my physician colleagues while I was there.

The common theme was the fear of what health care financing reform would bring. The fear and near hysteria were palpable. The physicians I talked with told of “friends” who would either stop taking Medicare or switch to concierge i.e boutique medicine. Under the concierge scheme the patient pays a membership fee and in return the patient gets more personalized 24/7 care. This includes on demand visits to the physicians office, or house calls and some concierge providers will travel to see you no matter where you are. While concierge medicine may work for a few who have the “right” clientele, it will not become the way of the world. Then, what happens to the patients who cannot afford the membership fee?

For those physicians who stop taking Medicare, I say you went into medicine for the wrong reason and you leave Medicare to your peril. What value do you place on the relationships you have with your patients?

In Alabama, the Blue Cross Blue Shield monospsony is the Medicare intermediary, in other words BCBS of Alabama administers the program…hello! Maybe if we begin to provide higher quality care and increase the patient experience we can lower per capita costs and we all win.

Does anyone really think you will see physicians on the corner with a sign saying “will work for food” and if you think otherwise just click on this link to look at a recent physician salary survey.

Yes, going to med school and residency training is long and expensive and yes physicians should be appropriately compensated. But sorry, this dog won’t bark.

The next argument is that we need tort reform because malpractice cases increase the costs of health care.  Again, I say REALLY. This is a red herring and a common cry of those who are obstructionists. Factually  “according to the actuarial consulting firm Towers Perrin, medical malpractice tort costs were $30.4 billion in 2007, the last year for which data are available. We have a more than a $2 trillion health care system. That puts litigation costs and malpractice insurance at 1 to 1.5 percent of total medical costs. Liability isn’t even the tail on the cost dog. It’s the hair on the end of the tail. Source: New York Times 2009.

There is really nothing to fear with respect to the  what happened last Tuesday when President Obama signed into law H.R. 3590the Patient Protection and Affordable Care Act [both pdf’s]. The sky is not falling.

Karen Davis writes in the Commonwealth Fund blog, “Many Americans will feel the effect of the reform this year, as significant changes start to go into effect. Within the year:

  • underwriting of children in the individual market will be prohibited;
  • young adults will be able to stay on their parents’ health plans to age 26;
  • insurance companies will be prohibited from revoking coverage when people become ill, and from setting lifetime limits on benefits;
  • small businesses will be eligible for new tax credits to offset their premium costs;
  • people with preexisting conditions will be eligible for subsidized coverage through a national high-risk pool;
  • new limits will be set for the percent of premiums that insurers can spend on non-medical costs and, beginning in 2011, carriers that exceed those limits will be required to offer rebates to enrollees;
  • Medicare will provide $250 rebates beneficiaries who reach the donut hole; and
  • Medicare will eliminate cost-sharing for preventive services in Medicare and private plans.

“The U.S. will now join all other major industrialized countries with a system for ensuring access to essential health care, and we will lay the foundation for a high performance health system that yields access to care for all, improved quality, and greater efficiency,” writes Davis. “It is a victory for all Americans, who deserve the finest health system in the world.”

Economist Uwe Reinhardt presents this view:

Passage of this Senate bill by the House on Sunday, and its signing by the president, have been noted around the world. In the United States, it has been widely described as “historic.”

Alas, gone are the days when a vast new federal entitlement could be passed without any pain to any contemporary, simply by putting it on the tab for future generations to pay — as was the Medicare Modernization Act of 2003 [pdf]. According to the latest spending forecast by the actuaries of Medicare, that act alone will add over $1 trillion to the federal deficit in the decade ahead.

The rigid, artificial rules under which the Congressional Budget Office must score proposed legislation unfortunately cannot produce the best unbiased forecasts of the likely fiscal impact of any legislation. Furthermore, these rules invite accounting gimmicks that have been exploited by this and previous Congresses.

But even if the budget office errs significantly in its conclusion that the bill would actually help reduce the future federal deficit, I doubt that the financing of this bill will be anywhere near as fiscally irresponsible as was the financing of the Medicare Modernization Act of 2003.

“We all want progress, but if you’re on the wrong road, progress means doing an about-turn and walking back to the right road; in that case, the person who turns back soonest is the most progressive.”
C. S. Lewis

Let’s join together as the great nation that we are and walk this road as one.

Yes we can.


Ernest Palmore Thursday, Mar 18 2010 

I have been in Alabama since March 2nd.  On that Tuesday, I got off the Red Line Alewife train in Harvard Square and had a missed call. When I returned the call, I was informed that my father-in-law had passed. My parents died when I was 18 years old, I am now 56. Mr. Palmore has been a part of my life for 26 years.

Here is a little bit about him. We honor his legacy.

Old school’ Tuscaloosa County educator dead at 92

By Jamon Smith Staff Writer

Published: Thursday, March 4, 2010 at 3:30 a.m.
TUSCALOOSA | A gentleman, trailblazer, and “old school” educator are just a few of the ways that friends and family of Ernest Palmore describe him.

Palmore, born Oct. 2, 1917, died Tuesday morning. He was 92.

“He was part of this great class of champions that lit the way for all of us to get where we are today,” said Carole Hill-Smith, niece of long-time Druid High School principal McDonald Hughes and a friend of Palmore.

Palmore’s only child, Pamela Palmore Wyatt, said her father died peacefully and in the exact way he always said he wanted to.

“He had a doctor’s appointment Tuesday at 11 a.m., but I couldn’t make it here to take him because it was snowing and raining in Huntsville,” said Wyatt, who sat in her father’s chair at one of his homes on 27th Street on Wednesday while telling his story.

“My son, Michael, said he would take him,” she said. “He came over at 10:43 to take him to his appointment and he called me and said, ‘I fear the worse has happened. He’s slumped over the table.’ He then called 911.”

Wyatt said Palmore had gone into the kitchen so he could be picked up, but he wasn’t wearing the clothes he would typically wear to a doctor’s appointment.

“He was dressed in his burial suit,” Wyatt said, rubbing her eyes and smiling. “He had always told me and Mike what suit he wanted to be buried in, and that’s what he had on.”

“He knew he was going to die,” she said. “He went the way he wanted to and lived an active life until the end.”

Born in Richland, Ga., Palmore was raised by his mother, who cleaned homes for white families, and his grandmother, who was a former slave.

His father, who was a blacksmith, left the family when Palmore was young.

Palmore left home in the late 1930s to attend Tuskegee University. He graduated from in 1941 with a bachelor’s degree in agriculture. Two years later, he earned a master’s degree in agribusiness from the university.

In 1944, he moved to Northport to teach agriculture at Tuscaloosa County Training School for Negroes, where he taught for 14 years before becoming an agriculture teacher and basketball coach at the blacks-only Riverside High School.

After teaching at Riverside for 14 years, public schools were desegregated and Palmore was transferred to Tuscaloosa County High School, where he also taught agriculture.

He retired in 1982, after 38 years of teaching.

Prince Preyer, a former Madison County commissioner who was a longtime friend and agriculture education colleague of Palmore’s, said Palmore was one of the best agriculture teachers in the state.

“There were state contests on the subjects we taught, such as public speaking and agricultural mechanics, and his students were first- and second-place winners every year,” said Preyer, 75.

“He was not just an 8-to-3 teacher,” he said. “He was a second father to his students. Palmore would visit them in their homes to see how they were taking care of their agriculture projects. He’d also encourage them to go to college and drive them to colleges so they could enroll.”

Palmore’s exploits went far beyond the classroom.

In 1973, he built a three-story second home on Lake Tuscaloosa with his own hands, becoming one of the first blacks to own a home in that area. He was one of the first members of Tuscaloosa’s Delta Phi Lambda chapter of Alpha Phi Alpha Fraternity Inc., a 33rd-degree Freemason, a former chair of the deacon board at First Baptist Church in Northport, a former chair of the board of directors at Maude L. Whatley Health Center, and a member of the Kiwanis Club where the Ernest Palmore Academic Scholarship was created in his honor in 2008 — the same year he was named Kiwanis Club 2008 Man of the Year.

The Ernest Palmore Crusaders Choir at First Baptist Church is also named for him.

“I’m not sad,” said Wyatt, whom the Palmores adopted at age 7 in 1963. “It hurts that he was waiting for me when he died, but my God, he had a great life. My father and mother (the late Bruce Palmore, whom Palmore Park was named for) left a great legacy, and I’m glad his life ended the way it did.”

The Wellpoint Blues is a Sickening Anthem Tuesday, Mar 2 2010 

In 2010, WellPoint announced that its Anthem Blue Cross unit would raise California insurance rates 39% insuring profitability for shareholders. The Company is being investigated by US Federal and California government regulators.

In the California Healthcare Quality Report Card 2009, Anthem received 2 out of 4 stars in Meeting National Standards of Care and How Members Rate Their HMO. Do the math and you get an F. What if you had a child who made an F and asked that his/her allowance be almost doubled.

WellPoint is a monospsony and an independent licensee of the Blue Cross and Blue Shield Association and serves its members as the Blue Cross licensee for California; the Blue Cross and Blue Shield licensee for Colorado, Connecticut, Georgia, Indiana,Kentucky,Maine, Missouri (excluding 30 counties in the Kansas City area),Nevada,New Hampshire,New York (as Blue Cross Blue Shield in 10 New York City metropolitan counties and as Blue Cross, Blue Shield or Blue Cross Blue Shield in selected upstate counties only), Ohio, Virginia(excluding the Northern Virginia suburbs of Washington, D.C.), Wisconsin; and through Unicare. In addition to Blue Cross, the company also operates under the Anthem name.

WellPoint Inc. spent more than $2.4 million on lobbying in 2009, according to the nonpartisan Center for Responsive Politics.

“The broader health care sector spend an unprecedented amount of money on lobbying in 2009, becoming only one of two business and interest group sectors to ever crack the $500 million mark for one year.” Now look at the CEO salaries and what we get for those fat paychecks.

Health insurance premiums dwarf worker’s earnings and far exceed overall inflation while companies like Wellpoint and it’s stock-holders dance away with record profits and stand accused of denying claims. In Febuary 2010, a California Department of Insurance probe of consumer complaints about WellPoint Inc.’s (WLP) Anthem Blue Cross claims-handling practices has uncovered more than 700 violations of state law, Insurance Commissioner Steve Poizner states. In the last three years, the California Insurance Department has conducted 10 market exams, six of which are complete. As a result, Anthem Blue Cross previously was fined $1 million and had to take corrective action for rescinding insurance policies, and other California insurers also had to make payments and take action for rescinding policies.

Leading the charge to the bank is WellPoint CEO Angela Braly, the company’s chief lawyer before moving up the corporate ladder to the top job in 2007. Last year WellPoint paid Braly $9.8 million. She lives in a 16,013 square foot mansion  in Indianapolis, valued at $1.98 million. She serves on the board of directors of America’s Health Insurance Plans, the industry’s powerful lobby group. Meet Angela Braly:

Ms. Braly, in recent testimony before Congress, said profits accounted for “a very small percentage of a member’s premium.”Braly became chairwoman of the Wellpoint board on March 1, 2010.She owns $4.6 million worth of WellPoint stock, or .02% of the company.

“Justice will not come…. until those who are not injured are as indignant as those who are injured”

Thucydides quote

The Health Care Commons..Tragedy Sunday, Feb 21 2010 

This was by grocery shopping weekend. So, I just got back from the Arlington Mass. Stop N Shop.

As I have previously stated, I am A George W. Merck Fellow at the Institute for Heath Care Improvement in Cambridge Mass. I will be here until July 2010 having left family and friends in Madison Alabama in late June 2009. I have only managed to get home twice. I receive and stipend from the Merck Family Foundation and a smaller stipend from my sponsoring organization, Huntsville Hospital. I am off salary for the year. My family and I therefore have to manage our very limited resources carefully. If any of us stray away from our common resources, we are all hurt by it. So, I put back chips, ice cream bars, and a few other items that would have made me a free rider. How does this relate to health care. Let’s start with the ancient Greek philosophers.

Thucydides stated:

[T]hey devote a very small fraction of the time to the consideration of any public object, most of it to the prosecution of their own objects. Meanwhile, each fancies that no harm will come to his neglect, that it is the business of somebody else to look after this or that for him; and so, by the same notion being entertained by all separately, the common cause imperceptibly decays. (Thucydides, The History of the Peloponnesian War, bk. I, sec. 141).

Source: Tibor R. Machan – the Ludwig von Mises Institute

Aristotle wrote on the problem:

That all persons call the same thing mine in the sense in which each does so may be a fine thing, but it is impracticable; or if the words are taken in the other sense, such a unity in no way conduces to harmony. And there is another objection to the proposal. For that which is common to the greatest number has the least care bestowed upon it. Every one thinks chiefly of his own, hardly at all of the common interest; and only when he is himself concerned as an individual. For besides other considerations, everybody is more inclined to neglect the duty which he expects another to fulfill; as in families many attendants are often less useful than a few.

In other words, when individuals are not owners of resources, they are not able to assess their value; and, when resources are publicly owned, their use will be systematically hasty and imprudent.

The IHI fellows met for lunch last week and the conversation was dominated by the current state of health care reform. The public option is still alive but on life support, a Senior IHI talks about health care as a “zero-sum game” and we continue to see embarrassing reports on the state of health care in the USA including the recent County rankings, wherein my home Perry County Alabama ranked 67th out of 67, the Commonwealth Fund and the Joint Commission state rankings that show very little progress with the Deep South continuing to lag the rest of the USA while the USA lags behind the entire industrialized world, and the promise of comprehensive health care reform seemed to be vanquished on a cold Massachusetts election night.

The Commons is suffering the Prisoner’s dilemma which goes like this:

Two suspects are arrested by the police. The police have insufficient evidence for a conviction, and, having separated both prisoners, visit each of them to offer the same deal. If one testifies (defects from the other) for the prosecution against the other and the other remains silent (cooperates with the other), the betrayer goes free and the silent accomplice receives the full 10-year sentence. If both remain silent, both prisoners are sentenced to only six months in jail for a minor charge. If each betrays the other, each receives a five-year sentence. Each prisoner must choose to betray the other or to remain silent. Each one is assured that the other would not know about the betrayal before the end of the investigation. How should the prisoners act?

In health care, the “prisoners” are physicians, patients and insurers. All three groups are mostly concerned about what benefits them the best and not what is the most cost-effective, which has resulted in the tragic end game of dysfunctional incentives.

The zero-sum is someone wins and someone loses but the commons suffer this tragedy, so we all lose. “Specialist” (primarily proceduralist) physicians who earn in excess of $5oo,oo0 annually do not want to make less but would like to make more if possible. Patients” seem to prefer the best possible surroundings and amenities, whether or not these add to the quality of their care and outcomes.

In the “commons” known as our health care system, there are several types of “free-riders,” all of whom drain care and/or money from the public system. The most obvious example is a person who does not have health insurance but uses a hospital emergency room when he requires care. The cost of this care eventually gets passed on to those who do have health insurance, either in the form of higher premiums or denial of coverage by an insurance company.

Governments, commercial insurers, and most employers still pay for people’s healthcare costs, collectively, while often fighting with each other over who is liable in particular cases.”

In A New England Journal article( August 2009) a possible solution set was framed very eloquently:

“For patients, the emphasis must be on personal responsibility. The current U.S. system is not structured to provide incentives for less expensive preventive care and healthier lifestyle choices. This failure has led to spiraling costs associated with largely preventable diseases. By contrast, insurance companies in the Netherlands have devised plans rooted in libertarian paternalism, offering patients discounts for healthy lifestyle and diet choices. This approach acknowledges process, which empowers patients, rather than outcomes and has led to sharply reduced costs and healthier patients.

Providers must address the well-documented disparity in cost and quality of care for even common conditions such as hypertension. A process-based metric for evaluating physicians — one that is easily grasped by the general public — will encourage transparency, force physicians to examine and ameliorate their deficiencies, and allow patients to make truly informed decisions, encouraging greater ownership.

And finally, payers must acknowledge health care’s status as a longitudinal concern, not a momentary one. Long-term-contract models such as that of India’s ICICI International have been demonstrated to lead to improved clinical outcomes and cost savings. Longer contracts would incentivize insurers to focus on preventive care and address end-of-life concerns, since a disproportionate share of Medicare dollars is spent in the final months of life.”

A Forbes magazine article summed it up this way:

If you want to know what went wrong with our health care system and the best way to fix it, all you have to do is look back a few decades to a time when health care was a community concern, considered as essential as any public utility. It should be again, not just because it makes sense but also because it’s the most profitable way to go.

The irony in the current debate over a “public option” health plan is that we once had a form of socialized medicine. Blue Cross, the most recognizable name, began in 1929 as a tax-exempt insurer covering a community of teachers in Dallas. Blue Shield was started as a tax-exempt insurer to cover employees of mining and lumber companies in the Pacific Northwest, with a group of local doctors providing care through a service bureau.

So in the end, “Lasting changes to the current paradigm must incorporate adjustments to the incentive structures. If we do not address these motivations, even with the best individual intentions, the U.S. health care system will continue its trajectory of unsustainability to the point of collapse.”

William Lloyd described a this example in his “Lecture on the Notion of Value” in 1833. He observed that when pastureland was held in common (a practice that existed in Boston which still has “the Boston Common”,  now a nice public park) – cattle owners have a short-term interest in having all their cattle graze on it. Unfortunately, when all do so, the commons are soon overgrazed, and the common pasture becomes worthless for all.

What a tragedy!


SWEET HOME ALABAMA Tuesday, Feb 16 2010 

I reside in Madison Alabama and my daughter attends the Discovery Middle School. She turned 13 last week. Two Fridays ago she did not feel well and stayed home. On that Friday, Todd Brown a 9th grade student at Discovery was shot at point blank range in the 9th grade hall way. He died a few hours later and another 9th grader is being charged. We do not know what happened. There is widespread rumor and speculation that the crime was “gang related” and that the alleged shooter was obsessed with “African American culture” whatever that means. In the end, two families are devastated and a small community is left hurt, confused  and deeply affected by this tragedy.

Discovery Middle School is a 15 minutes walk from where I live. The community is quiet and peaceful. Madison was ranked the top place in the USA to raise children in 2009. The schools are excellent and the city is very safe.  A 14 year old  9th grader somehow got a gun and ended the life of Todd Brown.

I practice Internal Medicine in Madison. No less than 200 yards from my office there is a huge billboard telling drivers the stop by Madison Guns and Ammo to “load up”.  Madison Guns is about a 20 minute walk from Discovery Middle School. In a country where many do not believe health care is a right…I question why so many feel so strongly about the right to bear arms. I have never owned a gun and I never will. We have the right to live in a civilized nation. I strongly believe in gun control. You decide for yourself.

I reside 8 miles from Huntsville Alabama proper and a 20 minute drive from the University of Alabama Huntsville campus where it is alleged that Dr. Amy Bishop, Braintree Mass. native, killed three people, one of which attended the same church that I attend.This story continues to unfold and again leaves my community in pain,  and anguish  which is now shared by many right here in Boston where many are second guessing past events.  How does a person with the alleged history of Amy Bishop manage to get a 9mm handgun?

Huntsville Alabama also has received many accolades over the last year including top place to start a business, top place to ride out the recession, top place to start a medical practice and many more. These two incidents are NOT what Huntsville/Madison Alabama is about. Madison County Alabama is a very diverse, professional, and safe place to live. Downtown Huntsville is lined by beautiful antebellum homes, you will find  US Space camp there, it is where the International Space station was built and is home of the US Space and Missile Command, Oakwood College and Alabama A&M University and many very nice people.

Our community is hurting and needs prayer, our children our confused and need to be listened to, loved and counseled. Please pray with us and for us.


Joy and Purpose – Finding the flOw Sunday, Feb 7 2010 

It’s Sunday morning which means Monday is closing in. How does the thought of Monday make you feel? Joy or pain? When was the last time you thought about what motivates you? Carrots or sticks. What is your purpose?

Last week in the Monday morning all staff meeting at IHI, Joanne Watson IHI/Health Foundation Fellow 2008-2009, led an IHI-University discussion on joy in work. This was followed by a leadership session led by Paul Batalden on motivation and how leaders and supervisors can create a work environment that motivates co-workers.

“The secret of joy in work is contained in one word – excellence. To know how to do something well is to enjoy it.” –Pearl Buck

In his book “Drive”, author  Daniel Pink asserts that there is a mismatch between what science knows and what business does”. He goes on to say that science shows that the carrot and stick approach works sometimes. The drive that really works is our desire to direct our own lives, to extend and expand our abilities and to live a life of purpose.

Pink offers three elements that are essential to creating an environment( at work or at home) that leads to higher levels of motivation:

  1. Autonomy-people need autonomy over what they do, when they do it, who they do it with and how they do it.
  2. Mastery: see your abilities as infinitely improvable. Mastery “requires grit, effort, and deliberate practice”. Mastery requires flow.
  3. Purpose: we seek purpose by nature. Motivation requires “purpose maximization” not profit maximization. Pink asserts that purpose is manifested in three ways: goals that use profit to reach purpose, words that emphasize more than self interest and policies that allow people to pursue purpose on their own terms.

Psychologist Mihaly Csikszentmihalyi posits that finding our flow is the key to reach optimal moments of satisfaction and finding the sweet spot between what we have to do and what we can do. Maybe reaching a state of  flow is the “ethic for living.”

We must all seek a life of purpose. In many cases, as with health care reform, we may need to re-purpose. Take the time to read Nehemiah and there you find a leader who successfully applied the three elements of Drive, he found his  flow and re-purposed his life to rebuild walls that had been demolished. He overcame confusion, criticism, loneliness, self-sacrifice, alienation and even broke long-standing rules, but he succeeded. After rebuilding, Nehemiah celebrated with great joy. Nehemiah “saw things as they should be and took action to make things happen”.

Joy in whatever we do is life sustaining. Author of “Supercorp” and friend of IHI, Rosabeth Moss Kanter, lists ten ways to find joy in work:

10. Identify long-term personal purpose. Write a personal mission statement, to review often.
9. Be an entrepreneur from anywhere. Even if you don’t start a business (now), imagine starting a project that will improve your current job, workplace, or community.
8. Discuss the idea informally to find others feeling the same way. Enlist them in the quest. Now they’re counting on you not to let them down. Describe it as an experiment that will benefit others. Incorporate feedback so that others hear their ideas in yours.
7. Get a Big Name to endorse giving it a try.
6. Negotiate out of demands that don’t contribute to the goal. Keep doing what you must to keep your job, but simplify.
5. Find every supporter a task, however small. Show that you’re working for their goals, too.
4. Widen the circle of the informed. Involve people not usually included.
3. Remain positive. Smiling takes fewer muscles than frowning and is contagious. Ignore skeptics unless easily converted.
2. As the bits of the cube start moving, keep communicating and coordinating.
1. Celebrate each “Rubik’s Cube” (when everything clicks into position) moment of accomplishment. Share the joy to multiply it.

Don’t sit around hoping for change…be the change. Have a fun and joy filled week.


Health Care Reform 2.0 – Time to Reboot Friday, Jan 29 2010 

So it is sleeting in Alabama (my home) but sunny and very cold here in Cambridge Mass. What? This is not the way it is scripted. Before leaving  and after arriving here in New England, I was repeatedly warned about the winter chill. Little did I know that the Big Chill would be the recent Senate election to fill the Senate seat left empty after the death of Ted Kennedy.

What happened? Seems no one is real sure or wants to admit it, so I will take a stab at it from my perspective. The Democratic candidate had never faced a tough campaign, the Democrats and Republicans assumed it was a forgone conclusion that Martha Coakley would win hands down, even the now Senator Brown did not expect to win until a few weeks before the election (trust me on this one),the Democrats largely ignored middle class independents and minorities and there was/is an anti-Obama sentiment.

The independents and middle classes are truly fearful of their future, have anger that Wall Street came before their needs and concerns, and that they would somehow have to help pay the health care tab for the rest of the country.

The new operating system has now stalled. Health Care 2.0 was to be the new operating system. Now, what we can expect is probably a Beta test version.

We can expect fewer bold initiatives like universal coverage and the public option. They no longer exist. What may remain may include accountable care organizations, patient-centered care, medical home models, comparative effectiveness research and improvements in health IT, focus on sustaining Medicaid, requirements to decrease hospital associated harm and error reduction, ways to incentivise primary care and general surgery in underserved areas  and hopefully no penalty for preexisting conditions. The commercial insurers will likely continue to adjust and innovate which is a good thing. There is already some evidence of this. United Health and Wellpoint are involved in really tough negotiations with hospitals and all insurers are putting more efforts and resources into quality improvement, patient safety and clinical outcomes. Their sincerity has to be met with skepticism.

Bob Blendon, renowned for opinion research, Professor of Health Policy at the Harvard School of Public Health told my Health Policy class that Health Care reform will not become a reality because of Obama but it will be the public and politicians who will determine the course. The public has spoken here in Massachusetts. Politicians are now on the clock.

As a country, we have to reboot, clean the hard drives, defrag the system and restart. Let’s hope we don’t have to hit the roll-back tab.

Or maybe it will it all comes down to money and getting re-elected. Which operating system to you prefer?


Pardon My Disruption….Please. Sunday, Jan 24 2010 

I got a nice haircut today. It was a shivering 22 degrees when I set out from here in Cambridge, across the frozen Charles River to the Mission Hill area. As I sat waiting my turn, it occurred to me that since childhood I can honestly say that I have not witnessed an incident of disruptive barber behavior.

On the other hand, I have witnessed, been a recipient of and have been guilty of disruptive physician behavior. In a recent study, “90% of the 2,500 survey participants ( physicians, nurses and senior level administrators) witnessed disruptive behaviors in physicians and more than one-third were aware of a nurse who left the hospital specifically because of physician disruptive behaviors.”

Before going on, let me give you a definition of disruptive behavior.

“Disruptive behavior is any behavior that adversely affects the ability of the team to achieve  its intended outcome. Let’s paraphrase Jim Reason. It is important to include the patient and family as team members.”

This is the definition given me by Gerald Hickson MD , Director of the Center for Patient and Professional Advocacy at the Vanderbilt University Medical Center in Nashville Tennessee.

January 2009, the Joint Commission, one of the organizations deemed by The Centers for Medicare with the authority to accredit health care organization,issued a definition and guidelines for organizations to use. Hospital who are Joint Commission accredited are now  required to implement a Code of Conduct that will address disruptive behavior. Why now? This is a problem that has been around for many decades.

Several studies have found that disruptive behavior can and has resulted in serious threats to patient safety due to it’s impact on human performance by leading to stress, frustration, poor hand-offs, adverse events, fear, errors and death. Despite these outcomes, many hospitals have lagged behind in addressing this issue for many reasons including  reluctance of leadership to communicate the problem to physicians who admit lots of patients or perform many procedures because of the potential to lose revenue if the physicians takes his/her practice to another hospital.

Disruptive behavior has been ignored by too many for too long. The time has come for hospitals to take action. Grena Porto, a nationally recognized expert in patient safety, writes that  the keys to success include:

  1. Enhance awareness and knowledge of the quality, safety,morale, and cost benefits of professional behavior.
  2. Connect to the mission and values and the calling of health care professionals.
  3. Address disruptive behavior not in a punitive way, but in a supportive way that helps everyone do the right thing.
  4. Be prepared for a multi-year commitment; culture change takes time.
  5. Never let up: this cannot be “the flavor of the month”

We can do this, for the sake of the safety of our patients, family members, and staff.


“Haiti Lord Haiti…From Misery to Poverty” Saturday, Jan 16 2010 

I got up this morning and put on my coat, boots and took my shopping bags to the #77  MBTA Bus stop…about a 2 minute walk. After a 5 minute wait and a 5 minute bus ride is was stepping off the bus at 950 Massachusetts Ave.  I walked into the Stop n Shop and 30 minutes later I was walking back into the house where I live in Arlington.  For many of you, you will get into your vehicle and drive to the local supermarket and have the same experience.  Or, you may say ” I am glad I don’t have to walk over the ice and snow in Boston, wait on a cold corner for a bus and then carry grocery bags back to my house”. We have also all experienced the angst of waiting to check out and the cashier has difficulty or the person in front of you cannot remember their debit card number or maybe cannot find it and you think to yourself “why does this always happen to me”. Go ahead and admit it..yes you have felt that way. Maybe you have even walked away and left a cart of goods out of frustration with the wait time to check out. Maybe you have raged because someone cut in front of you and took that parking space that had your name on it. Well, imagine if you were in Haiti right now, go ahead close your eyes and just imagine if you cannot find your loved ones, if your childs body was broken, if you did not know where or how to get help or water. Imagine!!

Before this devastating earthquake, PBS did a special on the recovery of Haiti and I was struck by this remark made by the Prime Minister , “we are trying to get from misery to poverty”. Imagine!!

Your prayers and your dollars are needed. Don’t just sit there in front of CNN and shake your head saying how awful and terrible this is. Partners in Health headed by Howard Hiatt, Ophelia Dahl and others have 0ver 500 people in Haiti( all accounted for post earth quake). They had clinics and Operating rooms going the day after the quake. The link is below so that you can get real time updates such as the one I pasted in below:


What’s been on the minds of Partners In Health/Zanmi Lasante staff over the past 24 hours? Below are just a few thoughts plucked from the torrent of emails that circulated through our servers:

  • From ER in Hinche: “Patients trickling in throughout the night. Doing all the surgeries we can around the clock.”
  • From St. Marc Hospital: “We are receiving a lot of people. Most of them are surgery cases. We have operating rooms, anesthesiologist, nurses, equipment but no surgeons.”
  • From a PIH doctor helping out at Diquini Hospital: “There are about hundred people lying on the floor and suffering. The pharmacy there ran out… Now I worry about infections of wounds and septicemia.”
  • From Belledere: CHAI truck from Santo Domingo in the Dominican Republic arrives with surgical supplies and “First Things First” kits.
  • From Florida: Planes with surgical teams (30 people) arriving in Port-au-Prince later today!
  • In Cange: Getting desperate for diesel. Fuel costs are soaring to $25/gallon in-country.

IHI is and has been a supporter of the work that PIH has been doing in Haiti.

Please join us in this effort. You can donate easily by going to IHI’s Stand with Haiti Fund raising page at:

I know these are tough economic times for many of us. I put the Oreos and Ben and Jerry’s ice cream back this morning. Do the same, you will not miss it but you can help ease the misery.

Blessings, –Ron

Saving Primary Care – Is It Too Late ? Saturday, Jan 9 2010 

Hi, Hard to believe that a decade has passed since the Y2K scare. Also hard to believe that Huntsville Alabama is colder than Cambridge Massachusetts today.

The last decade has seen a continuation of the death march of Primary Care medicine in the US. We primary care providers struggle to provide accessible quality care while trying to maintain the viability of our practices and sustain our relationships with our valued patients.

When I was in Huntsville for the Holidays the refrain continued to be “how are we as primary care providers going to survive”. The anxiety is palpable. Many  of my colleagues struggle with overhead, malpractice, lower reimbursements, fear of litigation, less time to spend with patients and family, how to afford EMR and more.

The US will have a Health Reform Bill by mid Febuary 2010. The Bill, in my opinion, has the beginnings of the resurrection of Primary care including  more focus on establishing a patient-centered medical home.

The components of the Patient Centered Medical Home are:

1. The medical home represents a relationship between an

individual and the health care system, that provides a point of

first contact, is continuous over time, and provides or secures

comprehensive services.

2. The medical home relies on teamwork to get the right things

done at the right time.

3. Comprehensive service means that people of every age and

background are welcomed into the medical home and that the

services rendered or secured for patients are sufficient to resolve

their problems to the extent possible.

4. The key function of the medical home is integration of care for a

particular individual. Integration means the pulling together of

what often are apparently disparate parts into a coherent whole

that has meaning for the patient and the health care system.

5. Quality and safety are hallmarks of the medical home, relying on

recurring measurements that depend on electronic health

records and information technologies sufficient for

interoperability across care settings, decision support at the

point of care, and assessment of results that matter to people.

6. Access is reliable in the medical home, achieved through face to

face visits, but also through other channels including

asynchronous communications by email, telephone, and via the


7. A crucial characteristic of the medical home is derivative from

the above capacities, ‐‐value. When the medical home functions

correctly, care and results improve and expenditures are more


” The U.S. health care reform legislation anticipates a strong foundation

of primary care — but that foundation is crumbling.”

Fewer US Medical school grads are going into primary care and graduate medical education ( GME) favors specialty and sub-specialty training over primary care and why? Simple accounting, hospitals get paid more for specialty and sub-specialty services.

This trend has to be reversed and Health Care Reform will be the path to resurrection of the value of primary care by implementing, funding and continued support of the medical home model.

According to the Robert Phillips MD MSPH of the Robert Graham Center, the mandate to graduate medical education will include:

  1. Provide incentive and remove statutory barriers to the establishment and expansion of training venues in non-hospital primary care settings, including rural and under served settings.
  2. Mandate accountability for GME funding in order to reshape the incentives for teaching hospitals and academic medical centers to improve the health of the nation.
  3. Make GME sites laboratories for innovation for primary care delivery and responsible for producing the next generation of physicians who will work in them.

“How can a country as generous as the United States fail repeatedly to accomplish in health coverage what every other industrialized nation has achieved?” Morgan JJ, Lee TH. Do We really want Broad Access to Health Care?

Further reading:


2.Patient-Centered Medical Homes in Ontario
Walter W. Rosser, M.D., Jack M. Colwill, M.D., Jan Kasperski, R.N., M.H.Sc., and Lynn Wilson, M.D. 10.1056/nejmp0911519

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