Colors of President’s Day, 2007

This year President’s Day is Black and Blue
That’s because of the Political Bruising
President Bush is taking from the War
Oh, I know the President would prefer
This Day be Red, White, and Blue
Or maybe even a Deep Sad Purple
Like Medals for the Dead and Wounded
But Purple is President Washington’s Day
Maybe the President prefers Blue and Gray,
To better reflect the Country’s Mood
But Blue and Gray is President Lincoln’s Day
After all, he kept the House United
Something President Bush has yet to do.
Even the President's Health Care Budget
Is seen by critics as Black and Blue,
Black for Democrats who want more,
Blue for Hospitals and Doctors,
Who thought they had more in store.
As for me, I wish Bush the very best
Until two years out when he can rest.

Clinical innovationsm- Retail Clinics: Not the Perfect Storm

I pause before I say this, but retail health clinics may not be the perfect storm after all. I pause because in prediction #9 in my January 11 blog, I foresaw decentralization – devolving of health care into smaller, more affordable, more convenient, more flexible units – would take health markets by storm. Like global warming experts, I may not turn out to be a flawless weather forecaster.

The term “perfect storm” refers to sudden confluence of events, which, taken by themselves, have far less power than their combined force. When MinuteClinic and similar nurse-staffed clinics burst onto the scene over the last five years, they seemed to be the perfect storm for the new health care consumer-driven market.

After all, these clinics shared these traits:

• Convenience
• No appointments
• No waiting
• Open for long hours, including weekends
• Lower prices than emergency rooms or doctors’ offices
• Location next to prescription counters
• Close to other shopping needs
• Staffed by skilled nurse practitioners
• Care-guidance by clinical protocols

What more could you ask? For retailers, there was the promise of more foot traffic, more prescriptions being filled, more shoppers buying other things. For entrepreneurs, retail clinics were an unprecedented opportunity to expand outside doctors’ offices. How could such a phenomenon fail?

Yet, I keep running across early warning weather signals that the perfect storm may not be at hand.

• Dr. Don Copeland, a veteran family physician in Cornelius, North Carolina, warns, “ The first time a guy walks into a retail clinic for chest discomfort and is given antibiotics for a URI, then drops dead from an MI, the whole concept will come crashing to the ground.”

• Some hospitals and doctors are reacting by competing -- extending hours, setting up more convenient clinics, and, in some cases, spreading the word that these retail clinics are too commercial and not to be trusted.

• A leader of a large primary care organization who is setting up a half-dozen retail clinics for his physicians, informs me, “Things are not going nearly as well as we had planned.”

Finally, on February 9, came a healthleadersmedia.com feature article, “Retail –Based Clinics: Passing Fad or Here to Stay?” The authors, Eben Fetters and Ron Luke, of Research and Planning Consultants in Austin, Texas, warn, “To many healthcare is still a very personal need that may not be acceptable and met by a quick visit to an unknown person in a non-professional setting.”

Those who believe retail clinics will take markets by storm may be ignoring history – passing fads of urgent care clinics of the 1980s and of primary care offices in shopping malls in the 1990s.

Times may have changed, but not that much. Maybe the emergence of nurse clinicians, use of computer-based protocols, reducing costs, avoiding hassles of traditional care, growing numbers of uninsured and underinsured, backing of health plans, and halo-effects of hospitals and physician groups providing oversight and backup will not overcome the stigma of “commercialism ” – or of seeing an unknown person you will never see again at Walgreens, WalMart, or some other retail outlet.

Only time, consumer experience, and consumer response will tell. Meanwhile consumers are free to choose and will make the choice of what is of value (quality/price) to them.

Doctor patient relationships, plain language, Read This Blog with Great Care: See If You Can Spot The Trick

Doctors should be more innovative with language. If we would talk more clearly to patients, using the right words, patients would know better what to expect, what to do, and might even hue to what we say.

The folks at Emmi Solutions, Inc, who produce interactive online videos to teach patients, say it all boils down to plain talk and to:

• Logical organization
• Jargon-free word choice
• Active voice
• Short sentences
• Common, everyday examples

One problem with doctors, say critics, is that we use too much jargon when we talk to patients. That is one reason why patients do not know what doctors are saying. I say this does not need to be so. Doctors can use plain words too, as I shall show here.

Read this blog with great care. For it shows one of the tricks of those who write and talk well. To write and talk well is no small trick. It takes skill, thought, and choice. There are no short cuts – no high roads. You have to spend time at it, and you must choose the right words. Still a trick or two helps.

As you read these words, see if you can spot the trick, which goes on right in front of your nose right now.

The trick works, and it works well. It works best for those with clear minds, but not so well for those who are not so sure what they want to write or say. It works, too, for you who read what we who use this trick write.

Look back at what you have read. Have you known each word so far? And have you got a good grasp of the flow of thoughts?

Oh, I know I have not told you what the “trick” is, but that will come. While I have you on the hook, I just want to make sure you know what each word means, and that you have the gist of all that passes in right in front of your eyes.

Now, if you are still with me, I shall go on.

The trick also serves those who write tales, as well as those who deal in facts. There are those who say the trick will not work in the field of health care. I do not think they are right. If I can do this trick, as I am now, you can too. But we can both learn from those who tell tales, as this tale shows.

“Life lays down strange paths which the feet of man must tread in the dark.

When Baer told me this tale, I felt full of awe and tears. Baer does not lie. He is a good man, and his eyes are full of strong truth.

I know Baer. He has the heart of a saint – fresh and pure as a deep well, in spite of all the hard, sad years of his life.

We met on the stairs of Time: I was on my way up: he was on the way down. I was young; he was old, and poor – so poor that he did not know when luck would send him a meal and a bed.

His coat was thin; wind and rain bit right through it. Yet he could hold his head high and face life with a fine calm.

It is sad when a man is too weak to work, too strong to die, and too proud to beg, sad, yet great. Bear was a great man. This is what he told me:

It has been the will of Fate – or what you like – that all I made they had to break. All that I got, I lost. Well, let it be like that.

All is gone – all but what was mine, as a gift, the gift to me, of God.

What I have not lost is best of all. That I can’t lose. I mean my soul. If a man keeps his soul, that is what he can keep in the end, so that in the end that man has won, not lost.

(That was how Baer spoke – in clear, short words.)

Well, the last sentence gives up the jig. What’s my trick? This: I set out to show I can write clear prose using words of one syllable. As Winston Churchill, said, “Short words are best and the old words when short are best of all.”

The 558 word italicized passage above is made up entirely of words on one syllable.

To throw you off the scent, so you would not spot the trick, in the opening four paragraphs introducing the italicized passage, I used 30 words of more than one syllable. In this entire essay, I have only used 10 words – innovative, video, organization, everyday, example, syllable, italicized, paragraph, introducing, clarity - with three syllables or more. Of 873 words, 863, or 99 percent, had one or two syllables.

I trust I have shown you the punch and pith of small words. Short words have grace, power, and clarity.

To sum up, short words are best. Think of that when you seek to engage or teach patients.

E-medicine - Tipping Points, Dot.Coms, and Connectors

What’s a Tipping Point? And what’s its relationship with Dot.coms, and Connectors? Therein lies the tale of this blog.

According to Malcolm Gladwell in Tipping Point: How Little Things Can Make a Big Difference (Little Brown, 2000), the Tipping Point is a sociological term describing how ideas or events trigger chaotic or disruptive changes resembling infectious disease epidemics.

The dot.com, or digital, revolution is such an epidemic. I was thinking of this epidemic on February 8 when Diane Sawyer interviewed Steve Case, CEO of Revolution Health (revolutionhealth.com) on ABC News. Case said his website will revolutionize health care by connecting all those health care dots, in the process igniting an epidemic infecting consumers and empowering them to control care, prevent disease, and improve health. We’ll see if that begins to happen in April, when a media blitz will highlight his site.

The dot.com epidemic is already roiling the U.S. media marketplace. Readership of major national newspapers is dropping like a rock, and viewership of major TV networks – ABC. NBC, CBS, and CNN – is plunging. Meanwhile, contagious Internet sites like Yahoo, Google, and YouTube are spreading the epidemic by offering free news and even free television programming, thereby siphoning profits and markets from major media.

Enter the “Connector.” The Gospel according to Gladwell is that a personality type known as a Connector may make a big difference in controlling the epdemic. Connectors are people with wide social contacts. Connectors are hubs of social networks and are capable of taking a huge industry, like health care, and cutting it down to size by connecting people and ideas.

I’m a connector (with a small “c”). I stumbled on my connector role,

• when writing a book Voices of Health Reform, which consisted of 41 interviews with national health care stakeholders;
• when interviewing forty of so innovators for Innovation-Driven Health Care, innovators who are making a difference;
• when answering phone calls and emails emanating from my 27 articles over the last three years that have appeared in healthleadersmedia.com, where each submission is read daily by about 50,000 healthleaders.

During these activities, it dawned on me we’re all in this thing called health care together. Two things– information technologies and human connections – now tether us all together. Dot.com technologies may be the Great Enabler, but it takes human networking and understanding to make the right connections. All that rises must connect, and it connects between you and me and all those other knowledgeable people out there.

Americanization of Health Care

In this blog, I‘ve experimented with essays on innovation in building patient-doctor trust, excerpts from an unpublished book on patient-doctor relationships under difficult patient circumstances, health care predictions, personal tributes, poetry, even a limerick or two. This outpouring lacks focus, but they may come.

Today I will return to doing what this blogger is supposed to do: write a daily log on the subject of innovation. I shall share conversations with two individuals about the "Americanization" of health care and how to bring this about through innovation.

What differentiates the U.S. health care from other health systems is innovation. As I have noted in Innovation-Driven Health Care (Jones and Bartlett, 2007), we produce more than 80% of the world’s new drugs, Nobel Prize winners, and clinical advances. This is innovation and entrepreneurialism at work.

America is a unique place, which is why our health care differs from that of other nations. In 1831, Alexis de Tocqueville coined the term “American Exceptionalism” to describe the U.S. We have a distinctly different culture, based on our beliefs that we represent a place of hope and opportunity for humanity, have checks and balances for private and public interests guided by the Constitution, possess personal and economic freedoms, and have the ability and spirit to conquer geographic and conceptual frontiers.

These beliefs sometimes give us a false sense of moral superiority and domestic and foreign overreaching . This sense of exceptionalism may explain why a single payer system has never taken hold here. Our penchant for innovation and entrepreneurialism, individualism, egalitarianism, distrust of government, and belief in equal opportunity but not equal results, leaves little room for single-payer.

Today I spoke to two individuals concerned with America’s health care future. Both seek “Americanization” of our system. By this they mean providing innovation-driven high quality care in the United States based on the freedom of well-informed consumers to choose in a market-based environment. According to Peter F. Drucker in Innovation and Entrepreneurship (Harper and Row, 1986), “So far, the entrepreneurial economy is purely an American phenomenon. Innovation is the specific tool of entrepreneurs. There are fast-growing hospital chains. Even faster growing are ‘freestanding’ health facilities, such as hospices, medical and diagnostic laboratories, surgical centers, maternity homes, ‘walk-in’ clinics, centers for geriatric diagnosis and treatment.”

Both the individuals with whom I spoke disbelieve that a socialized, European-style system can universalize, reform, or improve American health care, nor do they buy into reasoning that government’s moral duty is to redistribute income and to prove the market system is inherently unfair. They believe government-run systems stifle innovation.

Ever since Medicare-Medicaid was enacted in 1965, American politicians have vigorously promoted universal coverage, but to no avail. The latest effort to fall by the wayside was the Clinton initiative in 1994. Now, with health costs skyrocketing and with 47 million uninsured, the latest crop of politicians are pushing again for universal coverage – government-led and government-fed but increasingly paid for through taxes on employers and providers.

The two to whom I spoke today say government medicine is the wrong way to go. Their pragmatic reasons are vested economic interest groups’ resistance, American culture’s desire for freedom and choice, potential diminution of quality, inevitable bureaucratic burdens , and prohibitive costs.

On the latter point, I remember in 1966 when the Johnson administration assured Americans Medicare-Medicaid spending would never exceed $9 billion. Today these costs are just North of $500 billion.

The economic lesson, I suppose, is that when you’re spending someone else’s money, the sky’s the limit. This skyscraping is sometimes called the entitlement syndrome. Many Americans think health care is a special case and ought to be "free", i.e., not ut of their pocket, just as in Europe where, by the way, and not by chance, the tax burden on the economy averages 45 percent compared to less than 30 percent in the U.S., economic growth is one-half that of the U,S., and unemployment is twice ours.

But back to the two persons who argue they represent the American health consumer and who champion American free-enterprise.

• Dave Racer is founder of Alethos Press, LLC, a St.Paul, Minnesota, based publishing house. Its latest two books are: Your Health Matters: What You Need to Know About U.S. Health Care (April, 2006) and Facts, Not Fiction: What Really Ails the U.S. Health System (January, 2007). Greg Dattilo, owner of a St. Paul insurance agency providing health benefits, and Dave wrote the two books, which contain more than 350 footnotes documenting their case.

Basically the two argue as follows: single-payer systems abroad result in health monopolies, global budgets, rationing, stifling of innovation and individual freedom, and stagnant national economies with high unemployment.

They maintain the United States, given its current health system, has a strong vibrant economy built on freedom, a free market, and competition. These attributes , they say, are why the U.S. has the discretionary income to spend two times on health care those other nations do.

I will not go deeply into the counter-arguments here – that government care costs less with better and more equitable results – except to say that Datillo and Racer says these counter-arguments rest on myths rather than facts. In any event, the two authors are criss-crossing the country, speaking to many groups, predominantly made up of insurance agents, delivering their message. and distributing their books.

• The second person to whom I spoke was Phil Micali. He called to speak to me about a book proposal. The book is tentatively called Be Well-Informed About Your Health Insurance and is directed towards health consumers and American ex-patriots. He includes the latter because he spent four years abroad in Europe, primarily in Italy, working with European health systems and living under a single-payer system. He feels qualified to compare Europe and American systems and the American and European cultures.

Micali is founder and CEO of BWell International, Inc. (bwellintrnl.com), and now spends time educating employers and employees about consumer driven health care. He seeks to make health consumers better informed about insurance options for sickness and wellness. He looks upon good health as a necessary investment – not an accidental luxurty.

What I found fascinating about Micali was that he has worked multiple sides of the health care aisle – building and implementing government and business sponsored HMOs, public and private behavioral and chronic disease management programs, and had direct experiences living under and helping Europeans single payer systems manage care of the elderly.

Upon returning to the U.S., he joined a consumer-led health venture—Lumenos, one of the early firms selling high-deductible health plans linked to HSAs. Based on this and his current activities with BWell International, Inc., he foresees the emergence of a freer market-led American health system, requiring non-biased guides for learning and decision support. He often speaks and presents his views before employer, employees, and consumer groups on this on consumer issues.

For Racer’s and Micali’s views to prevail will be an uphill fight. These views will require Americans to take responsibility for their health, to become sophisticated health care shoppers, to choose between health care competitors, and to overcome the notion that health care is a special entitlement, immune to market forces and to which they are universally owed , regardless of cost t the American economy.

Alternatives for U.S. universal health, briefly stated, are.

• Universal health vouchers for all Americans
• Medicare for all based on government paternalism
• A consumer-driven, market-based, innovative system covering mostly all and requiring government subsidies at the edges
• Universal government care for all, based on European-style coverage
• Public-private partnerships and reforms guaranteeing universal coverage
• Apocalyptic events during which all bets are off– a nuclear World War, a deep international depression, massive global warming, or Argemegdon.

A Tribute to Robert Holmen, MHA, 1937-2007

Bob Holmen, my friend, confidante, and advisor, died at the Mayo Clinic in Rochester, Minnesota, on Monday, February 5, of complications of a glioblastoma multiforme, an aggressive brain tumor.

Bob was the ultimate realist. He would have wanted me to mention the precise cause of death. But Bob was the consummate sentimentalist, too. He would have wanted me to say he died at his beloved Mayo. He served Mayo off and on for two decades, and he thought of Mayo as the finest medical institution in the world, as a place where hospital administrators and physicians worked together closely to advance medical progress. Indeed, his latest project was promoting and participating in Mayo Forums, dedicated to reforming U.S. health towards a more universal model based on a market-driven, consumer-based, physician-led system.

Bob had a genius for genuine friendship. He was candid, earthly, and accessible. He teemed with ideas and energy. He seemed to know everybody worth knowing in the policy, delivery, and health care business world. He thrived on interacting with them and bringing them together, and he had a sharp sense of implications for society of what they were saying.

I thought of Bob when I read Malcolm Gladwell’s book, The Tipping Point: How Little Things Make a Big Difference. Gladwell said the most important people tipping events towards a better world were connectors, mavens, and salesmen. These three individuals made it possible for innovators to connect with early adopters. Bob was all three – a connector, maven, and salesman - wrapped up in one accessible easy-to-open package,

Bob was a translator, He took ideas and information from a highly specialized world and translated them into language the rest of us could understand. He dropped extraneous details and extravagant information, Without the chaff, his message acquired a deeper meaning.

Bob was an organizer. For several decades, he served as the host for a group of seven or eight multispecialty clinics that met once a year in the American West to share ideas. Bob Smoldt, Mayo’s chief administrative leader, until he retired last year, says, “ I called these meetings ‘Holmen’s Seminars.’ They were the best meetings I ever attended, and I only missed one over the years.”

Mr. Holmen received his MHA (Masters in Hospital Administration) from the University of Minnesota and his Bachelor of Science from Gustavus Adolphus College.

He was actively engaged in the health field since 1960. His early career included administration of community hospitals as well as a large multi-hospital complex. He developed and advanced early managed care delivery models. From 1973 on, he consulted with a variety of health industry clients. He contributed to numerous conferences and seminars and served on a variety of corporate boards.

Bob was a critical student of strategic productivity issues in the health industry. He served clients in purchaser, provider and government arenas. He specialized in new health information systems, innovations in healthcare, and cost-effective models of self care.

Bob held office at the Center for Policy Studies, a private, non-profit health policy research and application center. He was responsible for implementing the Pennsylvania state-wide health data initiative of the Pennsylvania Business Roundtable and the state’s hospital and medical associations. Bob actively advanced the personalizedlongitudinal medical record designed to afford higher levels of access, information flow, and industry connectivity.

Bob consulted with Mayo on strategic and national health policy, as well as purchaser, information, and networking initiatives. He was a senior consultant to Blue Cross Blue Shield of Minnesota. He was an associate of Dr. C. Everett Koop, a consultant to the C. Everett Koop Institute, and a developer of drKoop.com. He served on the editorial board of Business & Health. He worked on Consumer Directed Health Plan developments, Telecare and remote practice electronic connections, consumer health records, and privacy issues and innovative developments in cardiac diagnostics.

Bob’s latest and perhaps his greatest contribution was as a principal of Cardiac Risk Analysis Associates, who have developed, in conjunction with the Mayo Clinic, a medical device called SHAPE (Superior Heart and Pulmonary Analysis). This device will make it possible to evaluate, without the risk of the traditional coronary stress test, the heart fitness, pulmonary fitness, and prognosis of millions of Americans.

I will miss Bob. I will miss talking to Elaine, his beloved wife and designated telephone receptionist. I will miss our frequent chats. I will miss the belly laughs, the deep insights, and the generous referrals to the high and mighty in the health care world.

I cannot say goodbye to Bob. Somehow, some way, he will always be at my side and on my mind, nudging me towards a deeper understanding of health care.

Richard L. Reece, MD