Archive for July, 2011

The Smurfs and Culture

July 29th, 2011

The other day, I was imagining a conversation between our U.S. elected officials about the Smurfs.  On one side of the aisle, the rhetoric would go something like this: “I believe that Poppa Smurf  represents Karl Marx. He is not the leader of the Smurfs but an equal who is admired by the others for his age and wisdom.”  Then they might say, “And Brainy Smurf represents Trotsky, as he is the only one who comes close to matching Papa’s intellect.  He wears round glasses, is often isolated, ridiculed for being too professorial and is even ejected from the village for his ideas.”

Photo Credit: AP/Richard Drew

Furthermore they might add, “The smurfs don’t have private property, have adopted a collective-style economy and no individual Smurf is represented as either superior or inferior to others.” Someone would yell out, “They probably even have healthcare for everyone!” Consequently, the conclusion from one side of the aisle would be that the Smurfs are Socialists and are destroying the fabric of our society.

Then the other side might say something like: “Gargamel represents capitalism and embodies all the negative attributes associated with that economic system, such as greed, ruthlessness and the pursuit of personal gratification.”  “Gargamel is the quintessential symbol of Wall Street and will take his billions in tax cuts but never create even one job,” this side would say. At the same time, they might surmise that, “Azrael represents the worker in the ruthless, free-market state that is Gargamel’s house, and his union must be busted!”  Their final conclusion would be that, “The wealthy are taking all of our money and destroying the middle class.”

Is it any wonder we can’t get a debt ceiling bill?

One of my last professional trumpet playing jobs, “Smurfs on Ice,” was nearly 25 years ago. So, Brainy, Jokey, Grouchy, Greedy, and Stinky were all part of my early years, and now they are coming back, but the world is not the same!  So, be careful Smurfettes. Don’t invest in the market, real estate or dot.coms.  Try to avoid those outrageous credit card interest rates.  Don’t, whatever you do, don’t believe what the heads of the big banks and insurance companies are saying, and, for goodness sakes, buy gold, or maybe buy precious blue stuff.

When I was a kid, I was on journey to learn. So, when my dad bought me a box of vocabulary words and helped me learn ten new words every night, it wasn’t because he wanted us to grow up and be rich.  To him, the most important thing that he could do for his children was to make sure that they got an education.  He was all about the awareness that comes from exposure to information.

It started for me as a simple challenge to read the Bobbsey Twins books, and then the Hardy Boys, and from there, works by Mark Twain, Shakespeare, Dickens, Poe, Roth, Hemmingway and Tolstoy. Going through life without all of these friends would have been an empty and lonely journey. I’ll never forget when my brother, a young teacher at the time, introduced me to his classical record collection.  Yes, I was a trumpet player, but when I discovered Mahler, Beethoven, Mozart, Bach, Wagner, Brahms, Handel, Stravinsky, Chopin, Mendelssohn, Berlioz, Bartok and Sibelius, my life was changed forever.  Between the written word and the music, the mysteries, joys, challenges and humanness that is life became more apparent to me every day.

We have migrated away from anything but basic education and our favorite pastimes are video games, celebrity magazines and reality TV shows. Maybe that’s why we seem to have lost our way in this country.  We no longer embrace a culture of open mindedness, understanding and compromise.  Is it any wonder our U.S. Representatives can’t work together?  Maybe they are simply unenlightened…Maybe they all need to spend some time with the Smurfs and read a few blue books.

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The Budget Impasse and Death

July 16th, 2011

David Brooks wrote a very interesting column last week in the New York Times entitled  Death and Budgets,” in which he explains the current Washington D.C. budget impasse and compares it to our collective inability to come to grips with our own mortality.

David Brooks - The New York Times - Nick Jacobs, F. Nicholas Jacobs, FACHE - healthcare - healing hospitals - SunStone Consulting

David Brooks | Josh Haner/New York Times

His treatise quotes S. Jay Olshansky, one of the leading experts on aging, who argues that life expectancy is now leveling off, and others who say that, we are marginally extending the lives of the very sick. Brooks goes on to articulate that, “A large share of our health care spending is devoted to ill patients in the last phases of life.”  Then enumerates upon the fact that, as a country, we will be spending $1 trillion dollars annually, double Medicare costs right now, on Alzheimer’s disease alone by 2050.

His closing thoughts revolve around the fact that “unless we confront death and our obligations to the living like his friend who was recently diagnosed with ALS, we will not be able to reduce health care inflation and balance our budgets. “ He then concludes that “we think the budget mess is a squabble between partisans in Washington. But in large measure it’s about our inability to face death and our willingness as a nation to spend whatever it takes to push it just slightly over the horizon.”

Since 2005 I have written  many times about this issue. In fact, one of my most quoted experts on this topic is a previous Pittsburgh resident, former Colorado Governor Richard Lamm, who spoke openly about the immorality of “inter-generational resource theft,” where the voting senior citizens have pulled the majority of the healthcare resources away from the children of our nation. According to Lamm, this generational robbery has contributed to produce one of the highest infant mortality rates in the civilized world  and has provided the resources allowing our seniors to squeak out another few months or days of life.

I also remember one of my Carnegie Mellon professors, Ian Rawson, PhD, describing the resource challenges presented in certain extremely conservative states where they have refused to fund organ transplants for children.  Obviously, those who voted most often and most passionately were the seniors themselves who could then use those resources for mechanical life support or surgeries on the frail elderly that neither extend nor improve the quality of their lives.

As a former hospital CEO, it seemed clear that the medical schools had taught the Northern European philosophy that “Death at any time is failure.”  It seemed that the very reality of our mortality was overlooked.  Having had responsibility for funding a palliative care unit in my last hospital, it struck me as sad that the vast majority of patients being admitted there arrived for the last week, day or few hours of life, and the “life extending measures that had be foisted upon the patient and their families” prior to that time neither reversed the disease nor improved the quality of their lives.  Unfortunately, some of this is about income for the provider, but most of it is about our inability to face the end of our time here on earth.

It was always disconcerting to see a priest or minister as a patient in critical care screaming out in fear of their own death.  It would seem that they, of all people, could find peace in the upcoming transition. So, what about the rest of us?

In closing, and this too is my “one note samba,” until or unless we begin to reimburse for wellness care, embrace death as part of life, and stop rewarding our scientists for “not sharing their ideas” with each other, we will continue to act pretty much like my daughter’s dog, Chipper. Tail-Chasing-R-Us, and Washington DC is currently engaged in chasing a tail that could easily wipe all of the china off the dining room table.

All we seem to see are blades of grass in our fields of dreams.

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Geographic Variances in Medicaid Spending – And the Winner Is?

July 7th, 2011

Health Affairs cover - Nick Jacobs, FACHE - Medicare - MedicaidWhen Health Affairs released a first-ever study of geographic variances in Medicaid spending on July 7th, it was a new twist on transparency that is just the beginning of what will become a detail-by-detail exposé of care and treatment of patients in the United States.  Just imagine a few years from now, when every record is electronic and every detail will be instantly available to the government.  Like this variance report, we will begin to see the good, the bad and the ugly of how medicine is practiced in this country.  So… how do you spell transparency?

A few weeks ago, the New York Times ran an article in which the “overuse of Medicare-funded CT scans” was explored. Featured in the digital version of this article was an interactive map showing virtually every hospital in the United States, and as the mouse was passed over each hospital, the percentage of inappropriate CT scans appeared above the facility’s name. If yours was one of the hospitals that was 80+ percent over using this device in multiple single-day scans, you were, as they say, “busted.”

Well, this release exposed at least one entire section of the country that is overusing Medicaid on numerous levels.  Although the study revealed a wide variance in per-beneficiary spending, one geographic region outshined them all.  The findings showed that after adjusting for the case-mix of patients, variations are driven mostly by volume of services provided and, to a lesser degree, by price.  Per-beneficiary spending in the ten highest states was $1,650 above the national average, mostly caused by the greater number of services provided.

Image credit: New York Times

One of the most significant findings revealed by this study was that the supply of primary care physicians in specific areas was associated with reduced rates of admissions for diabetes, lung disease, and adult asthma.  The authors suggest that this finding might point to the fact that increased access to primary care providers may result in improved management of common chronic diseases for people on Medicaid.

So, by now you’re asking, “Who won?  Who used more money per capita to treat Medicaid patients?”  It was The Mid-Atlantic States : New Jersey, New York and Pennsylvania used more Medicaid funds per capita than any of the regions in the United States. For example, the per beneficiary cost in New York was twice that of California; $21,195 for New York vs. $11,200 for California.

As a region, New England used the least amount of Medicaid resources and as a state, Washington provided the best example of “how things should be.”  How did they do it?  They increased access to primary care and reduced hospital care.

Todd P. Gilmer, Ph.D.

Todd P. Gilmer, Ph.D. - UCSD

Finally, places that had higher numbers of hospital beds and specialists were associated with higher numbers of hospital admissions while higher numbers of primary care physicians were associated with reduced rates of hospital admissions… Todd P. Gilmer, PhD, professor of health economics in the Department of Family and Preventive Medicine at the University of California – San Diego said, “By looking at service mix, access and price, states can find ways to make their programs work better.”

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