27 October 2017

Dear Interested Readers,

What’s Inside and Some Things Never Change

The main part of the letter this week comes to you through the intellect and generosity of my good friend and colleague, Dr. Patty Gabow, who is the retired CEO of Denver Health. Dr. Gabow has recently been going around to meetings and conferences giving a very thought provoking speech that I have had the privilege to hear. What Dr. Gabow says deserves attention. She led Denver Health to become one of the premier providers of healthcare with top tier outcomes and some of the highest quality metrics in the country despite the fact that the majority of people who get their care at Denver Health are economically disadvantaged.

Her success over years at Denver Health make her one of our nation’s foremost authorities on the issues of providing care to populations that are traditionally underserved. At Denver Health, and other Disproportionate Share Hospitals (DSH), caregivers must do their best with resources that are much reduced compared with their fellow citizens from more privileged populations. Those who get care or give care in a DSH hospital must develop the ability to survive in an unfair world.

Dr. Gabow’s presentation was entitled, “Can the American Healthcare System Deliver Health?” That may sound absurd to some, especially politicians, so I have taken the liberty to change the title just a bit to reflect for sure what I think she meant. You will see that the main section of this letter is entitled, “Dr. Gabow’s Question: Can the American Healthcare System Deliver Health For Every American?” The question implies what we all know to be true, it does not do it now. When will it, if ever? At another level the title is asking a few more questions. Why doesn’t the American healthcare system provide care for every American? How do we compare to the rest of the world? What changes would be necessary for us to see more equality in healthcare? What prevents us from doing a better job?

I hope that the piece will generate even more questions and a few insights for every reader. We like to think about what we do well. Thinking about where and whom we fail makes us uncomfortable. Dr. Gabow succeeded at Denver Health in part by making politicians uncomfortable enough to let her improve the care of the population that depended on Denver Health. We all need to feel more uncomfortable about what we are allowing to happen to those with the greatest needs.

After listening to Dr. Gabow speak I realized that there are at least two questions that needed answers. First, why have we not unanimously decided that everyone in our society is entitled to the best care we can offer to anyone, or at least why have we not defined some “floor” of adequate care that we are willing to offer everyone? Everyone is entitled to a twelfth grade education. In some states we entitle kindergarten and a couple of years of college. Why is better care not a political priority for all of our elected leaders? Do they not see the value of citizenry that is both healthy and educated? How is it that recently we seem intent on making decisions that add to, rather than diminish, human suffering in our communities? I do believe that we live in a time when empathy should be expanding, if for no other reason than most of us have realized the self serving reality that if everyone is better off, we will all prosper.

A willingness to help others seems to be a core part of the human psyche. Following a natural disaster we frequently demonstrate that we have the capacity to care about the wellbeing of those who live far beyond our borders on the other side of the planet we share, but “during ordinary times” and for individuals who make us uncomfortable, we have problems establishing and funding ongoing programs that help those in our own communities who live just beyond the circle of our own family and friends. Someday we may find the capacity to care about all the people in the zip code adjacent to ours, but I am getting ahead of Dr. Gabow’s story.

Now to a “recurrent beef” or annoyance, that thing that never seems to change. It has some history. As I have mentioned before, I got most of my medical education in the quarter square mile known as the “Longwood Medical Area” that surrounds the Harvard Medical School. My medicine rotation in medical school, my internship, my residence in medicine, and my fellowship in cardiology all occurred within what was then the Peter Bent Brigham Hospital. It was a very provincial experience.

Medical mergers are not a new concept. In 1980, five years into my practice, the Peter Bent Brigham merged with the Robert Breck Brigham Hospital which specialized in the medical and surgical treatment of joint diseases, and with the Boston Hospital for Women which itself was the product of an earlier merger (1966) of the Boston Lying In Hospital and The Free Hospital for Women. After an initial launch with a new bed tower built in the employee parking lot, under the plain vanilla label of “The Affiliated Hospital Center,” Pete, Bob and the girls became the Brigham and Women’s Hospital, and all but the long in the tooth soon forgot where it came from. I had been in practice about twenty years when the next round of mergers within the constellation of Harvard teaching hospitals created Partners HealthCare in the mid nineties.

I always practiced at the “Brigham” and affiliated community hospitals, including the nearby community hospital that Harvard Community Health Plan acquired and used for a while in the early eighties. “The Brigham” was always my home and I loved to walk the halls of the older buildings and think about all of the heroes of medicine who had practiced there and how fortunate I was to be able to stand in the same place. Prior to the near financial collapse of Harvard Pilgrim Health Care, I never thought to question the cost of care at the Brigham or anywhere else, to tell the truth. Through my experience at Harvard Community Health Plan, I did think a lot about reducing the number of hospital days and avoiding unnecessary admissions, but once a hospitalization was required the cost of the admission was something determined by forces beyond my control.

Our method of lowering the cost of care was to ask for discounts through an exclusive contract and then work for early discharges while avoiding unnecessary testing and emergency room visits. It is not easy to question what is happening at home. We just accepted that even after a discount off of a high price we would still be paying a high price. As time passed and we were more and more committed to the affiliation, the discounts dwindled. In response, the management of our practice just focused more intently on the efficiencies we could create within the hospital and did not really consider other options even as the contracts yielded smaller and smaller advantages from exclusivity.

I am a slow learner and between 1997 and 2007 I was mostly concerned with the internal issues of the practice as board chair of Harvard Vanguard Medical Associates, and after 2005 as chair of both Harvard Vanguard and the larger ambulatory affiliation, Atrius Health. Things began to change in Massachusetts after 2006 when Romneycare was passed. By the time I became CEO in February 2008 I had a growing concern about the prices that we were paying for our risk based patients who were getting care within Partners affiliated institutions. It did not seem right that the hospital was not a partner in addressing the cost challenges. When I did bring it up with both the leadership of the Brigham and later with the centralized leadership of Partners, I was quickly advised that it was their opinion that their mission of research, teaching, and patient care should not be distracted by concerns about costs. The implication was that all things being considered, cost was really not an issue. I was dumbfounded.

As I sat with the spreadsheets that my colleagues in our finance and contracting departments prepared for me, there were many ways to do the analysis, but the answer was always the same. We were paying a double digit premium to use Partners hospitals when there were other less expensive institutions that were just as conveniently located to us that we used less often. We were doubly fortunate because any objective analysis suggested that the quality was just as high at those hospitals as at Partners. The care was just as patient oriented. The housestaff was just as bright. The faculty was just as accomplished. The facilities were just as comfortable. And the cost for everything was surprisingly less. After the senior management, clinical leaders, and our boards gave the issues a thorough consideration there was only one decision that matched our fiduciary responsibility to our patients, our community, and to the mission of our own enterprise, and that was to begin the difficult process of moving as much of our hospital care as possible away from Partners and to the lower cost, equal quality institutions.

Hundreds of doctors do not shift tens of thousands of admissions for a population of over 500,000 patients overnight, but through a Lean enabled process and the hard work of some dedicated medical leaders and skilled medical administrators, the shifts did occur. I do not know the exact number of accumulated dollars saved by now. I have been retired for almost four years. But, I would estimate, based on what I knew before retirement, that several hundred million dollars have been saved over the last seven years. Those dollars have been critical to the improvement of clinical quality, to program development for better outcomes, and to the ability to weather the external downward financial pressures that every healthcare provider has experienced over the last few years.

In 2011 I was appointed by then Governor Deval Patrick to a commission that was charged with looking at the variation in reimbursement across all Massachusetts hospitals. The results were astounding. The results were so astounding that doing much of anything about the variation was beyond corrective responses that were politically feasible. The most expensive teaching hospitals were often reimbursed at multiples of what was paid for the same care, such as a full term uncomplicated delivery or a routine surgical procedure at other, less favored hospitals.

The problem had become much worse over the previous 10 to 20 years. The differentials were often so great that if the better paid hospitals were “red lined” at the rates they were receiving in 2011 and those hospitals getting the lower payments had their payments increased each year by a factor equal to inflation or the growth in the state’s GDP, it would take much longer than a decade to approach equity. The problem reminded me of an old Southern saying, “Thems that gots, gets.” What we discovered was too big to fix considering the substantial political resistance that could be expected from the better paid institutions. In the five years after the commission’s work the rich have just gotten richer as was revealed by a second commission in 2016 that got the same results.

I am revisiting this issue now for two reasons. First, it gives substance to what I wrote last week that you can review on the Strategy Healthcare site in a piece entitled “Obamacare Is Not A Disaster!” In that piece I said that doctors and hospitals were part of the problem of the cost of care increases that are being passed to consumers and are being blamed on the ACA. Second, the debate about the variation in payments to hospitals is a hot topic once again in Massachusetts. The Boston Globe gets a little thin sometimes compared to the New York Times and the Washington Post, but over the past few months there have been a few short articles about a bill that was being developed and would be introduced in the state’s senate in an attempt to curb rising healthcare costs in Massachusetts. I often quote the great humorist and political commentator from Oklahoma, Will Rogers, and say, “All I know is what I read in the papers.”

I do know that the last significant healthcare bill in Massachusetts was passed in 2012. Among other things, it established a Health Policy Commission whose Advisory Council I served on for several years. The commission was given few corrective powers but does have review and advisory powers that have made a difference. The law also established a program and center for the collection and analysis of data concerning the cost and quality of care in Massachusetts (CHIA), and a target for annual healthcare cost increases to be no more than the annual increases in the state’s GDP. From my point of view the law passed in 2012 was a “half a loaf” type of compromise that lacked in “teeth,” but did represent some progress. It was the best that thoughtful politicians and advocates for a more progressive set of actions thought was possible in the politically charged environment where any attempts to control the cost of care were challenged by some of the state’s largest institutions.

I have been pleasantly surprised with what the “toothless” Health Policy Commision has been able to accomplish. It played a leading role in blocking the further expansion of Partners after they had received initial approval by the Attorney General for another merger. After some initial concerns, the insurers and providers of care have held the line on payment increases, so that the GDP goal has been partially met. Looking forward it appears that it is clear that more focused attempts to lower the cost of care are prudent and the legislature is considering a far ranging bill that would potentially curtail hospital payments to the better paid hospitals while improving the payment to the poorer hospitals as part of a broader attempt to legislatively lower the cost of care. I once said facetiously that the employers, taxpayers, and citizens who were concerned about the cost of care and the plight of the underserved in Massachusetts were having a conversation with a deaf medical community using the legislature as a loudspeaker.

Earlier this week The Boston Globe sent reporters to the Massachusetts Senate hearings on the new proposed law. As you might have read if you clicked on the link above, Partners sent the presidents of its two biggest and most expensive hospitals to testify about the harm the bill would cause. The testimony given to the State Senate by Peter Slavin, MD and Elizabeth Nabel, MD who are the presidents of the Massachusetts General Hospital and the Brigham and Women’s Hospitals was a recitation of the same song Partners has been singing for too many years. I know their song by heart, and the attitude that their testimonies express is assurance that some things never change.

Leaders of the state’s two largest hospitals made a rare appearance Monday on Beacon Hill to warn state senators against approving any policies that would slash their revenues in order to rein in health care spending.

We should not be surprised by the testimonies of Drs. Slavin and Nabel. They are doing their jobs, but we need not succumb to their arguments. Partners reported revenues of more than 12 billion dollars in 2016 and rung up a healthy profit in the hundreds of millions of dollars as it always does. If they are forecasting difficulties ahead, I wonder how the leadership at the Boston Medical Center and the Cambridge Health Alliance, two very large DSH providers of care to the underserved patients of Eastern Massachusetts, are viewing their futures.

The arguments for caution that Partners always make remain the same. Partners is the state’s largest employer by far, and they consistently argue that their success is aligned with the success of the Commonwealth. Partners is a major force in medical research and education and surely no thoughtful politician would want to be responsible for hurting research or medical education. Whether the usual arguments are good or have become a little specious with time is a matter of opinion. Partners has an incredible political reach. Legislators should exercise caution unless they plan to retire.

I do not expect that the bill will pass as it was introduced. There is evidence of resistance in the House, perhaps driven by effective lobbying efforts (my conjecture based on a personal knowledge of the Massachusetts political process) and Governor Baker has his own ideas, but I am happy to see that the questions of 2011 and 2012 are back on the table. I am sure if there were savings for Atrius Health in trying to use market realities to lower the cost of care in 2009 those cost savings are still there today. As the repeat analysis in 2016 of the work done in 2011 shows, nothing has happened as a result of the 2012 law to level the playing field and improve the ability of community hospitals in Massachusetts to survive. After Partners gets its share of the pie there are only crumbs left for those who lack Partners’ political clout.

I am not sure just how many extra dollars of revenue compared with other academic medical centers in Massachusetts these two famous hospitals have received over the past quarter of a century from the taxpayers, employers, and individual citizens since they affiliated for greater contracting clout, but it is a big bundle measured in billions. I expect that when compared to other well known and excellent healthcare institutions in the state, and even in other parts of the country the differential would take your breath away. It must take serious commitment to mission for Partners to suggest that they can’t do with less when virtually every institution on the planet, not just in Massachusetts gets by with less. I have said enough.


Dr. Gabow’s Question: Can the American Healthcare System Deliver Health For Every American?

About ten years ago, around the time the Triple Aim was a new concept, I was invited to attend a presentation by a visiting speaker that was being given to a small group of about twenty or thirty Partners executives and invited guests at their corporate executive offices at the Prudential Center in downtown Boston. There was an uncomfortable air in the room from the “get go.” I quickly surmised that I was there along with a few other leaders from Partners affiliated organizations to demonstrate that their heart was in the right place and that maybe there was something to the concern about the high cost and maldistribution of healthcare in America.

The speaker was Dr. Ed Murphy who in a relatively short time since his graduation from Harvard Medical School had risen through the ranks of hospital leaders to become the CEO of Carilion Clinic in Roanoke, Virginia and one of the founders of a new medical school at Virginia Tech. Ed’s presentation was spectacular. He not only believed that there was a cost and quality problem with American healthcare he accused the profession, himself, his institution, Partners and everyone in the room of being major contributors to the distress the country was just beginning to articulate. He could answer the question, “What part of the problem are we?” His answer put a chill in the room because it was reminiscent of the famous Pogo quote, “We have met the enemy and he is us.” Most of us thought that we were the origin of “solutions” for problems, not the origin of those problems. I can still see in my mind’s eye the slide that he flashed on the screen as a metaphor that made his point. It was a fancy doctor’s pen, much like the Mont Blanc that was in my own pocket. Through our actions, our orders, and our processes of care we determine much of the cost of care. He went on to assert that without the leadership of doctors and hospitals there could never be an effective resolution of America’s healthcare cost and quality problems.

I recently flashed back to those distant memories of “my awakening” during the presentation of Dr. Murphy as Dr. Patty Gabow began a talk that I was eager to hear with the rhetorical question, “Can the American Healthcare System Deliver Health?” Any rhetorical question is designed more to get the audience thinking than to deliver an answer. I was putty in Dr. Gabow’s hands as she presented fact after fact after her question that got me thinking.

She started with the fundamental question, “What is health?” I smiled to myself when I remembered a distant discussion about how doctors view health compared to how patients and families think about health. Doctors think about things like blood pressure, lab tests like glycohemoglobin, and EKGs. We want all of our patients to die with well managed metrics and pretty pictures on xray. Patients define health as the ability to take care of those we love and have the energy to have a little fun after our work day. Since 1946 the World Health Organization has defined health as:

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

Dr. Gabow reminded us that Howard Koh has said, “Some people need health care some of the time, but all people need health and wellness all of the time.” Our department of Health and Human Services audits our nation’s health and there are other organizations that have been continually comparing the health of Americans to the other developed nations for decades. We have been consistently at the bottom of the rankings. This ranking would surprise most Americans who have been lead to see us as the medical mecca of the world. Paul Ryan is reported to have defended American medicine as the world’s best because he knows plenty of foreigners who have come here for care and no Americans who have gone to another country for care.

Clearly healthcare is important to health especially when we become ill. I like to think of that as “repair care.” That is what we do best. That is what you saw glorified on “E.R.” and on “Grey’s Anatomy.” I am yet to see a dramatization of preventative healthcare, although Stephen Colbert recently made reference to a rectal exam as part of a yearly physical during one of his regular monologues about the current administration. Chronic disease management, office interactions in the ambulatory world, and long term therapeutic relationships may represent future topics for TV shows. Maybe we need a little help from Hollywood to get the message out that beyond the delivery system which is a minor determinant of the nation’s the biggest determinants of health are behaviors, income, education, the environment, quality of the community, and our genetics. “Breaking Bad” and “The Wire” touched on some of these subjects but their connection to health was probably lost on a majority of the viewers.

After setting the stage for the discussion, Dr. Gabow asked some more serious questions about our health system’s performance on cost, coverage and access, quality, and equity and disparities. The answers came in the form of a host of slides suggesting that compared with the other advanced countries we cost more, cover fewer, and have actual quality across the breadth of the system that is far from the best of the world, but most damning is the lack of equity compared to the rest of the world that leads to our huge disparities in experience.

You have seen the numbers before but here are some high points. We rank 50th out of 55 countries in the efficiency of our health system with estimated wastes of over 700 billion dollars a year. We spend much more, 18% of our GDP on health compared to the next closest country, Switzerland, that spends less than 12%. 30% of the care we provide either adds no value or is harmful. Even Medicare spent over 6 billion dollars in 2014 on low value care.

The ACA helped us gain some ground against the coverage gap between us and the 99.9% average coverage levels in Western Europe, Japan, Australia, and Canada, but we still have over 30 million Americans without insurance access. Anyone losing their job, retiring early, or faced with unexpected financial strains can add the potential of also losing their healthcare coverage to the list of their stresses. Who knows what the number will be following either eventual repeal of the ACA or the continuing administrative attacks on its vulnerabilities? Dr. Gabow stressed the point that coverage is not equal to access. Many patients, especially Medicaid patients, have a challenge finding a doctor.

It should not be a surprise to any of us that the accumulated effect of the deficiencies that Dr. Gabow’s data document is that we have the lowest life expectancy compared with our peer nations. If you lived in Japan your life expectancy would be 83.4 years rather than the 78.8 years that is our expectation. That 4.6 year differential is looking large to me at about 72.3. It’s hard to believe, but we are running neck and neck with Cuba and that is not fake news.

The most embarrassing reality that Dr. Gabow revealed was not that even though we have been to the moon we can’t get everyone into a medical facility for the care they need. The dirty little truth is that across this country your life expectancy is more a function of your zip code than genetic code. I have previously reported that the life expectancy in the Roxbury section (02119) of Boston is in the late fifties while the life expectancy less than three miles away in Back Bay (02116) is over 90! Those discrepancies can be seen across the country and are evidence that income, education, and environment are potent determinants of health.

The issues of income and locality have a life time impact on health and are experienced from conception to death. We have an embarrassing infant mortality rate of 6.7 deaths per thousand live births. Sweden gets the gold with 2.5. France and Denmark are tied for tenth place at 3.8. North of our border in Canada it’s 5.2. You may say that things aren’t so bad if you measure life expectancy at your current age. That would be nice, but before age 75 we never rank higher than 15th out of the 17 countries in our comparison group.

We are number one on money spent on the healthcare of those over 55. In 2009 if you were 90 we were spending on average almost $45,000 a year on your care. Number 2 was Germany at a little over $10,000. I imagine we have widened the gap over the last eight years. A recent analysis of deaths in America from all causes revealed that medical errors, caused 251,000 deaths. That is 100,000 more deaths than were caused by COPD. Medical errors were the third leading cause of death behind heart disease (611K) and cancer (585K). That is 688 deaths a day. Who is upset?

In the era of all the controversy over whether “Black Lives Matter,” it is clear that compared to white lives most outcome measurements for African American and Hispanic patients are worse. Compared to whites, African Americans have twice as many low birth weight babies. Mortality is twice as high in the first year of life for black children, and asthma is twice as prevalent. It doesn’t get better later. Stroke and heart disease rates are 1.5 to 2 times higher for African Americans and life expectancy is five years less for black men, and 3 years less for black women.

There are eerie similarities between the red state/ blue state election results in the last presidential election and the map of the states that did not expand Medicaid. A map placing states into four quartiles of health system performance shows all of the fourth quartile states to be “red” and most of the other red states are in the third quartile. Iowa and Wisconsin were the greatest exceptions. They voted red but are in the top quartile. Pennsylvania is the other exception, a red state in the second quartile. As in real estate, healthcare seems to be about location, location, location. Dr Gabow summed it up nicely, “Where you live determines if you live.”

You probably knew much of what I have just discussed. The real question is what to do about our collective problem. Do you remember Dr. Ebert’s assertion from over fifty years ago that the our healthcare problems could not be solved by spending more money? The implication was that we were inefficient and wasteful. Data now suggests that much of our spending has been misdirected. A National Academy of Sciences report from 2016 prepared by a committee of luminaries including Atul Gawande and Don Berwick tried to explain why our health system delivered such poor results despite spending so much money:

A major reason lies in the fact that the foci of our attention, our resources and our incentives are too narrow...our investments are primarily directed to a biomedical focus...

What you may not realize is that though we spend more money on healthcare than any other country as a percent of GDP many of the countries that have better outcomes than we do spend more than we do on the combination of social programs and healthcare. We are thirteenth in the combination of spending as a percent of GDP on healthcare plus social programs. All of those “socialist” societies of continental Europe spend more than we do. There is more to the story though because the UK, Canada, and Japan spend less on the combination than we do, but all spend more on social services than medical services. Spending lots of money irrationally or on care that is characterized as wasteful or without clinical value is wrong. That waste does create economic benefit for providers, institutions, big pharma, and medical device manufacturers, but does not improve the health of the nation.

Income inequality is a much discussed domestic issue as the rich get richer and the middle class pays taxes. We have tax legislation in Congress now that is largely crafted from a debatable economic concept that giving more money to the wealthy will stimulate business development and job creation with the resultant growth producing enough new revenue at the new lower tax rate to fund and justify the proposed tax reductions. That sounds great. It’s been tried. Going back to “Reaganomics” and the Laffer Curve it has never worked. Most recently Kansas has come close to bankrupting itself and destroying its system of public education while vigorously testing the theory that lower taxes create growth . Sam Brownback, the governor who made it happen, is hoping to get out of town as our new “ambassador for religious freedom.”

What happens to income inequality as a function of tax policy and legislation could have a greater impact on the health of the nation than most politicians eager to inure the richest 1% realize. The analysis of the association between income and life expectancy from 2000-2014 yields some important insights:

• Life expectancy at age 40 increases continuously with income percentile.
  
• The wealthiest 1% have a life expectancy at age 40 that’s 10-15 years greater than the poorest 1%. The life expectancy of the poorest 1% of men in America is that of men in Sudan.
  
• The rise in life expectancy associated with income becomes much smaller above a household income of about $200,000.
  
• Expected age at death for 40-year-olds increased for people in the top income quartile at a rate about 2.5 times that for people in the bottom income quartile.
  
• Life expectancy at age 40 differs by location, favoring New York and California for people in the bottom income quartile and Utah and Maine for those in the top income quartile.
  
• Most of the difference in life expectancy between the wealthiest and poorest seems attributable to health behaviors.
  

I was not surprised by Dr. Gabow’s data that correlated health and longevity with education or that Americans carry a much higher risk to their health from the environment than the citizens of European countries, Canada, and Japan. Unhealthy behaviors are tricky. Moralists have long held that “the wages of sin is death.” In the ‘80s many religious leaders blamed the victims of the AIDS epidemic for their own misery. We are now in the midst of an epidemic of opioid overdoses and trying to decide just who should be blamed. Opioid deaths now exceed gun deaths. It is a fact that we have improved deaths rates from automobile accidents so that guns now kill as many people as cars. A lower percentage of Americans smoke than thirty years ago, but it is still estimated that 40% of deaths can be attributed to tobacco use, unhealthy diets, drinking problems, and a lack of exercise. The realities of low income exacerbate all of these problems.

If health in America is to improve something different needs to happen. Perhaps more important is how much will health deteriorate under poor public policies that deny scientific facts, the information that can be gleaned from the social sciences, and a self analysis of who we are, what we are doing, how we have failed, what the reasons for failure are, and how we might do better. It’s one huge problem begging for leadership, Lean analysis, and a vision that can unite a divided country. Lean teaches us to asses the current state, imagine what an improved state might be, do an analysis of what might be changed to promote the vision of the improved state, and then test our hypotheses about what might be better.

Just like Ed Murphy did ten years ago, Dr. Gabow finished her presentation talking about short term and long term efforts that begin at home. She asked the rhetorical question, “Can the healthcare system be the entity that broadens our national focus from its current narrow biomedical focus to the broader determinants of health.” As you might expect, she thinks that we can if we…

• Continue the efforts on access, cost and quality
  
• Reduce waste in systematic way
  
• Increase focus on behavior components
  
• Contribute to community education on social determinants and advocate for addressing them
  
• Co-ordinate community benefits to address social safety net
  
• Create linkages with social safety net
  
• Pay a living wage to all employees
  
• Reduce income disparity within their institutions
  
• Institute robust tuition reimbursement programs (as she fostered at Denver Health)
  

Do you remember that when the “cold war” ended reductions in military spending were seen as a possible source for social improvements? It was a possibility that was never completely realized, but if we could reduce what we spend on healthcare by improving our delivery efficiencies, avoiding non value producing care, and by practicing more effective preventative and chronic care, then we might have a dividend that we could invest in social programs that are similar to the programs that our European friends use effectively.

We could use the money for the:

• Earned Income Tax Credit
  
• SNAP expansion (food stamps)
  
• Reauthorization of Healthy Hunger Free Kids
  
• Comprehensive School Physical Activity Model
  
• Home Visitation Program (For newborns)
  
• Tobacco Cessation
  
• Universal Preschool programs
  

The work will require a willingness to participate in a real transformation that will include an end of fee for service payment and a shift to value based finance. Our operating systems will need to be reengineered to reduce the fragmentation of care. We will need to practice patient centered care and care redesign that allows us to bring the wisdom of patients and families into the process. We will need to embrace all of the advantages of technology and augmented intelligence but apply them to reduce waste, lower the cost of care and improve outcomes by more effective clinical management, and not use them as mechanisms to generate revenue. Perhaps we might even get some advice from those other nations where the data suggests they do a better job.

You might say, “That sounds great and perhaps pigs will fly.” Healthcare is complex. Its complexity allows many experiments designed to generate improvements. We have made thousands of improvements over the forty years of my medical practice. What we haven’t been careful to do is to effectively align our improvements toward larger social goals. I believe as long as we can produce people like Dr. Gabow who can lead by example and insight, we will continue to make progress.


Family, Friends and Fall

The intermittently extra warm weather of the fall seems to have had the effect of prolonging the color season. While in California we had a couple of days that barely made 60 and then left as the temp rose through the eighties to top out in the low nineties. Family form the South is coming for a visit this next week so it is great that there are still more pretty leaves on the trees than on the ground.

Take advantage of the weather and get out this weekend if possible with family and friends. I am sure there are many interesting things you can do where you are. The picture in today’s header was taken by my son who lives in Brooklyn and enjoys walking through the Brooklyn Botanical Gardens. Last weekend he and his wife rode the subway up to the Bronx where they are sporting an exhibit of Dale Chihuly at the New York Botanical Gardens. It seems to have been worth the extra effort.