
Challenges to clinics
Last fall, when I was writing about my Cambridge Management Group (CMG) colleagues' work in helping to turn around a financially troubled Federally Qualified Health Center (FQHC) called Community Health Connections, based in Fitchburg, Mass., I learned about the role these centers play in addressing changing American health-care demographics in general and illness — especially chronic illness — in low-income populations in particular. Such centers will continue to face reimbursement and other issues as the restructuring of the health sector accelerates. The Affordable Care Act, in increasing the emphasis on primary care while more closely integrating it with acute care, will almost certainly increase the importance of FQHC’s and other clinics. With all the publicity about trying to get everyone signed up for insurance to use at physicians' offices and hospitals, we should keep in mind the need for facilities that are neither hospitals nor physician-group offices in treating underserved populations in places like the old mill towns of north central Massachusetts, with their high incidence of poor behavioral health and such related chronic diseases as diabetes, and sluggish economies.
Such institutions will have their hands full overcoming the clinical, financial and administrative challenges of meeting new federal and state health-care reform mandates while refocusing the payment structure on fee for value and away from fee for service in a new, far more accountable and evidence-based health-care sector.
Who knows what it will all look like in five years?
-- Robert Whitcomb
The VA hospital mess: Demographics, history, hypocrisy
This piece originated on the Cambridge Management Group Web site.
Merrill Goozner, editor of Modern Healthcare, has written a fascinating and provocative editorial that well explains why the Department of Veterans Affairs, which for some years had a stellar reputation for care, now faces a mess. And, sadly, it's become a political game mired in hypocrisy.
Consider Phillip Longman's book about VA health care, called <em>Best Care Anywhere</em>, which, Mr. Goozner noted, praised "the 1990s transformation that turned a scandal-plagued, dysfunctional system into one that pioneered the adoption of electronic health records, improvements in patient safety and coordinated care.''
He and many others note that the current scandal involving care delays reflects the VA's inadequate preparation to receive hordes of aging Vietnam veterans and veterans of Iraq and Afghanistan. But, he says, don't blame the folks who run it but the politicians who failed to adequately fund the VA.
Mr. Goozner notes that the health status of the Vietnam vets "reflects the fact that they are somewhat poorer and less educated than the general population since that was the first conflict where college-bound young adults were largely exempted from frontline military service.''
As for the vets of Iraq and Afghanistan:
"Like Vietnam-era vets, the younger vets bring with them a special set of problems brought about by the miracles of modern battlefield medicine and logistics. Compared with previous wars, many more survive disfiguring bomb blasts and traumatic head injuries, which will require a lifetime of care and support.''
"Yet until last year, the VA's medical care budget hadn't increased any faster than the general rate of medical inflation, rising from $25.5 billion in 2003 to $45.5 billion in 2012, according to data from the VA.''
Mr. Goozner also notes the hypocrisy of politicians denouncing the "high salaries'' of people running VA hospitals that are a small fraction of salaries paid to hospital execs at "nonprofit'' hospitals. "Maybe the real lesson here for Congress and the White House is they are getting what they pay for — from the VA executive salaries to the promptness of the health care services the VA offers our worthy veterans.''
ACA a boon for 'safety-net' hospitals
Except for states (mostly in the South) that refused to accept Medicaid expansion under the Affordable Care Act, the ACA has been a boon for "safety-net'' hospitals that service large numbers of poor people. That's because the ACA, by enabling millions of previously uninsured people to get insurance (many of them via Medicaid programs), has dramatically reduced pressure on hospitals to provide uncompensated care.
See this comment in Cambridge Management Group's Web site.
Blame Russia for Russian aggression
By ROBERT WHITCOMB (rwhitcomb51@gmail.com)
Some denounce the United States for Russia’s reversion to brutal expansionism into its “Near Abroad” because we encouraged certain Central and Eastern European countries to join the North Atlantic Treaty Organization. The argument is that NATO’s expansion led “Holy Russia” to fear that it was being “encircled.” (A brief look at a map of Eurasia would suggest the imprecision of that word.)
In other words, it’s all our fault. If we had just kept the aforementioned victims of past Russian and Soviet expansionism out of the Western Alliance, Russia wouldn’t have, for example, attacked Georgia and Ukraine. If only everyone had looked into Vladimir Putin’s eyes and decided to trust him.
Really? Russia has had authoritarian or totalitarian expansionist regimes for hundreds of years, with only a few years’ break. How could we have necessarily done anything to end this tradition for all time after the collapse of the Soviet iteration of Russian imperialism? And should we blame Russia’s closest European neighbors for trying to protect themselves from being menaced again by their gigantic and traditionally aggressive neighbor to the east? Russia, an oriental despotism, is the author of current Russian imperialism.
Some of the Blame America rhetoric in the U.S. in the Ukraine crisis can be attributed to U.S. narcissism: the idea that everything that happens in the world is because of us. But Earth is a big, messy place with nations and cultures whose actions stem from deep history and habits that have little or nothing to do with big, self-absorbed, inward-looking America and its 5 percent of the world population. Americans' ignorance about the rest of the planet -- even about Canada! -- is staggering, especially for a "developed nation''.
And we tend to think that “personal diplomacy” and American enthusiasm and friendliness can persuade foreign leaders to be nice. Thus Franklin Roosevelt thought that he could handle “Joe Stalin” and George W. Bush could be pals with another dictator (albeit much milder) Vladimir Putin. They would, our leaders thought, be brought around by our goodwill (real or feigned).
But as a friend used to say when friends told him to “have a nice day”: “I have other plans.”
With the fall of the Soviet Empire, there was wishful thinking that the Russian Empire (of which the Soviet Empire was a version with more globalist aims) would not reappear. But Russian xenophobia, autocracy, anger and aggressiveness never went away.
Other than occupying Russia, as we did Japan and Western Germany after World War II, there wasn’t much we could do to make Russia overcome its worst impulses. (And Germany, and even Japan, had far more experience with parliamentary democracy than Russia had.) The empire ruled from the Kremlin is too big, too old, too culturally reactionary and too insular to be changed quickly into a peaceable and permanent democracy. (Yes, America is insular, too, but in different ways.)
There’s also that old American “can-do” impatience — the idea that every problem is amenable to a quick solution. For some reason, I well remember that two days after Hurricane Andrew blew through Dade County, Fla., in 1992, complaints rose to a chorus that President George H.W. Bush had not yet cleaned up most of the mess. How American!
And of course, we’re all in the centers of our own universes. Consider public speaking, which terrifies many people. We can bring to it extreme self-consciousness. But as a TV colleague once reminded me, most of the people in the audience are not fixated on you the speaker but on their own thoughts, such as on what to have for dinner that night. “And the only thing they might remember about you is the color of the tie you’re wearing.”
We Americans could use a little more fatalism about other countries.
***
James V. Wyman, a retired executive editor of The Providence Journal, was, except for his relentless devotion to getting good stories into the newspaper, the opposite of the hard-bitten newspaper editor portrayed in movies, usually barking out orders to terrified young reporters. Rather he was a kindly, thoughtful and soft-spoken (except for a booming laugh) gentleman with a capacious work ethic and powerful memory.
He died Friday at 90, another loss for the "legacy news media.''
***
My friend and former colleague George Borts died last weekend. He was a model professor — intellectually rigorous, kindly and accessible. As an economist at Brown University for 63 years (!) and as managing editor of the American Economic Review, he brought memorable scholarship and an often entertaining skepticism to his work. And he was a droll expert on the law of unintended consequences.
George wasn’t a cosseted citizen of an ivory tower. He did a lot of consulting for businesses, especially using his huge knowledge of, among other things, transportation and regulatory economics, and wrote widely for a general audience through frequent op-ed pieces. He was the sort of (unpretentious) “public intellectual” that we could use a lot more of.
***
I just read Philip K. Howard’s “The Rule of Nobody: Saving America From Dead Laws and Broken Government.” I urge all citizens to read this mortifying, entertaining and prescriptive book about how our extreme legalism and bureaucracy imperil our future. I’ll write more about the book in this space.
Robert Whitcomb (rwhitcomb51@gmail.com), a former editor of The Providence Journal's editorial pages, is a Providence-based writer and editor, former finance editor of the International Herald Tribune and a partner and senior adviser at Cambridge Management Group (cmg625.com), a consultancy for health systems, and a fellow of the Pell Center for International Relations and Public Policy.
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Dr. Pierson's 'Triple A' for health-care reform
One of my gigs is to help out at a consultancy called Cambridge Management Group, which advises hospitals and other health-care institutions as well as physician groups. I learn the thoughts of some very interesting people. One is nationally known health-care reformer Marc Pierson. Here's the chat/interview I put together the other day and that ran on Cambridge Management 's Web site, cmg625.com.
We chatted the other day with James Marcus (Marc) Pierson, M.D., a Cambridge Management Group senior adviser. Dr. Pierson -- an internist, emergency physician and past vice president of clinical information and quality for PeaceHealth St. Joseph Medical Center, in Bellingham, Wash. -- is a major health-care reformer. His leadership in helping to create an integrated and patient-centered health-care system for Whatcom County, Wash., has received national attention.
As a leader of the Pursuing Perfection program in the county, he helped develop the community-based, patient-centric Shared Care health-record system and participated at the board level in the Whatcom Alliance for Healthcare Advancement (WAHA). <a href="http://whatcomalliance.org/ ">WAHA</a> helped lead to the recently approved Washington State Health Care Innovation Plan, which has put the power of the state government behind the many ideas arising from Whatcom County’s whole-community and patient-informed perspectives.
He told us that “the county level is the smallest appropriate geographic base for creating a coordinated-care system.’’ Whatcom County was particularly attractive for such efforts because it has attracted a lot of civic-minded and collaboration-minded physicians who “didn’t move here for the money but, among other things, for the natural beauty.’’
Dr. Pierson said that creating an integrated-care model requires first observing how the chaotic traditional “system’’ was or was not working, then trying to understand it and then writing down observations and designing changes. It was crucial to understand the inter-actions of all of the parts of the health-care system, and, crucially, to use patients’ knowledge and opinions – those too-often-neglected elements of health-care reform – in changing the individuals and institutions that serve them.
He cited the “Triple A’’ approach: 1.) research and analyze the needs and desires of the patient population; 2.) understand (clinically and financially) the other parts of the system (doctors, nurses, hospitals, insurers, etc.; 3.) design together one integrated health-care community in which patients’ decisions play the most important part.
With that, he said, we can build a health-care system whose treatment and payment system addresses the ever-changing needs of the whole community. “The quality of the entire system suffers,’’ he said, “when the focus is more on the individual parts and loses sight of the whole community health system. Perfect parts do not make perfect or even good systems. It is the interactions between the parts that must be designed….’’ In any event, the improve-the-parts approach is unsustainable.
Further, Dr. Pierson said, we need to move away from the “extractive financing model’’ of American health care, in which much of the savings from improving a community’s health care leaves the community, making it unavailable for reinvestment. And he touted the idea of setting targets for spending on health within a whole community, citing the success of Jonkoping, Sweden, which set a target of 8.3 percent of the local economy for health care and has had very good outcomes.
He said that his experience in the mid-'80’s as an ER doctor trying to pull together in an ad hoc fashion a variety of specialists to treat a young man badly injured in a motorcycle accident helped get Dr. Pierson thinking about systems and coordination.
This line of focused community building would ultimately lead to his campaign for integrated, community-wide care. Along the way, he made it a point “not to ask anyone to do anything that was against their economic self-interest.’’ And he sought out the “most respected players’’ in the Whatcom health-care community to help him carry out this vision for the county. A very practical and behind-the-scenes reformer.
Given the widening income gap in the U.S., we wondered about whether only the rich would have the finest sort of individualized “concierge care’’. Somewhat to our surprise, Dr. Pierson was optimistic that the use of genomic information, personal medical devices and other advances would make “concierge care’’ available to everyone in the fullness of time, aided by the doctors, nurses, social workers and other health-care ‘’navigators’’ who will increasingly see a major part of their jobs as helping to guide patients to the information they need as well as through the system.
It’s all part of his vision to have all of us see “medicine as a part of health and well-being.’’ The whole community, he says, owns its health and well-being and we must design our futures in that context.
Those overrated old mills; defending fraternities
Some can be renovated for artists’ lofts and small businesses and their owners can make a profit — often with special tax breaks. The mass of taxpayers must make up the lost tax revenue. And some owners are big tax deadbeats. Consider the owners of Hope Artiste Village, in Pawtucket, who owe the city $124,690 for the current tax year, or those of The Thread Factory, on the Pawtucket-Central Falls line, who owe Pawtucket $366,306 and Central Falls $410,000. There may be similar examples around the state.
It is hard to quantify how much Rhode Island has gained or lost from trying to preserve old mills because people think that they’re quaint. Many can never be retrofitted to make a fair (without tax breaks) profit. Preservationists (not a few of whom are financially secure and don’t have to worry too much about finding a job in the sluggish Rhode Island economy) fiercely fight to save as many of these mills as possible, once built for economically logical reasons that disappeared decades ago. Indeed, the Ocean State has not exactly become a boom town during all these years of trying to keep old factory buildings that don’t make anything anymore except the occasional arsonist.
Then there’s that Art Deco tower the Industrial Bank Building, which, because of its stepped-back structure and location in not exactly thriving Providence, has little chance of being a full-scale office building again. Maybe it would work for residential — but again with tax breaks to be paid for by people not benefiting from its redevelopment.
A rather similar stepped-back famous Art Deco skyscraper is the gold-roofed United Shoe Machinery Corporation Building, at 140 Federal St. in downtown Boston, which for many years was New England’s tallest building. It had been slated for demolition in 1981, after “Shoe,” as the once huge company was long called, disappeared. But Boston was/is a major financial center. The quantity of local money and tax breaks made retrofitting it attractive, and the building is now filled with Class A offices.
Providence doesn’t have that critical mass. Other than nostalgia, there’s little to justify taxing the public to maintain the now remarkably inefficient “Superman Building.” Anyway, Providence had its heyday before it was built and could have another after it’s gone. And even Chartres Cathedral will one day disappear. As Ira Gershwin wrote, “In time the Rockies may crumble, Gibraltar may tumble ... ”
The South Bronx, the famously poor and crime-ridden section of New York given up for lost 30-40 years ago, has enjoyed a revival in part because so many of the old buildings were torn down (often after arson) and new buildings put up in the newly available acreage. Perhaps Rhode Island should move away from its love affair with old factories that do nothing (or worse) for the macro-economy. New buildings can be beautiful too. Are old mills over-rated?
***
The cover story in this month’s Atlantic is titled “The Fraternity Problem: It’s Worse Than You Think.” The article, surprisingly, spends a lot of ink on a nasty fraternity at very liberal/PC/“Little Ivy” Wesleyan University, in Middletown, Conn., where various outrages involving booze, sexual assault and so on have taken place. (Harvard also has fraternities, called “Final Clubs,” where, as a guest, I have witnessed grotesque behavior fueled by alcohol and other drugs.)
Busybodies and other social engineers cry out for closing all fraternities, though legally that would be impossible.
Speaking as a past member of a fraternity, I object. At most of these clubs, while drinking goes on sometimes, as it does at many social organizations, activities are much tamer than the “Animal House” cliché. And they play the healthy role of providing a closer sense of community than can the wider and anomie-ridden college or university community. Indeed, fraternities are frequently the venue for the start of lifelong friendships. Many college administrations should monitor these organizations with more rigor and call in the police (the town cops, not the campus cops) when necessary, of course, but, still, fraternities all in all do more good than harm. And without a modicum of freedom of association, society would be very dreary indeed.
I recently got a note from a group that was in the fraternity house I was in in the late 1960s. They’re planning a reunion for next October. As I saw the names, the years peeled back. Dozens are coming, out of (mostly lapsed) friendship and even morbid curiosity.
Robert Whitcomb (rwhitcomb51@gmail.com), a former editorial-page editor of The Providence Journal and a former finance editor of the International Herald Tribune, is a Providence-based writer and editor and a director of Cambridge Management Group (www.cmg625.com)., a health-care-industry consultancy.
Of factories, Florida and Alzheimer's
Many citizens wonder what to do with 19 acres of Providence land that have been made available for development by moving Route 195. What a huge opportunity!
The property is in the middle of New England’s second-largest city; alongside the East Coast’s “Main Street” — Route 95 — whose intersection with 195 created one of the East's big crossroads; next to internationally known academic institutions; spectacularly situated at the head of a great bay, and near a large hospital complex. And just down the road is Green Airport, which is being expanded to allow nonstop flights to the West Coast and Western Europe.
What to put on the property? Offices and academic facilities, especially those connected with medically related activities; design businesses (Rhode Island School of Design spinoffs?), restaurants, hotels and stores. But let’s not ignore manufacturing.
This would not be the “dark satanic mills” of yore, emitting thick pollutants into the air and water. Most American manufacturing is much, much cleaner these days. It also employs fewer people, as foreign factories and robotic systems here have taken over much of the work, though the factory workers we have are generally well paid. To make such high-end stuff as pharmaceuticals in plants on the 195 land is just common sense. Consider that the proximity of Routes 195 and 95 and Narragansett Bay’s ports makes shipping manufacturing materials into and finished products out of this part of Providence remarkably easy. And there’s lots of engineering expertise in the region.
And if you think that a factory can’t co-exist attractively with a thickly settled area, consider Genzyme’s plant in the Allston section of Boston.
But the area needs more and better mass transit to serve the neighborhood, whose warren of confusing streets could scare away car-based people. Eventually a couple of trolley lines (real ones, with rails) should run through the newly developed area to connect the old downtown, the medical complex to the south and College Hill. But let development be dense; sociological and other studies associate density with lower crime and higher urban energy. Planners for the land should keep out windswept parking lots.
All in all, the 195 land offers the biggest opportunity to raise the profile and thus the prosperity of Providence since the rivers were moved.
***
We just got back from Naples, Fla., where I worked and we saw relatives in one of the most demure parts of the peninsula. The overloaded airline system makes travel to and from the Sunshine State increasingly difficult. And the urbanization and suburbanization of much of Florida have tattered much of its semi-tropical beauty. Still, the warmth, the greenery and the ease of strolling compared with walking on New England’s icy streets, narrowed by inadequate snowplowing, made it seem paradisiacal. And the quiet was addictive; the sound of wind through the palms and the surf were the main background sounds as I typed in my brother-in-law’s office.
It brought back memories of a quiet, lush Florida from my childhood. I remember the smell of the orange groves, the roadside juice stands and the long stretches of unbuilt-on beach backed only with palmettos and dune grass. My first memory is of an old man throwing bread to pelicans on the beach in Siesta Key, near Sarasota. Later ones include discovering Key lime pie and stone crab, drinking from a coconut and enjoying the best roadside kitsch in America.
Parts of my family had been going to Florida for part of the winter since around World War I. Naturally they complained about its over-development. Of course, they helped start the problem. (However, they never took part in the sort of crazy land speculation immortalized in the Marx Brothers’ 1929 film “The Cocoanuts,” in which Groucho’s character keeps trying to unload swampland on unsuspecting investors. Not much has changed since then!)
When there’s something nice, we overuse it, which is what happened to Florida, especially after air-conditioning, interstate highways and jet travel made getting and staying there so much easier. The Florida that I briefly revisited the other week, just before its high season, evoked in me balmy nostalgia for a time before Florida became a mega-state.
***
Kudos to Cape Cod-based writer/editor/publisher Greg O’Brien, 64, who has been writing (as self-therapy) about Alzheimer’s disease since he was diagnosed with it, in 2009. One of his projects is his book “On Pluto: Inside the Mind of Alzheimer’s.” Then there’s my friend Berna Huebner, whose movie and book, “I Remember Better When I Paint,” describe how her mother, a successful Chicago-based painter, regained some of her skills and energy after she was persuaded to return to painting after Alzheimer’s seemed to doom her to a life of, by turns, agitation and depressed passivity. We’d better be looking for many routes for relief for dementia victims — and their families -- as the number of victims swells in the next two decades.
(In 2010, I wrote a magazine piece about this.)
Robert Whitcomb (rwhitcomb51@gmail.com), a former editor of The Providence Journal's Commentary pages, is a Providence-based writer and editor and the overseer of www.newenglanddiary.com. He is also a director of Cambridge Management Group (cmg625.com).
See news and comment on health-care sector
See the "News'' section of Cambridge Management Group's Web site, www.cmg625.com for news and comment on health care.