Aetna CEO touts return to community-based healthcare

Via Cambridge Management Group (cmg625.com)

FierceHealthcare reports that Aetna CEO Mark Bertolini “is pushing for a return to community-based healthcare even as the insurance company prepares to merge with retail pharmacy giant CVS.''

“Critics of the merger have said the deal will hurt competition and cut local services. But Bertolini said the $69 billion deal with CVS doesn’t change the fact that the healthcare industry is moving toward a renaissance of community-based care,” the news service reported.

“Everything is going back to community,” Bertolini said at a conference in California. “I think the best way to manage the kind of shift we’re in is to go back to community and build smaller and smaller governance models to help support the growth of this. What you’re in essence building is a marketplace in the community around health.” Aetna is based in Hartford and CVS in Woonsocket, R.I.

To read more, please hit this link.

Vermont trying all-payer healthcare system to curb costs, improve care

Vermont's state seal, in a stained-glass window in the State House, in Montpelier.

Governing magazine has looked at Vermont’s development of  an all-payer healthcare system.

In this approach, the publication says,  ”{i}nstead of billing doctors for each service they provide, insurers in Vermont will now give them a fixed sum each month, along with bonuses for keeping patients healthy. (Doctors can also pay penalties for adverse health effects, like having a high number of patients getting readmitted to the hospital within 30 days.) The hope is to eliminate unnecessary procedures, reduce costs and elicit more positive health outcomes.”

“In the 1970s, a dozen or so states tried all-payer systems for their hospitals. Except for Maryland, they all eventually shifted back to the standard fee-for-service because there was little evidence that all-payer was actually reducing overall health-care spending.”

“All of those states, however, only applied all-payer to hospitals — leaving out a large portion of health-care providers and limiting its potential impact.”

“Vermont’s system will cover all providers — hospitals, primary care, specialists, urgent care clinics, you name it. And instead of the state paying the providers their monthly fixed sum, it will be up to accountable care organizations (ACOs), which are groups of providers that have the same goals as all-payer: to reduce spending by rewarding better, not more, care.”

But there will be big challenges to making this work.

To read the Governing piece, 

This item first ran in the Web site of Cambridge Management Group (cmg625.com).

Small N.E. hospital focuses on care transitions

This first ran on the Web site of Cambridge Management Group (cmg625.com).

South County Health, a small nonprofit system in bucolic southern Rhode Island, owes a large part of its success to its ability to manage transitions of care – an increasingly urgent imperative as healthcare moves from fee-for-service to value-based reimbursement.

The system’s flagship is South County Hospital, a 100-bed community hospital. The system also includes South County Home Health Services (a home health agency); South County Surgical Supply (home medical supplies); South County Medical Group, with 65 physicians and advanced-practice providers, and two Medical and Wellness Centers, one in Westerly and the other in East Greenwich, with urgent-care facilities and an array of primary-care and specialist physicians.

South County Hospital has long had very high marks for quality and patient satisfaction. Indeed, surveys have often called it the best hospital in its state and one of the best in New England. It was recently awarded a five-star rating by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), putting it in the top 2 percent of those surveyed nationwide.

Louis R. Giancola, the system’s president and chief executive, attributes much of the hospital’s success in patient satisfaction — and fiscal stability — to the strong engagement of its staff, which “we keep in the know’’; a “supportive board’’; the long-term loyalty of people in the service area, and the “nimbleness of a community hospital’’. Having a relatively affluent market with many well-insured people hasn’t hurt either, he acknowledged.

A particular point of pride is: “We’re good at transitions of care. Maybe that’s a result of our being small.’’

South County Hospital, like virtually all health systems these days, faces many challenges in dealing with the rewards and penalties involved in the forced-march transition to value-based reimbursement. Mr. Giancola notes:

“Medicare incents us to improve patient satisfaction, reduce hospital infections and avoid various patient injuries.  Most commercial payers (insurers) have followed suit. I believe the threat of reduced payments has focused our attention on these measures even though we sometimes complain that the measures are not always fair.’’ (See below.)’’

“It’s all about blocking and tackling. The biggest issue is readmissions within 30 days. {South County has long had lower readmission rates than most hospitals.}

We’ve really focused on managing the transition from the hospital to another level of care. The important element is good communication between the hospital providers and the skilled-nursing facility, home health and the doctors caring for the patients in the community.’’

Part of South County’s recognized success in overseeing clinically successful and financially efficient transitions – and, in so doing, reducing costly readmissions — has been its emphasis on using, when possible, home health care instead of nursing centers to save money and improve care, Mr. Giancola said.

The Centers for Medicare & Medicaid Services and other regulators and payers have been pushing hard for better patient-care management, especially since the Affordable Care Act took full effect. Much of South County Health’s work in this area involves helping primary-care physicians to be better traffic managers of their patients’ care.

Another transition success story he cites is medication reconciliation. “Often patients are confused about their drugs and that can lead to readmission because they take drugs that are contra-indicated or they take two meds designed to address the same problem. We’ve hired pharmacists that review meds in the hospital to ensure they are reconciled and the patients get clear advice on discharge.’’

He notes as an example of what might sometimes be unfair pressure from the Feds: CMS’s making hospitals put many patients who have to stay in the hospital for a night or two into “observation’’ status instead of as inpatients, thus slashing potential hospital reimbursement.

Bundled payments, Medicaid and an ACO

An increasingly important strategy for controlling costs and improving care is bundled payments.

South County Health participates in a bundled-payment program for joint-replacement patients with Blue Cross for their Medicare Advantage and commercial-insurance members. (Cambridge Management Group has been doing a lot of work in bundled-payment programs and so this particularly caught our eyes.)

With older-than-average market demographics, the joint-replacement business is a major contributor to the system’s bottom line. (However, while the system is financially stable, its operating margin is only about 2 percent; the system is closely managed.)

Mr. Giancola said that, as with many things in the brave new world of value-based medicine, it’s unclear what sort of savings may come out of the move to bundled payments. However, he thinks that the clinical benefits are clear:

“The bundling process helps us to get a better handle on the clinical process. Having to report quality throughout the entire episode of care makes for better transitions and final outcomes.’’

South County Hospital’s leaders are happy that the Affordable Care Act has put so many uninsured people into Medicaid. While Medicaid reimbursements lag those of Medicare it’s a lot better than no insurance for low-income people. Many of those people, of course, have long used the emergency room as their major source of “free’’ (to them) medical care.

But, perhaps surprisingly, Mr. Giancola told us, Medicaid expansion has not yet cut the flow of people into South County Hospital’s ER, despite efforts encouraged by public and private insurers to promote more and better preventive care to keep people out of the ER. “ERs are too handy for lots of people,’’ he observed.

South County Hospital has had to deal with many other changes, whose long-term fiscal effects are difficult to predict. One is the rising number of employed physicians, hired, Mr. Giancola says, to ensure that the hospital can maintain the range of services that patients want and need in an acute-care facility, such as obstetrics.

Mr. Giancola notes that’s expensive. “Hiring doctors away from private practices to be based in the hospital puts them in more expensive places, with expensive support staffs, equipment and technology. The jury is out on whether the increase in hospital-employed physicians will save money in the long run.’’

Also unknowable at this point is whether South County’s participation in an Accountable Care Organization with Blue Cross & Blue Shield of Rhode Island (BCBSRI) and Integra Community Care Network will ultimately save money. Integra is a partnership of Care New England Health System and its network physicians, Rhode Island Primary Care Physicians Corporation and South County Health and its network physicians. Focused on population-health management, the ACO provides incentives for Integra’s providers to proactively manage patient health, with a heavy emphasis on prevention of illness, while trying to restrain costs.

South County Health, as befits a, well, beloved local institution is big on promoting community-wide collaboration of institutions that can help improve not just healthcare in a clinical sense, but population health.

Toward that end, it has brought together such diverse agencies as the YMCA, the five Federally Qualified Health Centers in its area, school systems, the local Community Action Program and community members to harness the resources of the community. Whatever happens to the ACA, the move toward community and population health will continue, and South County Health will help lead it in southern Rhode Island.

Mr. Giancola has written: “Our long-term goal is to inspire the broader community to see health as a community issue and to mobilize government, schools, businesses and citizens at large to rally around efforts to ensure a healthy community.’’

Lia Spiliotes: To narrow N.E. rural healthcare gaps, boost nurse practitioners

Rural America lives with layers of demographic and geographic obstacles to health care, and not surprisingly, rural Americans face bigger health challenges than their urban and suburban neighbors. Berkshire County, the second most rural county in Massachusetts, is no different.

More than residents elsewhere in the state, our neighbors and communities struggle with high rates of obesity, cancer, diabetes, cardiovascular disease, mental illness and addiction to smoking and other drugs. The suicide rate in Berkshire County was the highest in the state in 2013, and admissions to mental-health facilities are above the norm.

Berkshire County mirrors other remote rural geographic regions in the nation, where recruiting primary-care providers is an ongoing challenge of economics, retirement, the allure of specialty medicine and big-city compensation. In these areas, the supply of primary-care physicians falls below federal standards. (Kaiser Foundation 2015).

The good news is that the education, experience and quality of physicians and nurse practitioners at Community Health Programs in Berkshire County, where I have been interim CEO since January, is on par with any of the best healthcare organizations in which I have worked in Massachusetts. Equally important is the work we are doing to educate patients about the front-line role that nurse practitioners play in the delivery of high quality primary care. Increasingly, patients understand that nurse practitioners are excellent partners in providing primary care.

National studies have shown that patients assigned to either nurse practitioners or primary-care physicians have comparable health outcomes. More than a dozen states — including Maine, Vermont, New Hampshire and Rhode Island — have long-since passed measures freeing nurse practitioners from physician oversight in treating, diagnosing and prescribing medication to patients.

States that have already done so show fewer emergency-room admissions, improved health status, and better overall healthcare experiences. Yet in Massachusetts, physician organizations have resisted giving nurse practitioners sufficient autonomy to practice to the full extent of their training. We need to maximize the use of nurse practitioners as a vital healthcare resource.

This lack of full practice authority for nurse practitioners has broad implications for healthcare access in Massachusetts, particularly in underserved communities. Competition for primary-care providers is intensifying. Physician salaries at community health centers, which serve mostly lower-income residents, remain 25 to 30 percent below entry-level salaries at many hospitals and private physician practices.

Outdated practices

At rural health centers, which continually struggle to attract providers away from urban areas, the impact is even more profound if nurse practitioners cannot provide the full range of patient care. The health of rural communities is compromised by policies that protect outdated ways of delivering primary care.

The role of nurse practitioners should grow as our health system moves toward the team-oriented, patient-centered care approaches — the foundation of post-Affordable Care Act healthcare delivery. Often referred to as the patient-centered medical home (PCMH), this coordinated model emphasizes a critical shift to staying well, not just getting better.

In addition, care for higher-risk patients with chronic needs, who account for so much of our overall healthcare spending, is better managed. In states that have lifted restrictions on nurse practitioners, early data show a reduction in ER admission rates, improvements in residents’ health status and increased patient satisfaction.

The time has come for the Massachusetts legislature to pass House Bill 1996/Senate Bill 1207. The bills, which draw upon guidelines developed by the Institute of Medicine, would remove barriers preventing nurse practitioners and certified registered nurse anesthetists from practicing to the full extent of their training. The bill also ensures that Massachusetts can meet workforce demands, address gaps in access to care and adopt new care models tied to healthcare delivery and payment reforms.

According to the National Council of State Legislatures, of the 2,050 rural U.S. counties, 77 percent are designated as health- professional-shortage areas. Around 4,000 additional primary- care practitioners are needed to meet current rural healthcare needs. There is no single fix to meeting the health needs of rural Americans, but by elevating the role of nurse practitioners, we believe we can begin to close the gap.

Lia Spiliotes, a Cambridge Management Group (cmg625.com) partner and senior adviser, is interim chief executive officer of Community Health Programs, the Federally Qualified Health Network in Berkshire County, and serves on the board of the Massachusetts League of Community Health Centers. This piece first ran in The Berkshire Eagle.

Robert Whitcomb: Mr. Brooks finally discovers that the natives are restless

In an April 29 column by The New York Times’s David Brooks headlined “If Not Trump, What?’’ he writes that to understand Donald Trump’s GOP popularity (and by implication Bernie Sanders’s among Millennials):

“{I]t’s necessary to go out into the pain. I was surprised by Trump’s success because I’ve slipped into a bad pattern, spending large chunks of my life in the bourgeois strata — in professional circles with people with similar status and demographics to my own. It takes an act of will to rip yourself out of that and go where you feel least comfortable….’’

“….Up until now, America’s story has been some version of the rags-to-riches story, the lone individual who rises from the bottom through pluck and work. But that story isn’t working for people anymore, especially for people who think the system is rigged.’’

How little effort  much of the elite have made  to know the plus-90 percent of the nation who aren’t. You’d think that big-time journalists would try to talk more to “everyday Americans,’ at least for show. But media celebs such as Mr. Brooks are addicted to the money, privilege and ego-gratification that go with spending most of their time with the rich and/or powerful.  Meanwhile, many business/economics journalists have been fired to help maintain media outlets’ profit margins. So rigorous, data-driven coverage of socio-economic changes has declined in the media that American most look at in favor of, well, nonstop coverage of Mr. Trump’s latest insults. (I’m a former business editor.)

Mr. Brooks, et al., now seem to fear that massive social unrest is coming unless members ofthe “middle class’’ think that they will get a better deal.  (Of course, many low- and middle-income people could help their situations by, for example, avoiding having kids out of wedlock and other disorderly behavior linked to poverty. They could also vote.)

The nub of the problem:

Government data show that American economic productivity  in 1945 -1973 rose 96 percent and inflation-adjusted pay 94 percent; in 1973-2014 productivity grew 72.2 percent and inflation-adjusted pay 9.2 percent, with almost all of the growth in 1995-2002. 

This suggests that the folks owning and/or running companies have become  much less willing to share. At the same time, tax laws remain very skewed in favor of investment income over earned income. This keeps reinforcing a plutocracy based on inherited capital and privilege. The Sunday New York Times weddings section displays this crowd in all its glory.

Meanwhile, the elite’s  disinclination to share has slowed economic growth by constraining most Americans’ purchasing power.

The very rich have increasingly sequestered themselves from the poor and the middle class through, among other things, jet travel, globalization,  the Internet and gated communities. Thus they’re less likely to  see and be embarrassed by extreme divergences of wealth. Ever more large local enterprises are owned by far-away companies and/or individuals rather than by people in the communities where the companies operate. The local employees are mere numbers on a screen rather than people whom senior executives and major shareholders might awkwardly encounter on the street.

In some of the burgs where my family have lived over the past century, such as Brockton, Mass., when it was a shoe-making capital, and Duluth, Minn., an iron-ore and grain shipping port, my relatives  who were executives, factory managers and the like would encounter a wide range of the population daily, from rich to poor. Now, the descendants of these folks who have not yet drunk away the old money made in these places tend to spend six months and a day enjoying tax avoidance in Florida , and those who own and/or run largeenterprises with operations in places like Duluth and Brockton may never visit them at all.

Out of sight, out of mind.

But now there’s the glint of pitchforks in the sun. It’s too bad that the leading spokesmen for the new “populism’’ are con man Donald Trump (see: www.trumpthemovie.com) and a naïf like Bernie Sanders, who doesn’t understand the need to always encourage entrepreneurialism  to raise living standards.  As for the Clintons, all too often they act like establishment grifters.

Anyway, we need capitalism, but adjustments are long overdue.

Robert Whitcomb (rwhitcomb51@gmail.com), a former Providence Journal editorial page editor, a former International Herald Tribune finance editor and a former Wall Street Journal editor, oversees New England Diary and is a partner at Cambridge Management Group and president of Guard Dog Media, based in Boston.

Robert Whitcomb: In the Amazon jungle

 

Amazon is an impressive if rather creepy company, with its style set by its cold, “data-driven’’ founder/CEO, Jeff Bezos. An Aug. 15 New York Times piece, “Inside Amazon,’’ laid out the travails of the monopolistic and Darwinian enterprise’s white-collar workforce. Their issues have gotten more attention than the much worse Dickensian conditions of the blue-collar employees in its warehouses and the company’s relentless accumulation, like the also Orwellian Google’s, of our personal information. Amazonianism’s causes?

One is in the mirror. Americans have grown addicted to buying stuff online -- of course, the cheaper the better. They seem to want to avoid face-to-face interactions in stores -- and community engagement in general -- and Amazon’s power ensures that they’ll get low prices, at least for now (see below), even as their local stores close because of such online competition.

The preference for communicating via screens rather than person-to-person is especially common among the young, who grew up in the Internet Age. Human-resource managers have told me that young job applicants often don’t look them in the eye because in-person encounters make them anxious.

The disappearance of many well-paying jobs, and static (or worse) compensation except for top executives and investors, have encouraged consumers to seek out cheaper stuff than a few decades ago. But – irony of ironies! – Amazon and other high-tech automators have helped destroy good U.S. jobs in their “data-driven’’ mania to take full advantage of the international low-wage, cheap-goods machine.

Physical-store chains such as CVS and Home Depot are doing their bit to kill jobs --- by, for instance, installing automatic checkouts. I try to boycott stores with these machines because I know that each means the loss of another entry-level or second job for someone who needs it. This makes me feel better for a few minutes.

If Amazon’s workplace brutalities offend some consumers, they could resume shopping in their own communities and thus help employ some of their neighbors. Most won’t.

And look to Washington, where ideology and campaign contributions ensure that the Justice Department’s Antitrust Division doesn’t go after such monopolies as Amazon and Google. Until about 1980, Republican and Democratic administrations actually enforced laws against monopoly. The long disinclination to do so will hit consumers hard when Amazon, which has been undercutting other retailers to gain maximum market share, killing many brick-and-mortar competitors, suddenly jacks up prices big time.

Also consider the collapse of the private-sector union movement. If there were unions at Amazon, the Third World work environment would quickly go away. Gilded Age working conditions helped spawn the union movement in the first place. Now, management’s utter dominance has employees ready to put up with anything to keep their jobs.

Meanwhile, the “Big Data’’ revolution is turning workers into organic robots, soon to be replaced by real, inorganic robots. When every move of workers is measured for maximum productivity and profit potential, as at Amazon, kindly treatment of employees pretty much disappears. Employees are mere data points.

This process started with assembly-line and other blue-collar workers. The generally affluent types who read, say, The New York Times didn’t care that much. But turning employees into metrics is now heading rapidly up the food chain. Physicians, lawyers, tech engineers, middle managers and journalists (monitored for the number of Internet clicks their work gets) are being measured daily by senior executives who see their employees as entirely fungible and disposable.

And don’t expect the executive suite to share the riches from this speed-up with lower-level employees. The tendency for more and more of the wealth of companies to be shared by fewer and fewer people continues apace. We’re on a selfishness wave.

Amazon has created a fascinating machine for distributing goods. (Its delivery drones are next -- maybe equipped with surveillance gear?) Mike Daisey, writing in The Guardian (“Amazon’s brutal work culture will stay: bottom lines matter more than people,’’ Aug. 22), quoted comedian Louis C.K. as saying about such enterprises that “everything’s amazing and nobody’s happy’’ . Well, some are.

Anyway, most Americans seem to adore Amazon, which will repay them good and hard.

xxx

Lovely dim late-summer light today, and  leaves are falling off the plane trees from sheer exhaustion.

Robert Whitcomb (rwhitcomb51@gmail.com) is a  Providence-based editor and writer, a partner at Cambridge Management Group (cmg625.com) and a Fellow of the Pell Center, in Newport, He used to be the editorial-page editor of The Providence Journal, the finance editor of the International Herald Tribune and an editor at The Wall Street Journal, among other jobs.

Robert Whitcomb: Drawbacks of deregulation and DIY

  For years, deregulation and the Internet have been pulling us into a more decentralized and freelance economy, in which there’s wider consumer choice, albeit with stagnant pay and a decline in person-to-person service that forces us to do more tasks ourselves that were previously done by those dinosaurs called “employees’’.

Consider Uber. As I discovered when one of my daughters pulled out her iPhone a couple of years ago on a busy Manhattan street to summon an Uber driver, it’s sometimes faster to find one of these mobile freelancers than it is to find a regulated Yellow Cab in a big city.

But the cabs, being regulated, function as a public utility. They have to meet certain basic minimums of availability, cleanliness and safety that can’t be imposed on the likes of Uber, whose drivers are, of course, not obligated to provide services in the same way as cabbies. I don’t think that we want unregulated drivers to totally replace generally reliable and regulated cabbies.

Long before Uber, of course, there was the partial deregulation of the airlines. While this led initially to lower prices for many travelers, it has also made travel more chaotic and unpredictable. And deregulation, the “Hub-and-Spoke’’ system and relentless airline mergers mean that mid-size cities get shorted on flights.

While better electronics systems make planes less likely to crash these days than three decades ago, air travel itself is increasingly miserable.

In the old, tightly regulated days, figuring out airline schedules and fares was comparatively easy. Now it’s an ordeal, and conditions within airplanes are increasingly crowded and unhealthy. And as the airlines, like other businesses, seek to outsource service to computers so that they can lay off more people, addressing problems by communicating with customer-service humans gets tougher.

Then there’s the new do-it-yourself, deregulated and decentralized energy world. Consider that many affluent folks are saving money and reducing their carbon footprints by having solar panels installed on their roofs. Good in itself! But this takes business away from the utility companies, which could jeopardize the viability of the huge electric grids that utilities maintain. We’ll continue to need that grid to support modern society, with its ever-increasing supply of electronic devices.

Might not it be better if we put more focus on producing green electricity with huge solar-panel arrays and wind-turbine farms maintained by utilities that serve everyone – rich and poor?

xxx

The Obama administration has worked very hard to craft a deal with Iran to try to get it to at least postpone continued work on nuclear weapons.

But the administration’s effort will probably turn out to have been in vain. For one thing, the corrupt theocratic dictatorship that runs Iran will cheat and cheat as it evades inspections. It may receive technical help in this cheating from the likes of fellow police states Russia and China, two of the signatories to the nuclear deal, which will happily sell them militarily useful stuff.

Iran will almost certainly use the billions of dollars freed up by the ending of economic sanctions to increase its troublemaking. Iran’s regime seeks to dominate the Mideast – partly to protect and promote its fellow Shiites and partly because domination is fun and profitable for its leaders. And Tehran hasn’t really toned down its “Death to America and Israel’’ rhetoric.

Now we have made the mullahs more macho. No wonder Iran’s neighborhood is scared.

Some complain that America, as the first nuclear power, is hypocritical in trying to keep nuclear weapons out of the hands of other nations. That seeks to make an equivalence between a democratic nation like America and a dictatorship like Iran. And remember why we started our nuclear-weapons program in the first place – to defend ourselves from Germany’s mass-murdering Nazi regime, which was working hard to create an atomic bomb.

Some say that expanding trade with Iran will somehow make it kindlier. They said that about Germany before World War I and China now. Nations have other reasons besides economics to be nasty – for instance, paranoia, power for the sake of power and religion.

Robert Whitcomb (rwhitcomb51@gmail.com) oversees New England Diary. He's also a Fellow at the Pell Center, in Newport, and a partner at Cambridge Management Group (cmg625.com), a healthcare-sector consultancy. He used to be the editorial-page editor of The Providence Journal, the finance editor of the International Herald Tribune and an editor at The Wall Street Journal, among other jobs.

Robert Whitcomb: Health-care beacons, Snowden, our big river

The Connecticut River at Orford, N.H. (See item at bottom.)

Much of American health care’s future can be seen in two synergistic kinds of institutions in Rhode Island.

One is Federally Qualified Health Centers (FQHCs). These facilities, set up around America, provide a wide range of free and insurance-subsidized clinical help for millions of patients, most of them low-income. The other is Johnson & Wales University’s spanking new Center for Physician Assistant Studies.

Consider the state’s biggest FQHC organization -- Providence Community Health Centers (PCHC). Its teams of physicians and other clinicians, such as nurses and nurse practitioners, work for what is the biggest single provider of primary-care services in Providence, with more than 35,000 patients. (I toured PCHC’s immaculate Prairie Avenue campus the other week, led by Merrill Thomas, its CEO, and Jane Hayward, the Rhode Island Health Center Association’s president.)

PCHC ‘s mission, it says, is to “provide neighborhood-based high quality and accessible primary medical care to improve the health status of the residents of Providence and surrounding communities regardless of their ability to pay.’’ FQHCs play especially important roles in inner cities and impoverished rural areas, such as Appalachia, where many physicians don’t want to practice, especially because of low reimbursement and so many difficult cases involving seemingly intractable behavioral-health issues.

Expanding primary care -- especially preventive care -- is essential if America is to improve overall health outcomes that are near the bottom of the Developed World while better controlling medical costs, which are the highest.

Whatever happens with the Affordable Care Act, the U.S. population’s aging (older means sicker); the daunting complexity of our health-insurance system; the permanent exit of many well-paying jobs; emigration to the United States of low-income people, and the decline of the stable, two-resident-parent family suggest that Federally Qualified Health Centers ought to play even bigger roles.

Of course, increasing the numbers of primary-care clinicians is essential for the long-term success of these clinics. Doing just that is the Johnson & Wales Center for Physician Assistant Studies, which has a beautiful building in Providence’s Jewelry District.  George Bottomley, its director, gave  me a tour the other week.

Its 24-month master’s program addresses the need to train many more non-physician clinicians who can perform highly professionally and cost-effectively some of the tasks now performed by over-worked (if highly paid) doctors. PAs are especially useful in getting patients to make the behavioral changes needed to prevent serious illness, in part because they can generally spend more time with patients than can physicians; many of the latter are more harried than ever because of onerous electronic-health-record duties and administrative pressures to boost patient volume.

J&W notes that PAs work in integrated medical teams to “provide diagnostic, therapeutic and preventive health-care services.’’ (By the way, the differences between physician assistants and nurse practitioners mostly involve some education details. They’re very similar professions.)

With physicians as supervisors, physician assistants take patients’ histories and perform exams; order lab tests; prescribe medications; diagnose illnesses; develop treatment plans, and counsel and educate patients.

No wonder that demand for PAs is surging. Forbes.com has listed Physician Assistant Studies as the “No. 1 Best Master’s Degree for Jobs.’’ The American Academy of Physician Assistants (AAPA.org) says that “demand for physician assistants and nurse practitioners rose by more than 300 percent in the last three years.’’

We’ll need Johnson & Wales PAs in droves in coming years as, technology, demographics and new cost controls continue to transform U.S. health care for all patients, especially in primary care, in which physician assistants will be at the forefront.

xxx

Edward Snowden – as a Russian spy and/or as an arrogant but naïve narcissist-- has provided vast amounts of U.S. security information to Vladimir Putin’s police state, perhaps resulting in the death of agents working for us. And he has aided the Chinese dictatorship’s relentless cyber-warfare against America. Some hero!

xxx

Last week we cruised the gorgeous Upper Connecticut River on a pontoon boat. Because it’s by far New England’s biggest river, on it you get a sense of what Mark Twain might have felt on the Mississippi. We yakked desultorily in the soft breeze about big projects we’d do – as if we were 30 years younger than we are.

Robert Whitcomb (rwhitcomb51@gmail.com), overseer of New England  Diary, is a partner in  Cambridge Management Group (cmg625.com), a healthcare-sector consultancy, and a fellow of the Pell Center for International Relations and Public Policy.

Robert Whitcomb: Oregon points to better Medicaid

  Unsurprisingly, Rhode Island Gov. Gina Raimondo is getting pushback from interest groups against her goal of “reinventing Medicaid’’ – the federal-state program for the poor. The Ocean State’s Medicaid costs are America’s second-highest per enrollee (Alaska is first) and 60 percent higher than the national average.

Many in the nursing-home and hospital industries will fight the governor’s effort to cut costs even if it can be shown that her plan can simultaneously improve care. After all, the current version of Medicaid has been very lucrative for many in those businesses. The Affordable Care Act has brought them even more money.

As we watch her plan unfold, let’s be very skeptical when we hear lobbyists for the healthcare industry and unions asserting that reform would hurt patients. Lobbyists are adept at getting the public to conflate the economic welfare of a sector’s executives, other employees and owners with its customers’. Ambrose Bierce called politics “a strife of interests masquerading as a contest of principles.’’ Often true!

So “nonprofit’’ Lifespan, the state’s largest hospital system, has just hired eight lobbyists to work the General Assembly to defend its interests. (And beware healthcare executives’ citing their businesses’ “nonprofit’’ status. Many of these enterprises take their profit in huge executive compensation.) Some unions are also on the warpath. They worry that reform to reduce the overcharging, waste and duplication pervasive in U.S. health care might reduce the number of jobs.

But economic and demographic reality (including an aging population, widening income inequality and employers’ eliminating their workers’ group insurance) make Medicaid “reinvention’’ mandatory as more patients flood in.

Oregon provides a model of how to do it.

There, in an initiative led by former Gov. John Kitzhaber,  M.D., an emergency-room physician, the state has both improved care and controlled costs. It did so by creating 16 regional coordinated-care organizations (CCO’s). The state doesn’t pay for each service performed but gives each CCO a “global budget’’ of Medicaid funds to spend. The emphasis is on having a range of providers work with each other to create holistic treatment plans for patients that include the social determinants of health (such as access to transportation and housing quality) as well as patients’ presenting symptoms.

Oregon’s “fee for value’’ approach rewards providers for meeting performance metrics for quality and efficiency and punishes them for poor outcomes and increased costs.

Oregon CCO’s have great flexibility in spending Medicaid money. For example, they could use it to buy patients air conditioners, which may make it less likely that they’ll show up in the E.R. And Oregon CCO’s pay much attention to how behavioral and mental problems can lead to the more obviously physical manifestations of illness. After all, many in our health-care “system’’ “self-medicate’’ through smoking, drinking, drugs, eating unhealthy food and lack of exercise. You see many of these people again and again in the E.R. –wheezing from smoking and obese.

In Rhode Island, 7 percent of Medicaid beneficiaries account for two-thirds of the spending; many of these “frequent fliers’’ have mental and behavioral health problems best addressed through Oregon-style coordinated care.

Unlike the Oregon approach, the “fee for service’’ system that’s still dominant in U.S. health care encourages hospitals and clinicians to order as many expensive procedures as possible, prescribe the most expensive pills and do other things to maximize profit – and send the bills to the taxpayers, the private insurers and the patients.

But “evidence-based medicine’’ -- as opposed to “reputation-based medicine’’’ -- has helped to show that doing more procedures does not necessarily translate into better outcomes; indeed overtreatment can be lethal. I recommend Dr. H. Gilbert Welch’s book “Less Medicine/More Health’’.

Meanwhile, Oregon points the way:

Among the Oregon Medicaid reform’s achievements: a 5.7 percent drop in inpatient costs; a 21 percent drop in E.R. use (which is always very expensive), and an 11.1 percent drop in maternity costs, largely because of hospitals not performing elective early deliveries before 39 weeks of pregnancy. Thus Oregon officials assert that the state can reach its goal of saving $11 billion in Medicaid costs over 10 years.

Rhode Island can achieve similar successes.

Robert Whitcomb (rwhitcomb51@gmail.com), overseer of New England Diary, is a Providence-based editor and writer and a partner  in Cambridge Management Group (cmg625.com), a national healthcare-sector consultancy. He's also a Fellow of the Pell Center for International Relations and Public Policy.

Robert Whitcomb: Still Golden State; Medicaid reform

  While driving around Los Angeles’s vastness last week, I kept getting a déjà vu feeling, and not just because I’d been in L.A. before.

My trip reminded me of motoring in the ‘60s, even in the Northeast, with the new and still mostly uncrowded Interstates, cheap gasoline and capacious sense of freedom so that you’d think nothing of jumping into your car, be it a beat-up Chevy or a death-trap VW bug (with the gas tank over your lap), and happily drive for hours to vague destinations.

There’s lots of color in my memories, but also black and white, as in those old Perry Mason and Dragnet shows set in  ‘50’s  L.A. They and the many films noirs shot in California (e.g., The Big Sleep) recall Somerset Maugham’s calling the French Riviera a “sunny place for shady people.’’

Southern California is preposterous:  mountains covered with highly flammable brush and an earthquake-vulnerable desert made to bloom with water diverted/stolen from the Sierra.

And yet, as I GPS’ed from Pasadena and the hip neighborhoods of Silver Lake and Mount Washington across Beverly Hills and out to the farthest points in Malibu, I saw few signs that people were worried.

Lots of water is still being wasted to evaporation via sprinklers and always-uncovered swimming pools – which seem to play more of an aesthetic than an exercise or cooling-off role. A few cars have stickers with which owners laud themselves for saving water by not washing their vehicles, but most seemed recently washed. You view only a few more cactus gardens and a tad fewer fantastically green lawns than two decades ago.

The state is starting to crack down on water waste with big fines, but it can only be the beginning, assuming that the statewide drought continues.

And yet, young people, many fleeing New York’s frigid winters, sweltering summers  and astronomical rents are pouring into Los Angeles these days, drawn by the  Mediterranean climate, cheaper  and more spacious housing and a very contemporary  species of decentralized creativity. (Few have read Nathanael West’s dystopian L.A. novel, Day of the Locusts.)

They love Californians’ ingenuity, most famously in recent decades in Silicon Valley but all over the state, as well as its style, much more relaxed than the Northeast’s.

The innovative spirit seems to overcome pessimism and anxiety about drought, general environmental destruction, earthquakes and illegal aliens crossing the border from Mexico.

So California remains the Golden State, the quintessence of the American Dream.

Whether even worse drought, a big quake or a surge in gasoline prices would end car-dependent Los Angeles’s latest boom is unknowable. In any event, mass transit is being expanded. Yes, you can take light rail in the City of Angeles.

This reinvention ethos also characterizes New England, with its ‘er, vigorous climate and rocky soil. Especially in Greater Boston, the capacity to churn out inventions keeps saving our region’s economy, albeit with the occasional recession.

Of course, Southern California has a sunny climate. But we have lots of fresh water, which in the long run is even better. Still, I now think that the Golden State has enough Hollywood and Silicon Valley risk-taking inventiveness to assure its long-term prosperity.  Giant solar-powered desalinization plants on the Paramount lot?

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Kudos to Rhode Island Gov. Gina Raimondo for tackling waste in the state Medicaid program. Oregon provides a model of how to do this. Medicare is a much bigger national cost problem for America but harder to control: The old have better lobbyists than the poor.

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Rachel Held Evans’s  Washington Post piece, “Want Millennials back in the pews? Stop trying to make church ‘cool’’’ was spot-on.  Trying to maintain religion through trendy marketing is doomed.  We seek ritual that resists the gyrations of modern commercial culture.  We want the permanent and the transcendent to help maintain our sanity.

Even if we don’t believe the theology, we’ll take, say, The Book of Common Prayer over a Facebook “spirituality’’. The faster that technology and the consumer economy go, the more we need the quietly “traditional.’’

Robert Whitcomb (rwhitcomb51@gmail.com), overseer of newenglanddiary.com, is a Providence-based editor and writer, a partner in a health-care-sector consultancy, Cambridge Management Group (cmg625.com) and a Fellow of the Pell Center for International Relations and Public Policy.

Robert Whitcomb: Where we can win; childlessness; water wars

  The metastasizing Mideast chaos and violence have shown yet again the limitations of American power there. We’re backing and opposing groups in a fluctuating toxic religious, ethnic, tribal and national stew and frequently contradicting ourselves as we do.

Some neo-cons want us to go in with massive military intervention. We tried that. Now consider that the Sunni fanatics called ISIS use American weaponry captured from the Iraqi “army’’ to attack “Iraq’’ -- whatever that is -- an ally of longtime U.S. enemy Iran, which has joined in the melee against ISIS, even as Sunni Saudi Arabia fights its long-time foe and fellow dictatorship Shiite Iran in Yemen. And in Libya and Syria, the civil wars go on and on in permutations and combinations.

The U.S. must occasionally act quickly in the Mideast to rescue its compatriots and to protect the region’s only real democracy – Israel. But after all this time, we should know that the Mideast has so much confusion, fanaticism and corruption that a heavier U.S. role won’t make things better. The best we can do is to marginalize the region as much as possible, such as by reducing the importance of Mideast fossil fuel by turning more to renewable energy in America and Europe, while, yes, fracking for more gas and oil.

We must focus more on Europe, where a scary situation is much clearer. Our Mideast projects have dangerously diverted resources from countering the far greater threat to our interests posed by Vladimir Putin’s mobster Russian regime.

Now that it has seized Crimea from Ukraine and occupied a big slice of the eastern part of that large democracy, Putin’s fascist police state is firing off yet more threats to “protect’’ ethnic Russians in what he calls “The Russian World’’ (i.e., the old Soviet Empire) from bogus “persecution’’ by the majority population in the Baltic States and Poland -- NATO members and democracies. Latvia is coming under particularly hard Russian pressure now. Hitler used the same strategy against Czechoslovakia with the Sudeten Germans. It’s past time to re-energize NATO to thwart Russian aggressio

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Regarding an April 4 New York Times story headlined “No Kids for Me, Thanks’’:

My mysterious father used to say ruefully that “your friends you can pick, your family you’re stuck with.’’ He had five children.

From observing my childless friends, I’d say that contrary to an old social cliché, they are generally happier than those who have children – so far. A simple reason: They have more money, time and freedom to do what they want.

Arthur Stone, a professor of psychiatry at Stony Brook University who’s co-authored a study comparing childless adults’ happiness and those with kids told CNN: “They {parents} have higher highs. They have more joy in their lives, but also they have more stress and negative emotions as well.’’

CNN said he found “little difference" between “the life satisfaction of parents and people without kids, once other factors -- such as income, education, religion and health -- were factored out.’’ Yes, but how do you ‘’factor out’’ income? Paying for children causes a lot of anxiety.

People tend to be more self-absorbed these days, and so less enthusiastic about sacrificing so much for, say, children. But this presents a problem that some childless Baby Boomers are already experiencing: Who will take care of them when they get really old? If they think that younger friends will feel as compelled to squire them through old age as their children, they’re in Fantasyland.

xxx 

The California dream of always-green lawns in McMansion developments in the desert is being revised as drought deepens. (Probably global warming.) The land of Silicon Valley, Cal Tech and Hollywood has more than enough intellectual firepower to address the conservation challenge. (“Dehydrated water – just add water’’?) However, don’t expect many new L.A. Basin golf courses. Californians will see more cactus and less lawn. Meanwhile, places with lots of fresh water -- e.g., New England and the Pacific Northwest – may now be in a better competitive position.

Regarding Golden State water-wars, see the movie “Chinatown’’.

Robert Whitcomb  (rwhitcomb51@gmail.com) oversees New England Diary. He's a partner at Cambridge Management Group (cmg625.com), a healthcare-sector consultancy, a  Fellow at the Pell Center for International Relations and Public Policy, a former finance editor of the International Herald Tribune, a former editorial-page editor and a vice president at The Providence Journal and a former editor at The Wall Street Journal. 

Robert Whitcomb: Small-college blues

  “Sweet Briar’s planned orderly retreat starts to look more like a mad dash for the door.’’

-- Travis LaCouter, in “Sweet Briar Fails to Keep Up,’’ March 13 Philanthropy Daily

That fiscally anxious Sweet Briar College, in rural Virginia, will close demonstrates the challenges facing liberal (in the nonpolitical sense) higher education in our harsher, more competitive times.

Of course, every college has different strengths and challenges (thus avoid the promiscuously misleading U.S. News & World Report rankings); colleges can’t be compared with precision.

Sweet Briar, founded in 1901, is a women’s institution that has an outdated reputation as a finishing school for affluent young ladies who like horses. For many years it has strenuously sought out applicants from many backgrounds to benefit from the highly regarded, small-class teaching on its bucolic campus.

But it has found it increasingly difficult to compete with co-ed, larger, richer and mostly urban or suburban schools in general, let alone the eight Ivy League colleges, MIT, Stanford, Duke, the University of Chicago, Northwestern and perhaps a dozen other “brand-name’’ establishments, public (to wit, the very prestigious University of Virginia) and private. And Sweet Briar’s cutting its tuition (thus revenue) to try to stay competitive may have been a mistake.

Even elite schools say they worry about their fiscal futures because of free college courses on the Internet. But they’ll be okay: Their national name-dropping appeal will keeping drawing many students, especially from rich and powerful families. On their campuses students will cultivate the relationships that will keep them on top of the self-perpetuating American aristocracy/plutocracy.

Whatever the college, being “liberally educated’’ within an academic residential community is a strong foundation for an interesting and productive life. And while courses in, say, history and literature might not initially seem “practical,’’ if absorbed they can in fact be very useful – in developing critical thinking, clarity in expression and in dealing with life’s innumerable and often ambiguous issues. A more “vocational’’ course might teach you how to write software for social media that might get you a first or second job, but as with all techno courses, its value will swiftly shrink as new technology comes along amidst the corporate drive to maximize profits by laying off more people.

Someone broadly educated in the liberal arts (including what we used to call “general knowledge,’’ which seems scarce among too many of us) is well positioned to deal with what life unpredictably throws at us.

Students also benefit from being in a residential community from whose relationships they can draw lifelong career and emotional support.

Many argue that taking free or very cheap courses online offers the same value. Wrong! Actually being in the same room with a teacher and other students is a much richer experience in retention of learning and in developing long-term intellectual and social relationships. (And neurologists have shown that retention of material is considerably greater in reading on paper than on a computer screen.) The social atomization and superficiality associated with living online decays civil society.

None of this is to say that some liberal-arts colleges aren’t partly to blame for some of their own woes. They cost too much, in part because they hire far too many overpaid administrators. And too many offer stupid courses along the lines of “Transgendered Aesthetics in 1950’s Beat Culture,’’ etc., and country-club luxuries. And too many of them don’t demand that graduates demonstrate the sort of general knowledge that citizens of democracy should have.

Further, the silly idea pumped up by politicians and others that “everyone deserves the right to get a college degree’’ should be dumped. For plenty of people more vocationally focused post-high-school education is appropriate.

Still, for those with the desire to energetically participate as leaders in our society you can’t beat a good liberal-arts education. The decline of the small, intimate colleges that have been exemplars of this education is troubling. Many of those who think that a very specific vocational education will serve them better are likely to find their skills obsolescent in a surprisingly short time after graduation.

Robert Whitcomb (rwhitcomb51@gmail.com), overseer of these pages, is a partner at Cambridge Management Group, a health-care sector consultancy, and a Providence-based writer and editor.  He's also a Fellow of the Pell Center for International Relations and Public Policy, a  former finance editor of the International Herald Tribune and a former editorial-page editor of The Providence Journal.

Robert Whitcomb: Hospitals should be insurers, too

  This piece first ran in the Huffington Post.

Steven Brill's latest book, America's Bitter Pill: Money, Politics, Backroom Deals, and the Fight to Fix Our Broken Healthcare System, has gotten a lot of attention in large part because of Mr. Brill's vivid anecdotes about the "jalopy'' of American health care. They're memorable stories, gathered with his famous work ethic and intense curiosity, though there's a bit too much about his own deluxe heart-surgery adventures at Manhattan's very expensive New York-Presbyterian Hospital, which comprises some of the narrative glue of this book.

(I found my own open-heart surgery a couple of years ago to be tedium interspersed by fantastical hospital "chargemaster'' billing. A doctor friend told me that the bills had little connection to the reality of the final  total bill.)

Since we're all healthcare consumers, it would be nice, even in this post-literate society, if most adults read this book, to see how their money is being spent. Mr. Brill brings a lot of transparency to this all-too-opaque sector.

Mr. Brill is a rich entrepreneur and journalist and very much a member of the elite, luminaries of which he has easy access to. But he also displays strong compassion for the low- and middle-income people with whom he talks. Many of these folks have a brutal time paying for essential care (especially the unexpected kind) and navigating the obscenely complicated and contradictory U.S. healthcare "system''. His richly reported book provides a colorful, disturbing and occasionally encouraging look at our medical maze.

It's also a sort of thriller about the near-death saga of getting the Affordable Care Act enacted amidst relentless lobbying and political conflicts of interest. Then comes the Obama administration's efforts to recover from the disastrous launch of the HealthCare.gov website. Mr. Brill provides a heartening counter-example by telling us about the triumph of healthcare reform in -- perhaps surprisingly -- the Red State of Kentucky.

Most readers are at least vaguely aware of the institutionalized squalor of much Washington lobbying by some healthcare constituencies, and Steven Brill doesn't stint on telling us more about that. One recalls the famous line by Otto von Bismarck to the effect: "Like sausage-making, you don't want to see how laws are made.''

But there aren't many big surprises, except perhaps that you may find from reading this book that the profiteering by the pharmaceutical and medical-device industries -- for which the public pays much -- is even more extreme than you thought.

Meanwhile, there hasn't been nearly enough comment on his very good ideas to improve the ''system's'' egregious lack of coordination, reduce its gigantic costs and even improve medical outcomes, of all things.

In my view, his most interesting proposals are to encourage more hospital systems to get bigger (and hence to offer broader population-health care and better, most cost-efficient care of individual patients, especially the chronically ill) and to be insurance companies as well as care providers.

And in fact more and more systems have been getting into the insurance business in recent years. It may be the best way to incentivize both care coordination and cost control. Most of hospitals' and their clinicians' financial incentives to over-treat and over-test would disappear if the hospitals were also stuck with the claims costs!

Mr. Brill emphasizes what most people in the public don't seem to get: That hospitals with cost-plus "chargemaster'' billing, big operating profits and hugely compensated senior execs have driven much of the health-cost surge. That very much includes the "nonprofit'' hospitals, many of which are hugely profitable. "Nonprofit'' usually just means that things are arranged so that these enterprises don't pay most taxes.

It is the insurance companies, with relatively small profit margins, they get unfairly blamed for just about everything in U.S. health care. (Mr. Brill would also have done well to note that U.S. physicians are by far the highest paid in the world.) Hospital-insurer mergers don't mean that all independent insurers would go away. They'd still be needed (barring extension of Medicare to everybody) to cover bills from small, independent hospitals, independent physicians and some other clinicians.

Hospital system-insurer combined entities are well-positioned to collect and analyze data about patients to improve care and better allocate resources. Indeed, Mr. Brill says, the bigger the hospital system in a region, the better opportunity a system has to coordinate a patient's care in various inpatient and outpatient venues and cut costs through efficient, expense-saving "bundling'' in treating individual patients' injuries and illnesses over time. This includes treatment at the outpatient clinics that systems are increasingly establishing as the number of inpatient beds steadily declines.

Mr. Brill quotes Jeffrey Romoff, the chief executive of the big-foot University of Pittsburgh Medical Center system, which has an insurance company, on provider-payer marriages:

"All the incentives are aligned the right way. It's the beauty of being the payer and the provider at the same time. When the interests are not aligned, it's why seniors dying of cancer get chemo when they should just get hospice care.''

Obviously the hospital systems becoming insurers take on new processing costs, but think of how much money could be saved by cutting out the third-party middleman. For one big thing, the hospital-insurance combo doesn't worry about paying dividends to insurance-company shareholders or insurance execs' multimillion-dollar salaries. And the new combos might become a little more disciplined about the hospital execs' compensation.

Mr. Brill also suggests capping operating profits of hospitals (including "nonprofit'' ones) to, say, 8 percent. While he doesn't use the term "public utility'' I was reminded of the old-fashioned model of state regulators allowing about that percentage for electricity and natural-gas utilities. Maybe it's time to look at hospitals as public utilities, which they sort of are.

This doesn't address pharmaceutical and medical-device companies' astronomical profit margins, protected by Washington lobbyists who are even more effective than the insurers' and hospitals'. They drive up healthcare costs a lot. But the increased transparency and rigor in looking at the unimpressive medical outcomes associated with some heavily marketed medicines and devices will help constrain their pricing.

Mr. Brill also wants to cap salaries of hospital executives. I'm always  leery of government micro-managing internal decision-making in nongovernmental organizations -- too clunky -- but the idea should be studied.

So let's hope that state and federal regulators don't put too many roadblocks in the way of many more hospital systems becoming insurers.

Extending Medicare to everyone might be the most cost-effective reform but economic constituencies, and ideology often divorced from macro-economic realities, in Washington will prevent that, at least for the foreseeable future.

But Mr. Brill's prescriptions could help a lot. Meanwhile, let us hope that the shrinking number of paid healthcare journalists, such as Steven Brill, do what they can to disinfect a  system with all-too-often mediocre care and exorbitant costs that threaten to bankrupt America. More sunlight equals more reform.

Robert Whitcomb (rwhitcomb51@gmail.com) is a partner and senior adviser at Cambridge Management Group (cmg625.com), a healthcare-sector consultancy, a Fellow of the Pell Center for International Relations and Public Policy and overseer of newenglanddiary.com. He's a former finance editor of the International Herald Tribune, a former editor at The Wall Street Journal and former editorial-page editor at The Providence Journal.

Robert Whitcomb: The light gets brighter and cars warmer

  A New England winter’s compensations? I’m so fed up with it now that making this list took strenuous self-hypnosis.

First, of course, there’s the beauty and quiet. For brief stretches, all seems sinless, albeit with intimations of a monochromatic death. Of course, you might also hear cursing as people fight over a parking lot’s sole remaining space amidst six-foot-high piles of dirty snow.

To me, the two best winter pleasures are 1) walking at night, with a soft snow falling straight down in big fat flakes and 2) on a bright still morning right after a snowstorm, with almost blinding sunlight. My fondest memories of this season, which too many persist in calling “character-building,’’ are from living in New Hampshire in the mid and late ‘60s. The sun on the snow was an anti-depressant, especially after drab November.

A crucial aspect to enjoying a snowscape is lack of wind. That’s why you should stay away from our coastal cities, damp and exposed to the gales of offshore storms. Head inland.

Walking down a street in Boston or Providence on a winter’s day with a northwest gale is advanced masochism. I’d rather stroll on the same day in, say, Windsor, Vt. (where J.D. Salinger used to regularly eat in a diner), in the Connecticut Valley. Clean, dry and open, but with the worst of the wind blocked by the hills to the west. Very different from the narrow, clogged and frozen-slush streets of Providence and Boston, which weren’t designed for thousands of cars.

Then there’s late-winter “spring skiing’’. In the sun the air finally seems warm, the corn snow bouncy and soft and the air fragrant with wood smoke from the chimney of the base lodge. After a day on the slopes, a rich languor falls over you.

Another New England winter asset is liquid. The snowpack helps ensure that our region will have plenty of water to get through the year. New Englanders underestimate just what a valuable resource this, and how lacking it is in most of the Sunbelt. Of course, we could do much more with it, especially with hydro-electric power.

Winter also forces innovation. That may be why the Northeast continues to be America’s richest region. Consider the subway systems of Boston and New York. The Great Blizzard of 1888, which paralyzed the Northeast for weeks, helped lead Boston to create America’s first subway system, followed soon by New York. The MBTA mess from the recent blizzards should not obscure that having such a public-transit system has been a huge boon to the New England economy.

Cold winters also reduce the incidence of many diseases. Microbes prefer warmer climates. The healthier states are the colder ones, although we associate cold winters with the flu and colds.

Anyway, about now you notice that car interiors are warming up faster in the stronger sun, you hear the morning music of birds you haven’t heard for months and see that the buds on the trees are swelling as the light lengthens.

Signs of future life and warmth just as you’re getting violent. Still, all in all, this year I’d rather be in Florida about now. Actually, North Carolina would do.

Late winter reminds me of what we used to say on my cross-country running team in high school: “It feels so good when you stop.’’

xxx

In other weather news, we have Wei-Hock Soon, of the Harvard-Smithsonian Center for Astrophysics, another poster boy for the economics of “expert opinion.’’ See http://www.nytimes.com/2015/02/22/us/ties-to-corporate-cash-for-climate-change-researcher-Wei-Hock-Soon.html?hp&action=click&pgtype=Homepage&module=first-column-region&region=top-news&WT.nav=top-news

Mr. Soon preaches that our burning ever-increasing amounts of fossil fuel isn’t the main culprit in global warming. Most scientists disagree with him. But then most scientists haven’t received, as he has, $1.2 million in fossil-fuel industry funds in the last decade without disclosing it in most of his scientific papers. In the same way certain “public-policy think tanks’’ are well compensated to promote positions that support certain industries.

The Times reported that, in correspondence with his corporate funders, he called many of his papers and testimony to Congress “deliverables.’’ A deal is a deal!

Robert Whitcomb (rwhitcomb51@gmail.com), is overseer of this site and a bi-weekly contributor to The Providence Journal, where for more than two decades he had been editorial-page editor,. He's also a former financial editor of the International Herald Tribune, a former Wall Street Journal editor, a Fellow of the Pell Center for International Relations and Public Policy,  and a partner at  Cambridge Management Group (cmg625.com), a national healthcare-sector consultancy. 

Robert Whitcomb: Republicans bother to vote

‘’The people have spoken … and now they must be punished.’’

-- New York City Mayor Ed Koch’s quip after an election loss

The politicians elected yesterday to new jobs will soon be blamed for doing the same sort of things that their ousted predecessors did as they tried to mate good governance with reality and ambition/ego with idealism.

Distracted and often ignorant citizens, many of whom are usually fleeing reality at a good clip, will demand a perfection from their elected officials that they would never demand of themselves. They will also praise, or more likely blame, the politicians for everything from the weather to the economy’s gyrations. (The first is out of politicians’ control --- unless you factor in the need for us to reduce the amount of carbon dioxide we’re pumping into the air. The second has so many global variables that government’s ability to manage economic cycles remains highly constrained.)

In its existential anxiety, the “the Public’’ will continue to depend on politicians to solve all its problems. Modern electronic media, with their instant ‘’analyses’’ and search for simple, vivid narratives, heighten this dependence and the resulting anger when public/personal problems aren’t immediately fixed.

Our news media (who roughly represent the citizenry’s character flaws) intensify our tendency to pour our hopes and fears into a few people, or even just one (especially the president). Such personalization is easier than trying to understand the details of, say, public policy, economics and history, let alone science.

My sense of the sloth of those who attribute all fault and praise in a big news event to one or very few individuals came together back in 1992, when President George H.W. Bush was in effect blamed for not restoring Dade County, Fla., to its pre-Hurricane Andrew strip-mall glory within 36 hours. Then in 2005, the public blamed his son for the Hurricane Katrina New Orleans mess, although that disaster was inevitable – New Orleans was/is a very corrupt, badly managed city most of which is at sea level or below.

And now some call the complicated (scientifically and otherwise) Ebola situation President Obama’s fault. (That his father was African may inform some of the attacks against him in this….)

Meanwhile, the public takes commands from the media and politicians about how they should feel. If the preponderance of the big (and small) media say that “Americans are pessimistic’’ or ‘’optimistic,’’ then we salute and feel accordingly, whatever the unemployment rate. But not for long, since the conventional-wisdom narrative can be changed overnight and the change “go viral.’’

That’s not to say that politicians’ characters and personalities don’t count – especially in great crises --- e.g., Lincoln in the Civil War or Churchill in the summer of 1940 as Britain stood virtually alone against the Nazi onslaught. But they rarely count nearly as much as we’d like to think they do. Life is far too complicated.

Now we look forward to more gridlock in Washington because the public doesn’t know what it wants (other than more services and lower taxes). It says “government doesn’t work’’ and ensures that it doesn’t by its conflicting and rapidly changing voting -- or, especially in a mid-term election, its nonvotes. The nonvoters are always among the biggest complainers.

Democrats have particularly little excuse for whining this year. A Pew Research Center survey shows that among those who were unlikely to vote last Tuesday, 51 percent favored Democrats and 30 percent the GOP. In this matter, Republicans are harder-working: They summon the energy to take 20 minutes to vote.

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The lack of a direct long-distance rail connection between Boston’s South Station and North Station has always seemed to me ridiculous. Connecting them would make it considerably easier to move between southern and northern New England and further energize passenger rail as demographics (including a huge increase in the number of old people and a new propensity of younger people not to drive) makes public transportation ever more important.

The link should have been made at least a century ago. But the dominant New England railroads of the time – the Boston & Maine (at North Station) and the New Haven (at South Station) -- the city and the state’s couldn’t get it done, as it wasn’t done between New York’s Grand Central Station and Pennsylvania stations.

The Big Dig’s cost overruns haunt efforts to make this link. But rail projects make rich cities even richer by making them more efficient and attractive. The Big Dig made Boston more of a world city. Past gubernatorial foes Michael Dukakis, a Democrat, and Bill Weld, a Republican, recently joined to promote the link. All of New England will benefit if they succeed.

Robert Whitcomb is a Providence-based editor and writer and a partner in Cambridge Management Group (cmg625.com) a healthcare-sector consultancy. A former editorial-page editor for The Providence Journal and  a former finance editor of the International Herald Tribune, he's also a Fellow of the Pell Center for International Relations and Public Policy and oversees this site, newenglanddiary.com

Robert Whitcomb: Ignore 'inverson'; marina people; Tughill Plateau

Corporate “inversion’’ involves a previously U.S.-based company merging with a foreign one, reincorporating abroad and, by so doing, taking advantage of foreign corporate income-tax rates generally lower than ours. Many public companies are not paying anywhere near the 35 percent federal corporate income-tax rate because of assorted tax breaks; some companies pay no income tax because of loopholes. Still, all in all, our corporate rate is not competitive with our major foreign competitors’.

Some have called companies using inversion “unpatriotic.’’ I disagree. The senior executives and members of the boards of directors making these decisions are legally maximizing their and the company’s wealth in a partly capitalist system that, for all its faults, fuels innovation and prosperity for the entire country — over the long haul. Most individual taxpayers also try to optimize their tax situation.

And, as I have long argued, the corporate income tax is stupid, except for the lobbyists it enriches. It encourages maneuvers such as inversions. It sends jobs abroad. It supports a lobbying system in Washington that spawns corruption and makes the world’s most complicated tax system ever more complex and inefficient as corporations seek tax breaks from elected officials.

Anyway, in the end companies’ customers, employees and shareholders pay the corporate income tax. Companies just pass along the cost.

We need to end the corporate tax and enact a value-added (consumption-based) tax. We should also put personal earned income and capital gains on a more equal tax basis and maintain substantial estate taxes. The aim should be to help streamline and detoxify our tax system, encourage economic growth and at least mildly mitigate the growth of a permanent plutocracy based on inheritance.

* * *

Automation and information technology are now rapidly wiping out well-paying jobs. They’ve long been wiping out low-paying ones. Indeed, those automatic store checkout machines are starting to make inroads into one of the last few fallbacks for those with only a high-school education.

The line is that somehow the economy, blessed by ever-increasing productivity, will create a whole new wave of well-paying jobs to replace the ones killed. We’re still waiting.

Even upper-middle-class jobs are in peril. Consider lawyers, much of whose routine work can be done through computers and low-paid (by our standards) people, in, say, India. And medical equipment, nurse practitioners and ever-better prescription drugs will undermine physicians’ affluence.

Then there’s finance. Many college undergraduates, especially at elite institutions, career plan as if Wall Street were the only sure way to fortune. But they may be guessing wrong. Just because finance was the big thing in the last three decades doesn’t mean that it will be in the next 20. Many young people could find their Wall Street jobs as redundant as many jobs in manufacturing became in the ’70s. We tend to fight the last war.

Some futurists suggest plausibly that such service jobs as plumbers, electricians, gardeners and maids, along with home health-care and social workers and other counselors, may have the best chance of survival. In some fields, even the middle class will still demand personal service.

To reduce social disorder, will the government eventually establish a minimum income for those millions who truly can’t find work?

* * *

I just visited the gorgeous Thousand Islands, on the St. Lawrence River. We cruised for parts of two days in our host’s powerboat, which he keeps in a roofed marina in Clayton, N.Y., another one of those small Northeast towns whose downtowns seem to be regaining a bit of their old energy as big-box stores lose some allure to an aging population.

The vast majority of boats remained in their slips, rather than being taken out on the river, on a beautiful summer weekend. This can be explained in part by fuel costs but more, I think, by the marina’s social role. Most of these boat owners, whose age generally ranges from 50 to 80, primarily see the marina as their summer colony, with the boats (most with sleeping space for from two to eight people) as their summer bungalows.

During the short North Country season, they relentlessly schmooze with their neighbors and derive some meaning from endless boat maintenance. They live in a cozy waterborne village. What most of these people would not have liked back home — living cheek-by-jowl — they thrive in for a few weeks every summer.

* * *

We drove home through upstate New York’s Tughill Plateau, which has hundreds of wind turbines. The white wind turbines and the vivid green of the countryside, with its view of the Adirondacks, create a spectacular, if a bit eerie, landscape. Most of the farms are far better kept up than I remembered from years before — because of the fees paid to them by the utilities. A very green cash crop and no cash paid to the Mideast!

Robert Whitcomb (rwhitcomb51@gmail.com) oversees New England Diary. He is also a senior adviser and partner at Cambridge Management Group (www.cmg625.com), a health-care consultancy,  a former finance editor of the International Herald Tribune, a former editor at The Wall Street Journal, a former  editorial-page editor and vice president at The Providence Journal and  currently a Fellow of the Pell Center for International Relations and Public Policy.

What really is meant by 'patient engagement'?

  Cambridge Management Group (cmg625.com) senior adviser <a href="http://www.cfah.org/blog/2014/what-physicians-told-us-about-patient-engagement">Marc Pierson, M.D., had some pithy things </a>to say when he and other experts were recently interviewed by the Center for Advancing Health.

Here are some of the remarks of Dr. Pierson, who is also retired vice president for clinical information and quality for PeaceHealth's St. Joseph Medical Center, Bellingham, Wash.:

<strong> CFAH: ''Here is the CFAH definition of patient engagement: 'Actions people take to support their health and benefit from their health care.' What's missing from this definition? What would you add, subtract or word differently?''</strong> <strong> Dr. Pierson:</strong> ''....Defining {patient} engagement is very much the product of who is doing the defining. If from within health care, then the key question becomes for what or for whom is 'patient' engagement primarily intended to benefit?...I would prefer thinking of 'people' engaged in their health and health care. However, I do like that this definition recognizes that both health and health care require people's active participation...Medical care is not the same as health. Health is much more than the lack of illness...We need to incorporate more perspectives from real people and ask them what they need to become more engaged with their medical conditions, their health, and their well-being.'' <strong>CFAH: ''If a person is engaged in their health and health care, what difference does that make? To whom?''</strong>

<strong>Dr. PIERSON: </strong>"Typically, engagement is defined by health care insiders as paying attention to what you are told to do and being compliant with 'orders.' The current non-system of health care plays into this by being disconnected and difficult for people to understand or navigate....

''Health care offers technology and knowledge but is set up for the people that work inside it, not for its clients' ease, safety, or affordability. Payment for health care is based on professionals managing clients' ill health, not on engaging with people to prevent illness, create well-being, or for self-care of illnesses and chronic conditions.

''People are scared of what they are not allowed to know or understand. They don't want to be more dependent. They don't want to end up going to an emergency room. Their primary relationships are with family, friends, neighborhood, and community — not professional service providers.''

Healing a health system together

(I have been working with Cambridge Management Group.  I found this project, involving  health care in  some old mill cities and smaller communities in north-central Massachusetts surrounded by some lovely countryside,  particularly interesting.)

-- Robert Whitcomb

By Yvonne C. Acquafredda, MBA, and Lillian J. LeBlanc, MBA

Today’s healthcare organizations face increased pressure to deliver high-quality and cost-effective care. A key element in enabling them to do this is creating work environments that encourage teamwork on all levels, from board members to all employees.

The Great Place to Work Institute, which studies organizations around the globe, notes the importance of collaboration in the workplace. Great enterprises of all sizes structure their operations to encourage employee cooperation to achieve their organizations’ goals.

Fitchburg, Mass.-based Community Health Connections (CHC), a system of outpatient clinics providing medical, dental and behavioral-health services to thousands of mostly low-income residents in 20 communities, achieved an operational turnaround through a new focus on cross-functional cooperation and clearer and more consistent management.

This was accomplished in partnership with the healthcare-sector consultancy Cambridge Management Group (CMG) and the executive-search firm ZurickDavis (ZD).

CHC is a Federally Qualified Health Center (FQHC). With changing demographics and healthcare reform, such institutions play an increasingly important role in the U.S. healthcare sector. CHC’s experience has lessons for a wide range of healthcare and other organizations across America.

Established just 10 years ago, CHC grew rapidly as it responded to urgent needs to provide primary care in north-central Massachusetts. As patient volume increased, clinicians and administrators worked diligently to meet the demand. But CHC’s organizational structure and culture acted as barriers to examining and improving business processes even as clinical demands surged. By 2013, CHC found itself near receivership. As CHC board member Gregg Buckman put it, “the financial issues were staggering.” In addition, employee morale fell to an all-time low.

Would CHC collapse in the face of the demands being put on it?

Cambridge Management Group Transforms the Organization

Fortunately, CHC’s forward-thinking board recognized the broad range of issues facing the organization and contacted CMG to find ways to stop the losses and then stabilize, focus and grow the organization.

Crucial parts of the engagement that followed were to emphasize collaboration at all levels and to clarify the institution’s needs and goals.

CMG typically operates as a partner of management, providing guidance, expertise and best practices learned over the company’s three decades. As Lia Spiliotes, a CMG partner and senior adviser, explained: “We don’t do what you do; we help you do what you do better.”

However, due to the depth of the challenges at CHC, the board and CMG agreed that interim leadership was needed. Thus Ms. Spiliotes became interim CEO and her CMG colleague Kevin Ward interim CFO.

CMG brought its corporate philosophy of servant leadership to CHC, emphasizing executive approachability and openness without all the traditional boundaries of organizational hierarchy. For example, before CMG’s arrival, CHC executive offices were in an area of CHC headquarters removed from most employees and patients. The interim leadership team established its base in a former gift shop called “The Fishbowl,” in the middle of CHC’s main building. All employees were welcomed to come by.

Another example of this approach was that Ms. Spiliotes invited CHC billing people to meet with the interim leadership team, to give the latter perspective on CHC’s billing processes and present ideas for improvement.

In the initial meetings, all employees were quiet, seemingly afraid to speak up. But over time, as staffers observed, and regularly interacted with, the interim leaders, candid discussion helped to reveal several core operational challenges. One, identified by the billing team, was a communication breakdown between the clinical and billing departments, resulting in many claims being denied. Absent cross-functional teams, the communication changes needed to capture lost revenue would never have been identified.

Over the months of CMG’s leadership, through regular communication and increased collaboration, employees identified many administrative, financial and clinical concerns. Workable solutions were designed in response as the newly collaborative process led employees to feel more empowered, energized and invested in CHC’s success. ZurickDavis Leverages Collaboration for the CEO Search

As a new culture took hold, the CHC board turned considerable attention to recruiting a long-term leadership team. Sustaining CHC’s turnaround would require leaders with the same understanding of servant leadership that CMG brought, able to relate to employees at all levels and willing to invest the skills, time and energy needed to support organization-wide collaboration to achieve operational success.

So CHC’s board reached out to a trusted business partner, the executive-search firm ZurickDavis. CMG and ZD had been familiar with each other’s work for years.

In the spirit of collaboration, so much a hallmark of the CMG-ZD engagement, the latter’s staff invested considerable time to understand the needs of the organization, including requirements for new leadership. ZD went beyond standard job descriptions and the conventional executive-search process; it approached the engagement with few assumptions. It intensely interviewed several CHC board members and the interim leadership team, letting ZD come to fully understand the organization’s evolution and needs.

Armed with this information, ZD developed a profile of the ideal CEO to maintain CHC’s momentum. Through careful listening to the stakeholders, ZD recognized that certain qualities of character would be even more important than very job-specific skills. The new leader must be someone “committed to serve, unpretentious and genuine,” ZD found. He or she should possess a “naturally respectful, consultative, collaborative and accessible leadership style,” but also show “a willingness to lead decisively, to energize and inspire.”

ZD was a full partner throughout the process. According to ZurickDavis’s Ellen Mahoney, who worked closely in the search, steady openness and collaboration informed the whole process. “Everyone was transparent. We were a part of all meetings and fully utilized as a resource.”

Jeff Zegas, ZD’s chief executive officer, said that this level of cooperation and candor, especially in hiring a new leader, is crucial to any organization wishing to strengthen its culture and thus achieve and maintain operational success over the long term.

Building a Collaborative Organization: The ROI

Although CHC’s transformation is still a work in progress, outcomes show the positive impact of the CMG-ZD engagement. CHC achieved a positive fiscal 2013 cash flow (before depreciation) of nearly $190,000, compared with a negative $1.2 million for fiscal 2011. Eligibility denials involving erroneously entered insurance claims were reduced by almost 65%. And the organization enjoyed unprecedented public support for its $20 million project to build a new Fitchburg Family Health Center.

However, much still remains to be done. CHC’s board chair, Mary Giannetti, offers this advice to other organizations that need to effect profound change. “It takes commitment at all levels, but you don’t have to do it alone. Call in the experts and place trust in those you hire.” CMG co-founder Bob Harrington sums up the process at CHC: “Give employees some autonomy and expectation of accountability and you will motivate them to succeed.”

Yvonne Acquafredda has provided broad-based marketing and communications support to several companies in consumer services and healthcare. She has extensive experience in multi-site organizations. Ms. Acquafredda has a bachelor of science degree in communications from the University of Miami, a master of business administration degree from Northeastern University and a certificate in digital marketing from Rutgers University.

Lillian LeBlanc has more than 30 years of experience in the healthcare industry, assisting organizations with cultural transformation and boosting organizational effectiveness. She has worked with healthcare systems in Boston, Maine and South Florida. Ms LeBlanc holds a bachelor of science degree in economics, summa cum laude, from Boston State College and a master of business administration degree from the University of Massachusetts. She is a guest blogger for the Great Place to Work Institute, which produces Fortune’s annual list of 100 Best Places to Work For in America.

'Triple A' approach to building community health

  I chatted a while back with  a colleague, James Marcus (Marc) Pierson, M.D., a Cambridge Management Group (cmg625.com) 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). WAHA 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. He's a very practical (and mostly behind-the-scenes) reformer, whose recommendations would be helpful anywhere in the country.

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.

-- Robert Whitcomb

Hospital luminary Dr. Daley speaks out on patient safety

Cambridge Management Group Senior Adviser Jennifer Daley, M.D., has held senior executive positions at Tenet Healthcare, Partners Community Healthcare and the University of Massachusetts Memorial Medical Center. She was director of the Center for Health Systems Design and Evaluation at Massachusetts General Hospital/Partners HealthCare, Boston; co-chair and director of research for the National Surgical Quality Improvement Program at the U.S. Department of Veterans Affairs, and vice president and medical director for health-care quality at Beth Israel Deaconess Hospital, Boston. We chatted with her the other day about various things and put it on the Cambridge Management Group site (cmg625.com) but I (Robert Whitcomb) thought that with hospitals so much in the news, it would be good to run it here, too. She focused on hospital-patient safety, on which she is a nationally recognized authority, and referenced the Department of Veterans Affairs situation too.

Dr. Daley said that while there have been heartening “inroads’’ in this area, much more needs to be done to prevent potentially lethal problems, especially avoidable hospital-acquired infections such as bloodstream infections, urinary-tract infections, surgical-wound infections, sepsis and pneumonia acquired from being on a ventilator. We also discussed how inadequate cross-checking by doctors and nurses can lead to perilous drug mistakes, such as with chemotherapy and anti-coagulants.

She said that not enough hospitals follow the protocols needed to dramatically reduce patient-safety issues. “Multidisciplinary groups’’ of physicians and nurses must rally around efforts in hospitals to address these problems. Tools include check-off lists and mandatory frequent repetition of oral questions: e.g., asking doctors “Have you washed your hands’’ and “Are we about to do surgery on the right side?’ ’ and asking patients “What are your allergic to? What’s your date of birth?” (Patient-ID error, of course, can lead to disaster.) And patients and their families, she said, must be further empowered to monitor their treatment and speak up when they sense that something might be wrong. She noted that particularly problematical times are when patients are “handed off’’ to other physicians and nurses during shift changes, when crucial information might fall between the boards.

She observed, meanwhile, that “The Baby Boomers {whose rapidly aging ranks are now flooding into the acute-care system} are more active in monitoring their own care’’ than older people (the “Silent Generation’’), with younger patients (heavy-laden with electronic communication devices useful in communicating with health-care providers) presumably to be even more involved in this ever-more connected world. But while patients, as they are admitted into hospitals, receive printed and oral information about their rights, all too often they are too sick and/or exhausted to fully understand this information. Thus Dr. Daley suggested that patients’ family members and other caregivers be given stronger encouragement to “speak up” and ask questions.

A major problem is that “you often don’t have the bench strength’’ of doctors, nurses and administrators in many hospitals, especially smaller community institutions, compared to academic medical centers, to ensure that more rigorous patient-safety protocols are quickly established, implemented and improved over time.

Dr. Daley said that the “Joint Commission has taken the lead’’ in patient-safety goal setting. That has helped bring along smaller hospitals. The commission, after all, has the sword of certification revocation to get their attention. She also singled out for praise the National Patient Safety Foundation and the American Medical Association.

And, she emphasized, mistakes must be brought out into the open so that providers can understand and prevent their repetition. “Everyone must be transparent about errors.’’

What other powerful weapons do patient-safety advocates have besides moral duty, the fear of license revocation and litigation?

Dr. Daley noted that, payers, most notably the Centers for Medicare and Medicaid Services, are beginning to withhold payments from hospitals with bad outcomes.

Still, the prospect of declining insurance reimbursements because of health-insurance reform and other factors may discourage many hospital senior executives from spending more, mostly on personnel and new, safer technologies, to reduce patient-care errors. They want to protect their institutions’ operating margins.

So, as Dr. Daley said, patient-safety advocates must frequently remind them that the (not very) long-term costs of failing to implement stronger patient-safety measures could be much larger than the short-term expenses of imposing more rigorous patient-safety protocols. After all, hospital-acquired illnesses and injuries do cause life-threatening illnesses and injuries.

Dr. Daley told of how at one hospital, the CFO and his colleagues were shown pictures of infected bed sores that could have been easily prevented by oversight and check-off lists “They quickly changed their minds about the short-term cost being more than worth it.’’

In any event, she noted rather drolly that new medications, technology and health-system organizational changes make it easier to keep patients out of the hospital, offsetting to some extent the expected flood of hospital-bound aging Baby Boomers. The less time that they spend in the hospital, of course, the less likely they are to get infections and other avoidable errors.

Finally, we asked her what she thought of the care-delay-and-coverup scandal at some Department of Veterans Affairs hospitals, with which she is very familiar. (See above.)

“I’m mad,’’ she said, noting “a kind of Civil Service mentality’’ that seems to imply to some incompetent VA managers that “You can’t fire me.’’ She noted that legislation in Congress would help address that problem by making it easier to dismiss problematic senior personnel. And she said the VA system clearly needs many more primary-care doctors – and higher pay for them and those running the hospitals.