PCFR speakers from far and wide

  Speakers at the 2014-15 season of the Providence Committee on Foreign Relations (thepcfr.org) were:

Anders Corr, a geopolitical analyst and former Defense Department official in Afghanistan, on Chinese expansionism.

Richard George, former high National Security Agency official, on international cyber-security.

Prof. Evodio Kalteneker, on the Brazilian economy and politics.

Professor and journalist Janet Steele on democratic Indonesia.

Jennifer Yanco, a public-health expert and a director of the West Africa Research Association, on the Ebola crisis.

Australian Consul Gen. Nick Minchin, on his nation’s relations with Asia and the U.S.

Delphine Halgand, a high official of the Paris-based Reporters Without Borders, on threats to free speech and journalism. (She spoke a few days after the Charlie Hebdo massacre.)

Amir Afkhami, M.D., a psychiatrist, on dealing with mental illness in war zones, particularly the Mideast.

Military historian and retired Army Colonel Andrew Bacevich on why America should stop fighting wars in the Mideast.

Famed Canadian journalist Diane Francis on why the U.S. and Canada should consider merging.

International landscape architect Thomas Paine on making cities more humane, especially in China.

Admiral Robert Girrier, deputy chief of the U.S. Pacific Fleet, on countering Chinese expansion in the South China Sea.

Gary Hicks, deputy chief of mission in Libya at the time of the Benghazi attack and now at the Center for Strategic and International Studies on lessons for the U.S. in Libya and the future of international trade.

The new season looks exciting too. (And maybe even useful for investing decisions.)

We’re still penciling in speakers and dates, but we can say that Cuban-American businessman and civic leader Eduardo Mestre will speak on Sept. 30 about the reopening of diplomatic relations between the U.S. and the land of his birth.

Mr. Mestre is a member of the boards of the International Rescue Committee and the Cuba Study Group.

He’s also a senior adviser at Evercore and was previously vice chairman of Citigroup Global Markets and chairman of its Investment Banking Division. Before then, he headed investment banking at Salomon Smith Barney and its predecessor firms from 1995-2001 and was co-head of Salomon Brothers' mergers and acquisitions department in 1989-1995.

Skedded for Oct. 22 is Scott Shane, the New York Times reporter who wrote the new book Objective Troy, about  Anwar al-Awlaki, “the once-celebrated American imam who called for moderation after 9/11, but a man who ultimately directed his outsized talents to the mass murder of his fellow citizens’’ and was eventually killed by an American drone. Among other things, he’ll discuss the moral issues raised by the increasing use of drones.

Some of the people we have on the drafting board for the rest of the season:

A U.N. expert on international refugee crises; a journalist or diplomat who will discuss the Greek crisis; a member of the Federal Reserve Board who will discuss international financial-system challenges; a Japanese journalist to talk about that nation’s increasingly muscular regional posture; an expert on international shipping in light of the widening of the Panama Canal; a status report on Mexico; a Chinese philanthropist; a member of the Ukrainian Congress Committee; (we have been trying for some time to get a Russian official or journalist to give Moscow’s side of the war in eastern Ukraine), and the director of the Aga Khan University Media School to talk about training journalists in the Developing World

All subject to change. We frequently repeat Prime Minister Harold Macmillan’s purported response when he was asked what he most feared:

“Events, my dear boy, events.’’

Members should feel free to chime in with suggestions.

Also, we’ll strive to frequently update the PCFR Website with supplemental news and commentary on international matters that may be of interest.

Please consult www.thepcfr.org or message pcfremail@gmail.com for questions about the PCFR.

Enjoy the rest of the summer!

Robert Whitcomb, chairman

pcfremail@gmail.com

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.

'Health-equity zones' for Rhode Island

  Rhode Island is creating "health-equity zones,'' reports The Providence Journal

“Health is not possible without community. Health-equity zones give communities the resources they need to focus on creating collaborations and building health through relationships,” said state Health Director Michael Fine, M.D.

RIP, Stanley M. Aronson, M.D.: Medical leader, educator, essayist

How very, very sad  today to hear of the death of Stanley M. Aronson, M.D., at age 92 after a long battle with age and illness that did not diminish his sardonic humor, warmth and  love of life. Stan was a giant of medical education,  at Brown University and elsewhere, a distinguished leader in global public health, especially in developing nations, and an elegant, learned and delightfully idiosyncratic writer. He somehow combined joy, enthusiasm and even exuberance with a deep skepticism and  (I think) a basically tragic view of life. And then there was this Brooklyn-born raconteur's amusement   about absurd situations, including involving himself.  Stan was also a very good visual artist and a gardener (indeed, almost a farmer) and lover of music.

I knew him in  various roles we each had over the years,  but especially in our editor-writer relationship.

I  had been well aware of his distinguished career well before I became The Providence Journal's editorial-page editor, in 1992.

But it was then, at the encouragement of my wife, Nancy, that we became friends after I hired him  to do a weekly column for The Journal's Commentary pages on medicine, history, science, language and a few hundred other topics. My wife had  become a fan while reading Stan's columns in  Medicine/Health Rhode Island, the  journal of the Rhode Island Medical Journal, where she had done some art and graphics work.

I left The Journal, except as a rarely read freelance columnist, in 2013, but my successor, Edward Achorn, also long a fan of Stan's, has continued to run the columns, many of which have been reprinted in newspapers across America and Canada. Collections of his columns have comprised the contents of three books.

Stan continued to write these essays until his death:  His work ethic was the equal of  his other legendary attributes.  His work has enriched the lives of multitudes and will continue to do so. Meanwhile, his many friends will mourn him as long as they live.

Our condolences to his widow, Gale Aronson, a person of great charisma and achievement herself, and to all the rest of his family.

How resonant it is that his Jan. 19 column for The Journal was entitled "And death shall have no dominion''.

-- Robert Whitcomb

A psychiatrist to speak about war-traumatized populations

  Americans understandably are very concerned about the mental-health effects on our military of serving in such war zones as Iraq and Afghanistan, especially regarding post-traumatic stress disorder. But there's remarkably little in the U.S. media about the effects of these seemingly endless wars on the populations in those tortured places.

Thus we at the Providence Committee on Foreign Relations have invited Dr. Amir Afkhami, M.D., a psychiatrist, who will talk about  mental health in such crisis spots at our Feb. 4 meeting.  He is also an expert in the global history of public health.

Dr. Afkhami holds a joint appointment in the Departments of Psychiatry and Behavior Sciences and the Department of Global Health at the George Washington University School of Medicine and Health Sciences.  Before joining GWU in 2007, he was a lecturer in the global history of public health at Yale University. He is an adviser to the U.S. Department of State and the U.S. military on issues pertaining to public health and mental health.

5 happy and 5 unhappy ACA elements

  Ken Bottles, M.D., discusses five unhappy things and five happy things about the Affordable Care Act as congressional Republicans plan a major new assault on it.

Hospitals must help create new community networks

  Health-system markets are being pushed toward a volume vs. value-payment tipping point. This is driven by the confluence of states’ moving Medicaid and state-employee health benefits to value-based (risk) contracts, corporations’  securing national contracts for high-cost care episodes and commercial payers’ creating tiered health insurance. Successful population-health (value-payment) programs, whether fixed-price bundled services for individual patients or comprehensive services for a specific population, as with ACO’s, require action based on these insights:

• Outcomes depend on patients’ behaviors over their lifetimes. Thus, patient and family participation must be increased. Success depends on getting “upstream” of medical-care needs.

• Broad local and regional communities, not individual institutions, can best allocate resources to improve the social determinants of health.

Indeed, improving community health depends more on the interactions among the parts than on individually optimizing the parts themselves. Hospitals and health systems have a time-limited opportunity to help develop community-health networks, the backbone organizations for improving population health.

To get started, leaders of hospitals, public- and private-sector social-service organizations, payers and representatives of the broader community must first frame the discussion from a policy perspective and then map linkages across the community.

Our experience with community health networks underscores the importance of social determinants of health, teamwork within/across collaborating organizations and accepting risk within global budgets. Sustained system thinking across the community’s health assets, shared insights, and much generosity and patience from every sector are critical factors for success and flow from visionary hospital leadership and community/political leaders. Case studies from Oregon and Connecticut, among others, show what can be done.

To get started, leaders would do well to convene a perspective-and-policy-setting discussion to frame context and mutual dependencies. Complex, foundational change is emotionally and organizationally disruptive. Thus establishing a fact-driven and respectful dialogue is an essential first step. We recommend that community leaders, especially hospital leaders, convene a community conversation and use linkage mapping as way to structure the conversation for progress. Based on readiness, one or more work streams would be selected to explore and improve the interactions between the parts.

This  is a summary of an Oct. 13 presentation developed by a Cambridge Management Group team led by Marc Pierson, M.D., Annie Merkle and Bob Harrington for the Society for Healthcare Strategy & Market Development's Connections conference. Oregon State Sen. Alan Bates, D.O., provided invaluable information and insights from his work as both a primary-care physician and community/political leader enlisting colleagues in all sectors.

Film about the arts vs. Alzheimer's to be on PBS

 

Watercolor by HILDA GORENSTEIN (aka Hilgos), part of a series she did after developing Alzheimer's disease.

Note to  southeastern New England readers: This movie  discussed below will be shown at 10 p.m., Friday, Nov. 7, on Rhode Island PBS. 

I Remember Better When I Paint shows how the creative arts can enhance the quality of life for people with Alzheimer’s. The film will be shown  on public television stations nationwide during November, which is National Alzheimer’s Awareness Month in the U.S.

Narrated by Academy award-winning actress Olivia de Havilland, this international documentary includes visits to a variety of care facilities, as well as leading art museums in North America and Europe, to demonstrate how creative activities such as drawing, painting and museum visits can reawaken a sense of identity, dignity and engagement among those with severe memory impairment.

Leading doctors and neurologists explain how parts of the brain can be spared and discuss the life-enriching benefits of these new approaches. Among these experts are Dr. Robert Butler, M.D.,  founding director of the National Institutes on Aging (NIH) and a Pulitzer Prize-winning author; Dr. Samuel Gandy, M.D., of Mt. Sinai School of Medicine; Dr. Robert Green, M.D., of Brigham and Women’s Hospital and Harvard Medical School,  and Dr. Robert Stern, M.D. professor of neurology at Boston University.

Inspiring personal stories are featured, including that of Rita Hayworth, as told by her daughter, Yasmin Aga Khan, to highlight the transformative impact of art and other creative therapies and how they are changing the way we look at Alzheimer’s.

The inspiration for the film came from the artist Hilgos, who had severe memory loss. When her daughter, Berna Huebner, asked: “Mom, do you want to paint?” She unexpectedly responded, “Yes, I remember better when I paint.” Art students helped her regain a capacity for exchange and communication through painting.

The movie was written and directed by Eric Ellena and Berna Huebner, and is a French Connection Films and Hilgos Foundation production. The program is a presentation of WTTW National Productions in Chicago, and is distributed nationally by American Public Television (APT).

I have been following  the saga  of this movie for years, even before I wrote about it in an article  in a fine magazine then called Miller-McCune and now called Pacific Standard.

-- Robert Whitcomb

Community networks for transforming health care

  Video: Marc Pierson, M.D., a senior adviser at Cambridge Management Group West, sets forth a practical program for creating networks of community health workers to help transform American healthcare. Dr. Pierson, a former emergency department physician and hospital executive, has a national reputation for innovation aimed at improving care while reducing per-patient costs. He discusses how real healthcare reform must encompass far more than just the medical sector.

--- Robert Whitcomb (a colleague of Dr. Pierson)

'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

James P. Freeman: Mass. Democrats in fantasyland

“Without a doubt

When it comes to ideas about everything

King Friday XIII has them”

-- King Friday XIII, from “Making and Creating,” 1986

As Gov. Deval Patrick, the commonwealth’s veritable King Friday, prepares the dissolution of his domain, Democrats, with yeomanly purpose, searching for progressivism of yore, will soon descend upon the hills of Worcester to nominate a gubernatorial candidate. Who will play Queen Sara Saturday or Prince Tuesday to Patrick’s Friday?

In 1867 (the year Republicans held majorities over Democrats of 40-0 in the Senate and 230-10 in the House) Walt Whitman first published “O Me! O Life!.” If life is “a powerful play that goes on,” distressed Democrats may wish to control-alt-delete the last eight years of verse.

Patrick may be the most supercilious (about his abilities and policies) and super-sensitive (about criticism of his abilities and policies) public servant in modern-day Massachusetts. Given the official record, it will be interesting watching his party apply a progressive pumice to the corrosive and incorrigible government he has led.

A sampling of the governor’s ideas, leadership and management efforts: Funding at the embattled Department of Children and Families has been cut by over $100 million from fiscal 2007 to 2015 (12.4 percent). Unfunded pension liabilities have grown substantially to $23.6 billion. Government spending has increased by an average of $1 billion per year. State sales tax has increased by 25 percent. The gas tax, now pegged to inflation, will increase in perpetuity. Property taxes have risen by billions.

The once vaunted health-care exchange is left in ruins — now the worst performing in the country -- with $57 million having been spent on an unworkable Web site, with 160,000 residents being placed indefinitely on Medicaid, costing uncounted millions of dollars. Bankrupt Evergreen Solar, costing residents $50 million, “wasn’t a failure.” Welfare waste and fraud (19,000 “missing” recipients) is described as “leakage” and full of “anecdotes.” The imposition of near-martial law in the wake of last year’s marathon bombings was euphemistically called “shelter in place.”

A number of Democrat candidates have cited the following: Massachusetts has ranked in the bottom 15 states over the past decade in job creation. It has the sixth highest rate in America of drug users under the age of 18 (during an “opiate epidemic”). The commonwealth ranks 8th worst in the country for income inequality. The homeless population has grown by 8.7 percent in the last year, while rates have fallen nationally; taxpayers now spend $50 million annually to place homeless in hotels.

This has all occurred with the complicity of Democrat super-majorities in the legislature.

In polite progressive circles, however, there must be unimaginably little mention of Patrick’s “accomplishments” given the sheer puerility of them. At least former governor Michael Dukakis, the last true progressive, talked about competence. Of the five major Democrat candidates for governor, none speak about progress made because of the sheer preposterousness of the suggestion.

Today’s candidates surely must be living in the Neighborhood of Make Believe given their willful ignorance of serious matters affecting the commonwealth. Each echoes a narcissistic sentimentalism for timeless and timely liberal themes; each exhibits a certain cognitive dissonance about what is important, given the absence of addressing critical issues and proposing sensible ideas in their campaigns.

State Atty. Gen. Martha Coakley, consistently leading in primary- and general-election polling, believes that citizens should have greater “access” to community health centers. She desires expansion of “learning time” for education while lowering the costs of higher education (was Elizabeth Warren’s $347,000 salary at Harvard too high?).

State Treasurer Steven Grossman, who will “combine his progressive values and business experience,” has presided over an increase in the commonwealth’s unfunded pension liabilities while at treasury. He claims to have “revolutionized the way government operates at treasury.” He is also “fully committed” to achieving the goals of the MA Global Warming Solutions Act.

Corporate executive Joseph Avellone, M.D., is convinced “our largest challenge is and will be climate change.” Yet his “highest priority” is education.

Juliette Kayyem, former assistant secretary for the federal Department of Homeland Security, “will focus on the issues that matter most to Bay Staters.” Among them: “combat[ing] climate change” and “protect[ion] of women’s reproductive rights.”

Finally, Donald Berwick, M.D., former Obamacare administrator, also believes climate change is the “most pressing concern to the health of our planet.” He sees Massachusetts leading the charge to have 3.3 million electric vehicles on our roads by 2025.

Here is a real pressing problem: The last time a Democrat succeeded a two-term Democrat governor was November 1934 when James Michael Curly was elected after Joseph B. Ely (1931-1935), when terms were two years. It has never occurred in the modern era when terms were extended to four years in 1966.

What should be clear in 2014, regardless, is that whomever the nominee, he or she may need a magical Boomerang-Toomerang-Zoomerang to ensure the neighborhood corner office remains in control of a Democrat.

James P. Freeman is a Cape Cod-based columnist.

--30--

Dr. Pierson's 'Triple A' for health-care reform

  One of my gigs is to help out at a consultancy called Cambridge Management Group, which advises hospitals and other health-care institutions as well as physician groups. I learn the thoughts of some very interesting people. One is nationally known health-care reformer Marc Pierson. Here's the chat/interview I put together the other day and that ran on Cambridge Management 's Web site, cmg625.com.

We chatted the other day with James Marcus (Marc) Pierson, M.D., a Cambridge Management Group senior adviser. Dr. Pierson -- an internist, emergency physician and past vice president of clinical information and quality for PeaceHealth St. Joseph Medical Center, in Bellingham, Wash. -- is a major health-care reformer. His leadership in helping to create an integrated and patient-centered health-care system for Whatcom County, Wash., has received national attention.

As a leader of the Pursuing Perfection program in the county, he helped develop the community-based, patient-centric Shared Care health-record system and participated at the board level in the Whatcom Alliance for Healthcare Advancement (WAHA). <a href="http://whatcomalliance.org/ ">WAHA</a> helped lead to the recently approved Washington State Health Care Innovation Plan, which has put the power of the state government behind the many ideas arising from Whatcom County’s whole-community and patient-informed perspectives.

He told us that “the county level is the smallest appropriate geographic base for creating a coordinated-care system.’’ Whatcom County was particularly attractive for such efforts because it has attracted a lot of civic-minded and collaboration-minded physicians who “didn’t move here for the money but, among other things, for the natural beauty.’’

Dr. Pierson said that creating an integrated-care model requires first observing how the chaotic traditional “system’’ was or was not working, then trying to understand it and then writing down observations and designing changes. It was crucial to understand the inter-actions of all of the parts of the health-care system, and, crucially, to use patients’  knowledge and opinions – those too-often-neglected elements of health-care reform – in changing the individuals and institutions that serve them.

He cited the  “Triple A’’ approach:  1.)  research and analyze the needs and desires of the patient population; 2.) understand (clinically and financially) the other parts of the system (doctors, nurses, hospitals, insurers, etc.; 3.) design together one integrated health-care community in which patients’ decisions play the most important part.

With that, he said, we can build a health-care system whose treatment and payment system addresses the ever-changing needs of the whole community. “The quality of the entire system suffers,’’ he said, “when the focus is more on the individual parts and loses sight of the whole community health system. Perfect parts do not make perfect or even good systems. It is the interactions between the parts that must be designed….’’  In any event, the improve-the-parts approach is unsustainable.

Further, Dr. Pierson said, we need to move away from the “extractive financing model’’ of American health care, in which much of the savings from improving a community’s health care leaves the community, making it unavailable for reinvestment. And he touted the idea of setting targets for spending on health within a whole community, citing the success of Jonkoping, Sweden, which set a target of 8.3 percent of the local economy for health care and has had very good outcomes.

He said that his experience in the mid-'80’s as an ER doctor trying to pull together in an ad hoc fashion a variety of specialists to treat a young man badly injured in a motorcycle accident helped get Dr. Pierson thinking about systems and coordination.

This line of focused community building would ultimately lead to his campaign for integrated, community-wide care.  Along the way, he made it a point “not to ask anyone to do anything that was against their economic self-interest.’’ And he sought out the “most respected players’’ in the Whatcom health-care community to help him carry out this vision for the county. A very practical and behind-the-scenes reformer.

Given the widening income gap in the U.S., we wondered about whether only the rich would have the finest sort of individualized “concierge care’’. Somewhat to our surprise, Dr. Pierson was optimistic that the use of genomic information, personal medical devices and other advances would make “concierge care’’ available to everyone in the fullness of time, aided by the doctors, nurses, social workers and other health-care ‘’navigators’’ who will increasingly see a major part of their jobs as helping to  guide patients to the information they need as well as through the system.

It’s all part of his vision to have all of us see “medicine as a part of health and well-being.’’ The whole community, he says, owns its health and well-being and we must design our futures in that context.