A smoke-making machine: My Don Berwick & his CMS Nomination

Twenty years ago, when my son was a toddler, my wife and I brought him with us to the National Forum of the Institute for Healthcare Improvement (IHI). He had a cold at the time, but was otherwise fine. As we checked into our hotel room, we saw Dr. Don Berwick, who was entering his own room next door. He said we could call him, even in the middle of the night, if needed, to come and take a look at our son. The gesture was doubly generous because no doctor can cure a cold; the visit would be for the purpose of reassuring us young parents. My son slept peacefully, so we didn't need to take up the offer of this internationally known pediatrician to make an unpaid house call.

Senators Orrin Hatch, Mike Enzi and 40 other Republican U.S. senators sent a letter to President Obama on March 3, asking the president to withdraw the nomination of Dr. Don Berwick as head of the Center for Medicare and Medicaid Services (CMS).

The letter cites four reasons. One is Don’s "lack of experience managing an organization as large and complex as CMS." CMS is the largest organization in the world, so only people who have already led CMS could have that prior experience.

The letter criticizes the President's nomination as "abrupt and unilateral." The Republican legislators' recent habit, of refusing to even formally debate many congressional matters via the filibuster, makes "unilateral" an example of the pot calling the kettle black.

Third, the letter cites Don's past record of "controversial statements." The most loudly voiced (though utterly ungrounded) Republican concern has been to "death panels." Don's father, himself a doctor, died in a nursing home. Don has long pushed hard to make treatment at the end of life – which some call "death by intensive care" – far more humane, via his leadership of the nonprofit Institute for Healthcare Improvement. Don has certainly made controversial statements over his long career in the midst of efforts to greatly change our healthcare system.

The final stated reason in the letter is Don's "lack of experience in the areas of health plan operations and insurance regulation." Before founding IHI, Don led a unit in a large pioneering health maintenance organization (HMO) that was really about health maintenance: Harvard Community Health Plan. (I'm proud to have worked in a sister unit there at the time.) Perhaps Don does not have experience in insurance regulation; I don't know.

Thus, these senators seem to be asking the President to bilaterally nominate someone who led CMS in the past, who has not made controversial statements. No such person exists, of course.

We have to assume that the senators made as compelling a case as they could. But there's no smoking gun here. There is smoke, however: the fact that so many senators agree is itself newsworthy. Well, where there's smoke, as they say, there's a smoke-making machine.

That machine has been quite busy lately. I hope that the President will use his training as a law professor to see the true crux of the senators' objections. Since the stated reasons in the letter aren't genuine, there must be some other reasons. My hunch is that these senators think Don has been, or will be, too effective. And that they must win at all costs, even at the costs of logic, and at the cost of depriving more than 30 million Americans of health insurance.

Read a story about President Obama's personal commitment to health care reform.

Be brave anyway: Marcelas and Tiffany Owens and the Patient Protection and Affordable Care Act

Here's what I imagine the late Tiffany Owens would say today to her 11-year-old son Marcelas, who was beside Pres. Obama at the signing of the healthcare reform bill:

To my beautiful young man Marcelas,

I'm so proud of you! Thank you so much for being brave in speaking for me to all those important men and women. I wish I could be with you.

A lot of people have been yelling at you on TV and blogs. Try not to let that bother you. When you stand up for something you believe in like you've been doing, people on the other side can get mad, especially if you're effective. Maybe, like they say, I could have done things that might have prevented my health from getting so bad, but maybe not. I don't know enough about pulmonary hypertension to know. I'm not sure anyone does. And that misses the point, anyway. The point is that sick people should still be able to be taken care of by doctors and nurses, even if they lost their job, and don't have health insurance anymore. That's what you told all those people, and that's exactly what I wanted you to tell them.

People won't always listen to you as much as they did about this. But you should still speak your mind, with respect. And, of course, you may well never get to the White House again! Don't expect that you'll always be rewarded for being brave – but be brave anyway.

There are lots of people here with stories like mine – 45,000 every year, who died because they didn't have health insurance. You helped to speak for them, too. And you helped to save the lives of lots of people like them, from now on, because of the new law.

I miss you so much, Marcelas! Give a big hug to your Grandma, and do what she tells you.

Much love,

Your mother

Advice: Remember Tiffany Owens.

Read another story.

Wracked with worry: Loss of insurance for a cancer patient

Natoma Canfield is a 50-year-old cancer survivor, a cleaning lady from Medina, Ohio. She had written the White House in late December about her inability to afford insurance.

 Natoma's premiums had risen 25% in 2009. She had paid $6,700 in premiums in 2009, and more in copayments, and yet received less than $1,000 in insurance benefits. In light of that, and the likely rise of 40% in her premiums in 2010, she had dropped her policy.

White House officials had reached out to her last week and asked her to introduce Pres. Obama to the stage at a speech today promoting health reform. But days after the White House made the offer for the introductory slot, Natoma collapsed. Taken to an emergency room for tests, she was diagnosed with leukemia, and hospitalized.
"The reason Natoma is not here today is that she's lying in a hospital bed, suddenly faced with this emergency - suddenly thrust into a fight for her life. She expects to face a month or more of aggressive chemotherapy. And she is wracked with worry not only about her illness but about the cost of the tests and treatments she will surely need to beat it," Obama declared.

Advice: Consider if the same thing could happen to a friend with cancer, as you make up your mind on health insurance reform.

Read a story about a loss of insurance. Thanks to David Herszenhorn for the source story in today's New York Times, and Sam Stein in today's Huffington Post.

The genie I dreamt of: A very good year for public health

On Dec. 31, 2008, imagine that a genie told you that in a year's time, it would be more likely than not that people seeking health insurance would soon receive insurance even if they had a serious pre-existing condition. And that 31,000,000 more Americans would soon have health insurance. And that in the meantime, if someone was laid off and at risk of losing the insurance they had through their employer, they would be able to keep that COBRA coverage for a much longer period. And that this would be produced via the leadership of an African-American president, without Teddy Kennedy playing a major role.

You would have thought, I'm dreaming of that genie.

Voila! As the Zionists said, If you will it, it is no dream.

Happy New Year!

He's the guy with the medical degree: Obama's vision of government's role on treatment options

President Obama outlined his vision for the healthcare system in an interview with Andrew Leonhardt, published in the New York Times Magazine:

Consumers have gotten more active in their own treatments in a way that's very useful.  That should continue to be encouraged, to the extent that we can provide consumers with more information about their own well-being.

When it comes to medical care, I know how to ask good questions of my doctor.  But ultimately, he's the guy with the medical degree.  If my doctor tells me, You know what, you’ve got such-and-such and you need to take such-and-such, I don't go around arguing with him or go online to see if I can find a better opinion than his.

And so, in that sense, there's always going to be an asymmetry of information between patient and provider.  And part of what I think government can do effectively is to be an honest broker in assessing and evaluating treatment options.  And certainly that's true when it comes to Medicare and Medicaid, where the taxpayers are footing the bill and we have an obligation to get those costs under control.  

When Peter Orszag and I talk about the importance of using comparative effectiveness studies as a way of reining in costs, that’s not an attempt to micromanage the doctor-patient relationship.  It is an attempt to say to patients, you know what, we've looked at some objective studies out here, people who know about this stuff, concluding that the blue pill, which costs half as much as the red pill, is just as effective, and you might want to go ahead and get the blue one.  And if a provider is pushing the red one on you, then you should at least ask some important questions.  

Thanks to Andrew Leonhardt for the source article in the NY Times Magazine.

One job and one accident away: Universal health insurance

Many Americans are one job and one accident away from financial ruin. That's one of the reasons why universal health insurance is so important.

Starla Darling is a young mother who lost her job, and her health insurance, with the closure of the cookie factory she'd worked at for eight years. Pregnant at the time, an emergency C-section left her with an unpayable bill for $17,000.

Several times, Barack Obama’s mother, Ann Dunham, would lose her insurance coverage for her cancer treatment when she switched jobs. Desperately ill, she had to grapple with insurers while she lay in bed to make them pay for her treatment.

David Tallman of Atlanta, who was born with a congenital heart condition and now has a degenerative eye condition, is one of many people who have had to make career choices that are based on the need to maintain medical insurance.

Advice: Vigorously support universal health insurance.

It's our heads under the knife: Comparative effectiveness research on treatment outcomes

I'm in training again toward an ambitious personal fitness goal, and it feels good. That's a real change from a few months back, when I had to stop jogging, biking and rowing because of a nasal condition. Here's the story:

Feeling congested all the time, I saw my primary care doctor. He referred me to an ear-nose-throat (ENT) surgeon for a consultation. The ENT surgeon examined me, and suggested – surprise! – surgery. (Indeed, Jack Fowler of the Foundation for Informed Medical Decision Making says surgeons recommend surgery in most of their consultations.)

I found and read a book on the treatment options for this condition, written by a surgeon who has widely performed this operation. To my surprise, I learned that he has started generally advising patients against this operation. I looked on the Internet to find the comments of patients who had had the surgery, and learned that many patients needed the operation again a few years later. Others reported that their recuperation had been particularly uncomfortable.

Luckily, I learned that an alternative to surgery was available: a steroidal inhaled spray, which has eliminated the congestion. It seems that I don't need surgery.

So now it's springtime, and I can train again, and breathe deep of the fresh air. And there's the fresh air of a new presidential administration. A thousand flowers, and a thousand legislative bills, are blooming.

One big bill would fund and publicize comparative effectiveness research on treatment options. Pres. Obama said that government should serve as an honest broker in helping people assess and evaluate treatment options. As he told interviewer David Leonhardt in Sunday's New York Times Magazine, "[it's] not an attempt to micromanage the doctor-patient relationship. It is an attempt to say to patients, we've looked at some objective studies, people who know about this stuff, concluding that the blue pill, which costs half as much as the red pill, is just as effective, and you might want to go ahead and get the blue one. And if a provider is pushing the red one on you, then you should at least ask some important questions….You have to have some independent group that can give you guidance."

Yes. For the septoplasty et al that I was considering, it would have been helpful to know what fraction of these surgical patients would recommend the surgery to a friend, how many needed the surgery repeated, how uncomfortable the recuperation was, how they rated the long-term improvement in how they felt, and how dangerous it was. The treatment decision is about the clinical quality as patients define it – not as it's usually defined by clinical outcomes researchers.

I hope that the $1.1 billion to be spent very soon on comparative effectiveness research will be spent on outcomes as patients define them. It's our heads that are under the knife…

In buying a car, I first look at Consumer Reports. This esteemed nonprofit routinely surveys car owners and portrays their findings on key dimensions of the cars' quality. We need something similar so that we can become smart buyers of our own healthcare.

Advice: Read widely about treatment options before you make a decision.

Read another story on a treatment decision.

Beginner's Luck & the Darlin' Spector of Universal Health Care: Obama's First Hundred Days

Today was Barack Obama's 100th day as president, giving us wags an irresistible chance to bloviate.

Are you healthier than you were on January 19? Probably not. Will you be healthier in the future, based on the last 100 days? Probably so, though not for the reasons you think.

Pres. Obama chose a guy from Scranton, Pennsylvania as his vice president. Joe Biden had been commuting home from Washington DC on the train, sharing seats with passengers he came to know well – like Sen. Arlen Spector of Pennsylvania. Biden influenced Spector's decision to change his party affiliation, giving the Democrats a nearly filibuster-proof majority in the US Senate. And it significantly strengthens the chance of passage of legislation favored by Pres. Obama like the coming universal health care bill.

Today the Senate voted by 53-43 to accept the president's budget, which includes funding for universal insurance. Sen. Spector, along with all the other Republicans, voted No. Presumably the newly Democratic Sen. Spector will vote Yes in the future, adding a critically important vote to the slim majority for the very controversial universal health insurance bill, forthcoming by October.

The conservative Democrats who voted against the budget because of what they saw as its excessive funding will likely insist on cost controls in the future universal health insurance bill, according to today's NY Times. Electronic medical records are being touted for this purpose for their role in limiting costs. For example, an EMR might reveal to a doctor that an expensive test like an X-ray or CT scan has already been performed, saving costs and time in the hospital. Or the legibility of the EMR's typed doctors' orders and progress notes might prevent costly errors. Or the automatic reminders generated by the EMR might lead to the earlier detection and cheaper treatment of cancer. Of course, in addition to these financial benefits of the EMR are their savings of lives and suffering: fewer days in the hospital, invasive tests that need not be performed, less chemotherapy, etc.

Obama was lucky to have Sen. Spector become a Democrat. Arguably, he created his own luck by choosing the guy from Scranton as a vice president. Either way, the result is a higher chance of passage of universal health insurance, and of substantial financial support for the widespread use of electronic medical records.

The result, ultimately, in your life: you're more likely to get an automatic reminder from your doctor about your next appointment. When you call your doctor's medical practice at night and get a covering doctor on call, that doctor is more likely to have electronic access to your medical record, and to give you better advice. When you're in the hospital, the computer will be more likely to intercept would-be overdoses and wrong drugs.

And, if you’re one of the 50 million Americans who don't have health insurance now, you'll be more likely to get coverage, and health care, based on Obama's decisions, and luck, during the last 100 days.

These likely future improvements of broader health insurance and broadened use of EMRs add to those in Obama's first month.

All in all, not a bad start in improving public health.

While she lay in bed: Insurance denials for pre-existing conditions

"My mother died very suddenly and very young," her adult son told AARP Bulletin last fall.

Ann Dunham died in 1995 at age 52 after working as a consultant for the U.S. Agency for International Development, the Ford Foundation and Women's World Banking. She taught her son an important lesson about access to health care. "She'd go from contract to contract and would be able to buy health insurance [only] when she got a new contract," her son said. "When she got sick, she had just signed up for a new job, a new contract, and she had a lot of arguments of whether this was a pre-existing condition of which she had no knowledge whatsoever….As someone who watched my mother argue with insurance companies while she lay in bed dying of cancer, I will make sure those companies stop discriminating against those who are sick and who need care the most."

This is more than wishful thinking on the son's part, as he is now president of the United States – Barack Obama. As he said frequently during the presidential campaign, "These are not abstractions for me."

Advice: Fight for health insurance for all.

Read a story about a pre-existing condition.

Thanks to Jim Toedtman for the source article in the March issue of the AARP Bulletin.

Deamonte, Barack, and Valentine's Day

The first month of the Obama Administration is nearly complete, and it has been a great month for public health, with four big accomplishments.

1.Four million (or 11 million, depending on how you count it) more poor children will have health insurance, thanks to the expansion of the SCHIP program. That will save many children’s lives, ending disgraces like the death of Deamonte Driver, who died from the lack of dental and medical care.

2.More doctors will use electronic medical records (EMRs). As of now, the stimulus bill will provide $16 billion (in the Senate bill) to $17 billion (in the House bill) in incentives for Medicaid and Medicare providers to adopt health information technology, according to a comparison appearing in the online Wall St. Journal on Feb. 10. There are many likely benefits, depending on the technology. One likely result is to make test results more immediately accessible to doctors, speeding their diagnoses and shortening patients' suffering, among many other benefits. In my own case, the electronic availability of an MRI enabled my ENT doctor to promptly provide me a diagnosis and a prescription. That saved me weeks of misery until another MRI could be done (and a saving to my insurer, since the test only needed to be done once).


3.The extension of unemployment benefits will add some peace of mind for many newly laid-off workers. Reducing that stress should improve mental and physical health for many people.

4. Single working mothers, many living in or near poverty with their children, will get higher wages because of the passage of the Lilly Ledbetter Act to reduce wage discrimination. Poverty is the biggest risk factor for poor health, so higher wages will improve health for poor and near-poor families.

Advice: Be glad that our President is putting our money where his heart is.

The inauguration of Pres. Obama: A new era of responsibility - aleinu

In his inaugural speech, the President called on us to "begin again the work of remaking America." He later commented,

"What is required of us now is a new era of responsibility – a recognition, on the part of every American, that we have duties to ourselves, our nation, and the world, duties that we do not grudgingly accept but rather seize gladly, firm in the knowledge that there is nothing so satisfying to the spirit, so defining of our character, than giving our all to a difficult task."

I've been giving my all to this difficult task, as have many readers. Now, in our healthcare and patient safety realm, there is both an encouraging early sign and a special sense of urgency.

Encouragingly, in the economic stimulus package, the version being considered by the U.S. House of Representatives includes $20 billion for health information technology. The President has called for making electronic medical records widely available to make our healthcare safer and less expensive.

Sen. Teddy Kennedy experienced a seizure during his lunch with Pres. Obama. Kennedy is terminally ill with brain cancer, and he has focused the rest of his life on achieving national health insurance. This underlines our sense of urgency: the time is now. As Rabbi Hillel said, "If not now, when?"

Indeed, many Jewish services end with the song Aleinu ("it is our duty," or literally, "it’s on us"). We can make that our personal closing benediction to the inauguration of our Community Organizer in Chief.

Advice: Host a house meeting on health care reform, and summarize the story for www.change.gov

Read another story from a speech by Barack Obama.

A state senator named Barack Obama: Disclosure of hospital infection rates

A night-shift nurse slipped into Jeanine Thomas' hospital room and whispered, "I don't know how you're taking this so well. If I were you, I'd be curled up in a ball crying."
The remark mystified Jeanine. She'd had ankle surgery, and yes, there had been complications. But she thought she was recovering. Was there something she didn't know?

In November 2000, Jeanine, then a 45-year-old antiques dealer, had slipped on ice and shattered her left ankle outside her suburban Chicago home. But days after surgery at her local hospital, the skin surrounding the incisions turned black, and her body swelled. Doctors wanted to amputate, but Jeanine, an avid tennis player, refused to let them.

Then, a friend told her about her mother's battle with MRSA, an antibiotic-resistant germ. Their symptoms matched. Jeanine confronted a doctor and learned the truth: She, too, had MRSA. Only now did the nurse's comment make sense.

Jeanine asked doctors how many people get MRSA. She was met by silence. "That's when I knew ― a light bulb went on in my head," she says. "They don't want anyone to know about this."

Jeanine epitomizes a revolt in health care. A growing number of consumer advocates ― many bound by ordeals with MRSA, or methicillin-resistant Staphylococcus aureus ― have vowed that if the U.S. hospital system will not heal itself, they will do it.
Five years ago, not a single state forced hospitals to reveal how many patients contracted infections while under their care. Now 25 states have some form of "report card" disclosure that can make hospitals more accountable.

After her ankle healed enough that she could walk, Jeanine cobbled together bits and pieces of information about a germ that few seemed to know about.

In 2003, she helped muster support for a bill requiring Illinois hospitals to disclose infection rates. A state senator named Barack Obama co-sponsored the legislation, which passed that year.

Thanks to Helen Haskell, and Seattle Times reporters Michael Berens and Ken Armstrong for the source story.

Dear Mr. President-Elect: Patient Safety Legislation

President-Elect Barack Obama
The White House
1600 Pennsylvania Ave., NW
Washington, DC 20500-0001

Dear Mr. President-Elect,

The Consumer Health Quality Council is a unique grassroots organization. The Council consists of individual consumers who have experienced poor quality care, either directly or through loved ones, and who are motivated by their experiences to advocate for better quality care for all residents of Massachusetts.

The Council would like to advocate for certain provisions that we strongly hope to see in the new administration’s healthcare agenda. These provisions became state law in Massachusetts after we advocated for healthcare quality improvement legislation during the most recent session of the Massachusetts legislature. We chose the following areas of focus based on our experiences: reducing the rates of healthcare-associated infections and other serious preventable errors, promoting consumer empowerment, and improving patient and provider partnerships and communication. The following provisions are now law in Massachusetts:

1. Hospitals will no longer be reimbursed for care associated with serious preventable errors;
2. Hospitals are required to establish rapid response methods to allow for immediate assistance if a patient is deteriorating;
3. Hospitals must set up patient and family advisory councils; and
4. The Department of Public Health will publicly report hospital-specific rates of healthcare-associated infections and serious reportable events.

We are hopeful that quality improvement and cost containment and others will not only improve care for all residents of Massachusetts but will help to make healthcare reform a success. You can read the specific language for these provisions in the corresponding Sections 51H, 53E, and 53F of Chapter 305 of the Massachusetts General Laws here.

We urge you to emphasize the importance of access to high-quality healthcare for all Americans. Attached to this letter are several stories we have written on how medical errors have affected us, our families and caregivers, and our communities. These stories communicate the very real threat of errors happening in anyone regardless of income level, race, or educational level. We share these stories in the hope that they lead to changes in the healthcare system so that what happened to us will not happen to someone else.

Please let us know if we can provide any assistance. If you have any questions or would like any information from us, please contact Deborah Wachenheim, Health Quality Manager at Health Care For All (617-275-2902), or Ken Farbstein, President of the Consumer Health Quality Council (781-444-5525).

Mustard and relish sandwiches: Broadening health insurance coverage

From Barack Obama's More Perfect Union speech, March 18, 2008, Philadelphia, Pennsylvania:

There is a young, twenty-three year old white woman named Ashley Baia who organized for our campaign in Florence, South Carolina. She had been working to organize a mostly African-American community since the beginning of this campaign, and one day she was at a round-table discussion where everyone went around telling their story and why they were there.

And Ashley said that when she was nine years old, her mother got cancer. And because she had to miss days of work, she was let go and lost her health care. They had to file for bankruptcy, and that's when Ashley decided that she had to do something to help her mom.

She knew that food was one of their most expensive costs, and so Ashley convinced her mother that what she really liked and really wanted to eat more than anything else was mustard and relish sandwiches. Because that was the cheapest way to eat.

She did this for a year until her mom got better, and she told everyone at the round table that the reason she joined our campaign was so that she could help the millions of other children in the country who want and need to help their parents too.

Now Ashley might have made a different choice. Perhaps somebody told her along the way that the source of her mother's problems were blacks who were on welfare and too lazy to work, or Hispanics who were coming into the country illegally. But she didn't. She sought out allies in her fight against injustice.

Anyway, Ashley finishes her story and then goes around the room and asks everyone else why they're supporting the campaign. They all have different stories and reasons. Many bring up a specific issue. And finally they come to this elderly black man who's been sitting there quietly the entire time. And Ashley asks him why he's there. And he does not bring up a specific issue. He does not say health care or the economy. He does not say education or the war. He does not say that he was there because of Barack Obama. He simply says to everyone in the room, "I am here because of Ashley."

I'm here because of Ashley." By itself, that single moment of recognition between that young white girl and that old black man is not enough. It is not enough to give health care to the sick, or jobs to the jobless, or education to our children.

But it is where we start. It is where our union grows stronger. And as so many generations have come to realize over the course of the 221 years since a band of patriots signed that document in Philadelphia, that is where the perfection begins.

Advice: Vote for, and work for, a presidential candidate who will broaden health insurance coverage.

Read another story of poor access to care.