THE LIGHT AT THE END OF THE TUNNEL
We are seven months into the worst recession since 1932. We are 10 weeks into Barack Obama's presidency. And already some pundits are using an up-turn in a down market and a 60% approval rating as the end is in sight. Others believe unemployment that matches a point 24 months into Ronald Reagan's presidency, record budget deficits and the firing of a GM president as signs of another train bigger than the one we're on. President Obama spends his time building confidence that even the worst recession will end if we are prepared to change our behavior coming out of it.

Polls show a majority of Americans are ready to do just that if our political and business leaders will show the way and the adverse consequences are shared. So far Obama seems to be the only one with the lofty goals and the small sacrifices to get there. The loss of one CEO in exchange for saving what was once the nation's symbol of manufacturing process is hardly a big price to pay. A 28% deduction from adjusted gross income for charitable contributions and mortgage interest for people in higher tax brackets is hardly painful unless your political contributions are more important than saving jobs and savings. A cap on farm subsidies at $250,000 a year will not destroy the family farm or the small town - that happened through bad pricing and trade policies a long time ago. Five to ten thousand European troops in Afghanistan along with our $38-68,000 to stomp out Al Quaeda and Taliban terrorist safe-havens takes a little guts the euro's don't have.

Illustration from The New Yorker

WHY NOT TRY SOME OPTIMISM FOR A CHANGE
I broke into the Senate on the 1979-84 economic dilemma and have chosen to be optimistic about the future of this country. You and I are going to be much better off more quickly if we acknowledge we have but one President at a time and one Congress. And 535 "experts" can't make the tough decisions that need making. It falls to the majority party, in this case, the Democrats, to make a success of the President's decisions. It falls to the minority party to help where they can and call them to task where that's the appropriate course. But we are in desperate straits, and a minority which lock-steps opposition to every decision is unbelievably bad for them and for us. "Be joyful in hope, patient in affliction, faithful in prayer." Romans 12:12

MINNESOTA SENATE ELECTION RECOUNT
Al Franken came by the office last week to talk about the Senate Health, Education, Labor and Pensions (HELP) Committee on which he expects to serve. It was the day after the Minnesota district court panel ordered a final 400 absentee ballots counted and promised a final decision perhaps as early as April 10. It was also the day after Texas Republican Senator John Cornyn announced he wanted Norm Coleman to appeal not only to the Minnesota Supreme Court, but to the U.S. Supreme Court...and to consider starting a new case in federal district court, which could take years to decide or "until after WWIII." Cornyn, a former Supreme Court justice in Texas, has the chair of the National Republican Senatorial Campaign Committee that Norm Coleman wanted. He has been helping Norm raise the money needed to prosecute the recount. It is a good bet that the recount costs to the two candidates alone are approaching $20 million. Think of what WW III would cost!

TED STEVENS FREED
Attorney General Eric Holder dismissed the Justice Department's criminal suit against former U.S. Senator Ted Stevens (R-AK). Stevens had fought the prosecution and lost in a D.C. trial court last October. A few weeks later he was defeated in his re-election bid by Mark Begich in a race Begich wouldn't have won had it not been for the trial and the guilty finding. Holder said he discovered that the Justice Department prosecutors had withheld material evidence from Stevens' defense lawyers on the government's key witness.

I must say how happy I am for Ted that someone at Justice can be just. It's a well known fact that there is no way a member of Congress can get a fair trial from a District of Columbia jury. Once the judge ruled against his motion to try the case in Alaska, the game was over - except for the justice of the new Attorney General.

Since Holder's announcement, much has been written about injustice, and Alaskans are even demanding a new Senate election. The real reform that is required is in the grand jury system. Once indicted, you're behind the eight-ball. Ask any indicted high profiler without a big bank account. Prosecutors use grand juries and the people they can drag before the jury without counsel to "make their case" to the public, and to make the defense that much more difficult and expensive.

OBAMA ADMINISTRATION HEALTH LEADERSHIP
Millions of Americans are filing their federal income tax returns this week. Despite the downturn in the economy, a growing number of filers are paying more tax than expected. These are all persons who have been nominated for or applied for positions in the Obama administration. Kansas Governor Kathleen Sebelius is the latest to learn how to be more accurate in reporting income and expenses. She and her federal magistrate husband have paid $7,000 and a penalty, and she can't seem to get confirmed for HHS Secretary until the end of the April, if she does.

Perhaps more importantly to health policy reform efforts is the Center for Medicare and Medicaid (CMS) in HHS. The administrator's job may well be Nick Wolters' if the 61-year-old physician executive from Billings, MT, chooses to accept it. The position of administrator has been held by a variety of academics, academic M.D.s, policy experts and other Washington-centric health policy types for years. Nick Wolters, M.D., would be the first practicing physician and systems builder whose experience with both Medicare and Medicaid has been from the doctor-patient real-world standpoint rather than the policy world. Nick was born in Kenyon, MN, graduated Carleton College in Northfield, MN, and the University of Michigan Medical School. He has been CEO of the Billings, MT, Clinic a number of years and one of the most effective members of the Medicare Payment Advisory Commission during his six years there.

HEALTH REFORM IS A JOURNEY
Not a destination.... The Health Security Act of 1993, which we all call "Hillarycare" or President Clinton's effort at "health reform," led many to believe that health care or health system reform starts with health policy reform. It does not. The Clinton policy reform was a well-intentioned effort to summarize every good policy reform initiative in a bill that had to pass because it contained all the cost savings that were needed to pay for the president's promise of universal coverage. It was symbolized by the plastic insurance card he waived before the Congress in his 1994 State of the Union message.

Health system change can be seen in many places in America today. It's what influences senators such as Ron Wyden (D-OR) or Bob Bennett (R-UT) to believe in policy reform. They can see it any time they're home in Oregon or Utah. The same is true of Amy Klobuchar (D-MN), Max Baucus (D-MT) or Judd Gregg (R-NH) and Chuck Grassley (R-IA).

In the "good old days," senators such as Russell Long and John Breaux (D-LA), Lloyd Bentsen (D-TX), Pat Moynihan (D-NY), Jay Rockefeller (D-WV), Bob Dole (R-KS), Howard Baker, Bill Frist (R-TN), John Chafee (R-RI) and John Heinz (R-PA) believed in learning policy reform from system reform even if it didn't exist in their states.

If you do not understand the cultural nature of medical practice and the local nature of systems change, you will not understand the iterative process of health policy reform. It is imperative we get this. When the president and congressional leaders talk of "doing health reform by August 1" or "by the end of the year," THEY JUST DON'T GET IT. Health systems change occurs in some communities even though private and public payers don't recognize it and pay for it and employers only "leap frog" it.

If I wanted to develop a genuinely "American health system" in as many communities of this country as possible, I'd start by changing the way we pay physicians. In Medicare it's called Part B. If Congress does not find a way to pay American physicians for results rather than services this year, it will cost us $300 billion we shouldn't have to spend in the next 10 years - and that's to reward doctors for trillions of dollars in unnecessary medical care and hospitalization, and to penalize doctors in places such as Oregon and Utah for not wasting our resources on inappropriate, unnecessary and harmful services.

UNIVERSAL COVERAGE OR UNIVERSAL ACCESS
Another anomaly in the health policy world. We recently celebrated National Universal Coverage Week. Invented and funded by the Robert Wood Johnson Foundation, it's an annual focus on the millions of Americans who do not have health insurance. Health policy reformers have long reminded us the U.S. is the only developed nation in the world that does not guarantee its citizens access to health care through some combination of public and private insurance. The assumption is that if everyone has insurance, access is assured. IT IS NOT.

John W. Glaser has been a health care ethicist for 35 years and founded the Center for Healthcare Reform at St. Joseph's Health System in Orange, CA. He recently wrote on the "Public Conscience" of health care reform. In it he traces the moral pathology of the quest for universal coverage and argues that it keeps us from securing "a system or comprehensive national health care for everybody in the United States."

He accuses us of having a "chronic fixation at the health care program level." John's right. We have a government-subsidized program of some kind from private health insurance to Medicare and Medicaid to the CHIP to the VA for everyone. We keep on reforming these programs, but we can't assure everyone that the care they need will be there when and where they need it.

A lot of patients have turned to high deductible, limited benefit coverage, consumer-directed health insurance plans because it's all they can afford. Too late they realize they can't afford the care they need because these plans aren't designed to provide it, only lower-than-group premiums. The problem isn't just the economy, and it isn't the uninsured.

UNIVERSAL ACCESS IS A NATIONAL RESPONSIBILITY
Massachusetts is the only state committed to universal insurance coverage with a mandate that everyone own a policy. To keep the program afloat, the state will use $764 million of stimulus money for various hospital and consumer subsidy programs. What will they do for encores? They used a lot of extra federal money under Romney and Bush to launch the program. You won't get there from there.

I've watched the Washington reformers negotiate with Karen Ignani and her 1,340 member America's Health Insurance Plans (AHIP) which is, next to PHRMA, the most powerful medical industry group in the country. As long as "health reform" is universal insurance coverage, whether public or private, the industry will play profitable games with national policy makers. People will die when diverted from hospital EDs. Hospitals will be collection agencies. And everyone will be frustrated at the $2.5 trillion consequence.

ELDERLY FACE RISING MEDICAL EXPENSES
Both a recent study by Fidelity Consulting Services and an earlier study by the Employee Benefit Research Institute (EBRI) predict that a 65-year-old couple retiring this year will face something close to $650,000 in medical expenses in retirement. Much of these costs are in excess of Medicare coverage. They anticipate the costs of Medicare premiums and other cost-sharing such as co-pays and deductibles, and prescription drugs not paid by Medicare.

HEALTH INSURANCE REFORM
22 Washington DC health policy conservatives have joined in explicit opposition to Obama health policy reform. Most are from traditional conservative think tanks or health policy institutes and centers. What they have in common is opposition to national rules designed to foster informed consumer choice and competition among health insurance plans. They favor individual indemnity plans regulated at the state level funded by tax-subsidized Health Savings Accounts. They oppose "federal interference in the practice of medicine" which, for 82 years has been a proxy for no evidence-based information like national public or private research on comparative effectiveness of procedures, technology, or physicians.

Illustration from The New Yorker

WORKERS COMPENSATION INSURANCE
Each time health policy reform rises to the top of our national agenda, there is a series on workers compensation. The New York Times series on workers compensation earlier this month is the latest and worth the read. The workers compensation statutes in every state are closely tied to union efforts to improve workplace health and safety. Unlike health and safety which now has a national priority in OSHA in Labor Department, workers comp is still run at the state level because that's where the unions have always been most successful in maintaining one of the most costly anachronisms in health and disability compensation.

The first workers comp case I tried back in the 1960's taught me all I needed to know about which doctors testified to 100% disability for petitioners and which opposed or minimized disability findings. Subsequently I learned how to get disability determinations which would more than satisfy my client; and how to win labor votes in an election by improving access to the system for 50-year old car-riding cops and other public employees with chronic lower back pain or heart attacks for which work, not obesity, was the principal cause.

As a policy reformer I concluded a disease is a disease and an injury an injury and chronic lower back or congestive heart failure is what it is regardless of how/where it occurred. That's one reason I became an advocate for private health insurance coverage for all to reduce the waste inherent in some public insurance programs like workers compensation. The other reason is that the long term care system in this country desperately needs policy reform. People with a disability sustained at birth, at work, or at old age need supportive services. We need a public/private disability insurance system which everyone can purchase at a young age that pays off when a disability of any kind occurs. Thus removing the dysfunctional incentives to lie, cheat, and steal from public programs like workers comp, Medicaid and medical assistance, disability insurance, and the like.

IS IT REALLY WORTH WHAT WE HAVE TO PAY FOR IT?
In Washington the Congress is debating the president's budget. Republican Senator John Kyl of Arizona is attacking the effort to make major investments in researching the comparative effectiveness of the many new medical procedures, drugs, devices and diagnostics that pour out of the current $30 billion per year taxpayer funded NIH research pipeline and the tax-subsidized research funded by drug and device companies in major academic medical centers in this country.

Kyl's amendment would make it unlawful for Medicare and other federal health programs to refuse coverage based on comparative effectiveness analysis. This is a sponsored effort on the part of America's medical-industrial complex which likes dysfunctional medical markets because automatic diffusion of every new and iterative "innovation" to as many "beneficiaries" as possible is necessary to return the investment costs plus a minimum profit margin of 80 percent. Device manufacturers take a step beyond Kyl and would prohibit any effectiveness program from using costs as a comparative in determining comparative effectiveness.

Illustration from The New Yorker

HOSPITAL SAFETY
My parish bulletin this week announced the death of Ohadiwe Mgeni. He grew up in St. Paul where he was known as Evan Anderson and taught in Minneapolis. He died two weeks ago after an infection, which occurred during knee replacement surgery, spread through his body. Two days earlier I saw Dr. Benjamin Chaska, who was a health policy student of mine in the University of St. Thomas Health Care MBA program. Ben is chief medical officer and patient safety officer at River's Edge Hospital and Clinic in St. Peter, MN. Four years ago Ben noticed the number of "unanticipated patient deaths" at the St. Peter Hospital reached 12 (out of 600 plus annual admissions). He decided to do something about it. He enlisted the help of Dr. Don Berwick and IHS. For the last three years the death rate has been zero every year. And the hospital/clinic has 80 different patient and employee safety programs under way.

FROGS AND THE BOILING WATER
At the recent meeting of the American College of Cardiology in Orlando, FL., 340 health companies paid $6 million for exhibit space. Of that, $3 million, plus another $1 million from medical drug/device industry went to the ACC to reduce the cost of attending the conference for cardiologists (who are among the highest income specialists in the country). The Pew Charitable Trusts have funded work by Columbia University physician David Rothman and others into the issue of appearance of conflict of interest at the intersection of medical education and medical decision-making. The resistance from doctors is enormous, because the financial rewards have always been very substantial.

That's the rationale behind every politician, every corporate CEO and every professional who claims "I can't be bought," while at the same time admitting they can't live without it.

"EVERY DECISION COUNTS"
President Obama, on the challenge of being president right now: "This is not a time for a caretaker presidency." How true that is. Obama responds to implied criticism of his handling of the A.I.G. bonuses simply by saying at first," I took time to make sure I did it right." And, later, "My goal is to restore our economy and its impact on everyone adversely affected. There will be time to deal with our anger, with blame, and with retribution, after we learn to get it right and assure ourselves we've done all we can not to let it happen again."

PRESIDENT OBAMA RECRUITS JOHNNIE CARSON
The president announced that veteran Foreign Service officer Johnnie Carson will be nominated Assistant Secretary of State for Africa. Carson has been serving as National Intelligence Officer for Africa at the National Intelligence Council. I knew him as our ambassador to Uganda in 1991-94, Zimbabwe 1995-97, and Kenya 1999-2003. He was in the latter post when my high school classmate, Father John Kaiser, was murdered near Naivashu, northwest of Nairobi. Carson brought in the FBI hoping for an independent investigation and was as surprised as I when they concluded John's death was a likely suicide. Carson also served in Botswana, Mozambique and Nigeria and, more recently, at the Army War College in D.C.

NO. 1 LADIES DETECTIVE AGENCY
Speaking of Botswana, Alexander McCall Smith is bringing his world famous series of Precious Ramotswe novels to television in an HBO serialization of his nine incredibly readable and highly successful books. Jill Scott plays Madam Ramotswe, Anika Noni Rose is her "97% in the secretarial exam" assistant, and Lucian Msamati is her auto mechanic/husband J.L.B. Matekoni. Anthony Minghella and Richard Curtis write and direct the HBO series which is filmed in Botswana, airing Sunday nights at 7 p.m. CDT.

BEMIDJI STATE HOCKEY IS KING
Minnesota is called "the state of ice hockey." We have four college teams in the usually hockey-dominant 10-member WCHA, none of whom made the NCAA Final Four. But the Bemidji State University Beavers did after knocking off the No. 1 team in the nation this year - Notre Dame. Coach Tom Serratore has a team of youngsters from several countries and states, including MN, who love playing together in frigid northwestern MN. He and his kids are also likely to meet the Air Force Academy team coached by his brother Frank Serratore in the Final Four. But Bemidji is unlikely to have its application for membership in the WCHA approved this year (at a meeting in Florida, of all places) because no other college has applied and schedulers can only do even-numbered pairings.

BILL NOVELLI
...leaves an outstanding career of leadership in public relations, the capstone of which was a term as CEO of AARP. He now has a faculty appointment as Distinguished Professor of the Practice at Georgetown University's McDonough School of Business. Bill will focus on non-profit management, social responsibility and social marketing.

CONGRESSMAN JOHN KLINE WON'T DO EARMARKS
John represents Minnesota's second congressional district and is being true to his word never to seek special earmarks for constituents. This is bothering Dakota and Scott County officials who need to get in on the upcoming transportation reauthorization and are fearful they need earmarks to get around DOT and Mn/DOT transportation spending priorities. County commissioners say they respect John for his principled stand, but need him to get a piece of the pork for them. I say hurray for John, and for the effort to move transportation spending and gas tax money back to the states.

AT LONG LAST - INCOME TAX POLICY REFORM
Buried everywhere but the Financial Times is the story that President Obama tasked Paul Volcker with reforming the U.S. tax system "by reducing benefits to companies, tackling tax havens, and clawing back unpaid taxes." CBO Director Peter Orszag called it "corporate welfare, loopholes, tax evasion and tax simplicity." The timing is December 2009 and the stated goal is making up $300 billion. Let's hope the effort morphs quickly into income and wage tax overhaul just as Treasury secretary Don Regan's charge from President Reagan did in 1986.

"You have the poor with you always, you will not always have me."
"Something in me always wants to turn the way of Jesus into a way that is honorable in the eyes of the world. I always want the little way to become the big way. But Jesus' movement toward the places the world wants to move away from cannot be made into a success story....He warns us about striking off on our own: 'cut off from me, you can do nothing.' But he also promises, 'Whoever remains in me, with me in him, bears fruit in plenty. (John 15:5.) I now see clearly why action without prayer is so fruitless. It is only in and through prayer that we can become intimately connected with Jesus and find the strength to join him on his way...In prayer, we meet Christ, and in him meet human suffering. In service we meet people, and in them the suffering of Christ...When we live in an ongoing conversation with Christ and allow his Spirit to guide our lives, we will recognize him in the poor, the oppressed, the downtrodden, and will hear his cry and respond to it whenever he reveals himself...so worship becomes ministry and ministry becomes worship..." Henri J. M. Nouwen

High Performance Health Care Blog
Keep up to date with the latest trends in health care leadership and management by reading High Performance Health Care. This blog is authored by the faculty and staff of the St. Thomas health care programs. In our weekly postings we identify significant new articles in the business literature, review key concepts being taught in St. Thomas programs, report on findings from faculty research projects and summarize the many events held here on campus. This blog is written to be of use to progressive health care leaders, clinicians, policymakers and academics.

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Data mining to reduce hospital readmissions
The primary care doctor and the conflict between efficiency, professionalism and innovation
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