Commentary from Dave Durenberger
June 17, 2009
OBAMA MOVES TO D-DAY ON HEALTH POLICY REFORM
Having spent time in Normandy commemorating the 65th anniversary of D-Day, President Obama returned to launch what appears to be a White House offensive to bring health policy reform legislation out of two committees in the Senate and three in the House. Matt Bai in New York Times Magazine informs us that the first senators elected president and vice president in nearly 50 years have deliberately allowed the legislation to develop in the Congress with minimal prodding. They have, however, built a power house congressional relations staff in the White House drawn from congressional leadership. The implication from Bai, and from other stories, is that the president intends to light the fuse this month.
WHY IS OBAMA ADVOCATING HEALTH PLAN SPECIFICS?
Presidents are not meant to work "in the weeds" of health policy reform. That's especially true of this president whose gifts are much better focused on the American people rather than the congressional process. Since blowing up Tom Daschle's leadership role, the White House hasn't found the voice it needs to fend off attacks on legislative proposals before they even become committee mark-up documents.
THE AMA
Whoever made the decision to send the president of the United States home to Chicago to spend an hour talking health reform with the American Medical Association (AMA) has done neither the president nor the rest of us any favors. The speech was more Bill Clinton than Barack Obama. Obama's gift is to give the people of America a sense of hope. Of what could be. What it would be like to live in an American health system, that played to our strengths rather than to our weaknesses. Speaking to the AMA was to play to the problem not the solution. You could tell by the applause lines.
MEDPAC
The previous week someone suggested the president endorse cutting Medicare and Medicaid spending by hundreds of billions of dollars by giving an obscure panel, the Medicare Payment Advisory Commission (MedPAC), power to set payment Medicare payment rates. That would insulate Congress from lobbying by every group whose income might be reduced.
Bad idea. I helped create the predecessors to MedPAC and served six years as a MedPAC commissioner. Congress needs to make the hard as well as the less hard decisions and MedPAC is the only resource to work well with Congress and its staff has to fight off special interests. MedPAC can work well if Congress posed the Medicare payment policy issues that should be posed. Like how best to accomplish differential payment by hospital referral region or by region of the country based on quality/cost/value results. Or specific recommendations for private Medicare health plan alternatives to the current MMA 2003 version. Or a new insurance system for long term care or a reform of financing for so-called "dual eligibles."
Payment rates will vary with the outcome indicated and the outcome achieved and rate-setting by anyone is a bad idea. Interestingly, similar provider politics plays out in the private insurance market especially in the southeast, the southwest, and the big metro east where doctors leverage both hospitals and insurance companies for payment increases regardless of performance results. Combine that with low insurance coverage in those geographies and costs get shifted to the higher quality regions and states like Hawaii, the northwest, intermountain, upper Midwest via the Medicare program. The AMA speech indicates Obama may now get this point.
WALL STREET JOURNAL CARRIES THE FIGHT TO THE HEALTH CARE REFORMERS
The editorial/opinion pages of the Journal have published every evangelist for consumer-driven health care and against reforming public financing and regulatory programs. On Monday last week the editors took on the only real hope for improving access, quality and affordability. The impossible to ignore variations in the amount of medical services and costs from one practice community to another across the country. The targets are the Dartmouth Atlas, practice variation, "organized" medicine, and "socialized medicine." Plus President Obama who uses the Atul Gawande New Yorker piece to argue for financing change.
On Tuesday Robert Pear of the New York Times picked up the story and quoted health service researchers Jack Hadley and Bob Berenson to the effect that there was "too much uncertainty" in the years of Dartmouth research on variation. By implication, Congress would be ill-advised to improve payments to high quality/low cost physicians and hospitals at the expense of the high cost/low quality care providers. The president is sticking to the facts. But financing reform that varies payment by areas of the country, even in the name of improved quality of care, is a Congressional Achilles heel.
NO DOUBT IN MY MIND
That the case for the president's appeal to the public is stronger than his influence with a Congress that thinks more highly of its own sense of the body politic than of the president's ability to influence it. No president has ever made the public case for the role that policy reform must play in bringing out the best in America's health care delivery systems. And every president who has tried major reform has failed - either to pass the reform, or to insist on a design that plays to the best America has to offer in an incredibly complex health care system. This is the golden moment and Obama the gifted leader who can help us understand what we've been missing all these years.
To quote Matt Bai: "At critical times in his young political life, and several times already in his presidency, Obama has fallen back on his gift for explanation and oratory to try to change the dynamic of a national debate...It seems likely that Obama, who has to this point focused on sophisticated legislative strategy for achieving health care reform, will at some point soon have to take his case to the public instead -- this time asking Americans not just to support an ambitious expansion of government but to accept the sacrifices necessary to do it. Only a president will make that case and only a president can."
BI-PARTISAN MAJORITY LEADERS
Tom Daschle weighs in with former Republican leaders Howard Baker (R-TN) and Bob Dole (R-KS) today with their attempt to bridge the partisan gap in health policy reform. George Mitchell (D-ME) was part of this year-old effort until he took an easier job peace-making in the Middle East. Six months ago this very well-informed (Mark McClellan and Sheila Burke staffed Baker-Dole and Chris Jennings staffed Daschle) effort might have worked. But unless someone brings Ronald Reagan and LBJ back from the dead it's difficult to see big impact even from the most statured political leaders.
The most important message in this bi-partisan leadership message is not in its policy plan recommendations, but in its "Now or never" message. Or in Reaganesque, "If not us who? If not now when?"
HEALTH REFORM IS A JOURNEY - NOT A DESTINATION
Steven A. Burd is the CEO of Safeway Foods. In a must-read piece in the June 12 Wall Street Journal, Burd informs us that the impact he has seen of health and fitness efforts at Safeway leads him to believe that "well-designed health care reform , utilizing market-based solutions, can ultimately reduce our nation's health care bill by 40 percent." Safeway targeted the causes of heart disease, cancer, diabetes, and obesity because they are responsible for 74 percent of our costs. And used a HIPAA provision permitting them to differentiate health premiums on the basis of behaviors. In Safeway the healthy behavior savings were $780 for individuals and $1,560 per family per year.
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Illustration from The Hill |
THE NEW ECONOMY
Just in the last week I've seen three signs of the post-bail-out economy. All in hospitals. President Obama suggests the Congress will find ways to expand public access to healthcare in changing Medicare payments to hospitals. He suggests they might get moving on productivity, a word poorly understood in the industry. Speaking at an event for Minnesota pediatricians, I suggested that the $500 million of our money the Twin Cities hospital industry is investing in three new children's hospitals might have been better spent on improving the health of moms and kids.
A physician being honored for 35 years as the father of innovative neonatology (and saving lives of preemies) says pediatricians were in unanimous agreement with me on this before the money-changers at the hospitals decided otherwise. Old economy. The retiring CEO of the Allina Hospitals and Clinics, in 7 years, has demonstrated how to invest in workforce productivity, invest in non-profit community benefit, and how to make money in a down economy. New economy.
This Sunday I was struck by another example of the clash between the old and new hospital economy. Articles in both Twin City papers suggested that asking the public to invest $325 million in re-routing a 130 year old railroad line in Rochester, MN to "protect" the Mayo Clinic was an unsound economic and an unproven public health and safety investment. Read article. Maybe, just maybe, the medical industry will get the message that its monopoly on the public interest in health care is coming to an end.
ARTHUR GONZALEZ, DR.P.H.
Has been appointed the new CEO at Hennepin County Medical Center in downtown Minneapolis. He succeeds Lynn Abrahamsen and is the first "outsider" in a long time to get the job. HCMC has a long and respected reputation nationally for quality care and medical education and it serves a disproportionate share of the state's indigent population in its 465-bed hospital and outpatient facilities. Most of HCMC docs are part of a separate corporation, Hennepin Faculty Associates, and negotiations to bring the two organizations together are continuing.
Gonzales is a second generation Texan who served several Texas hospitals, plus hospitals in Shreveport, LA and Tucson, AZ before his current CEO job at the Tri-City Medical Center in the San Diego, CA (Oceanside) area.
KEN PAULUS
Is the new CEO of the Twin Cities largest health system, Allina Hospitals and Clinics, succeeding Dick Pettingill who announced his retirement last year to take effect this month. Paulus, a Wisconsin native educated at UMN, came to Allina as COO in 2006 from tours of executive duty in Boston at Health One Care System and the Harvard Vanguard Clinic and earlier at Partners Health Care System. Health Care One is one of the largest physician organizations in the country and is a teaching and research affiliate of Harvard Medical School.
DICK PETTINGILL
Took his leave of Allina last week about the way he came here in 2002. Purposefully. In a 30-minute review of the State of Allina from his hiring to retiring Dick gave an accounting of his stewardship to 150 board and former board members and executives (including all the local hospital boards he dismantled to strengthen the corporate board) plus Al Franken. Dick took an organization that seemed to have lost its confidence and led it to one of the strongest in the country and the only one in this area whose EBITDA is rising rather than falling in this economy. (The accepted comparison of business performance before tax etc adjustments.) Epic CEO Judy Faulkner recounted how Dick built Allina's IT system called Excellian into a role model for America's hospitals.
Minneapolis Mayor R.T. Rybak told us how Dick's decision to headquarter Allina in the deserted Sears Roebuck Building in mid-town has turned the south side of Minneapolis around, and of his decision to commit $100 million in community benefit to a center for innovation, a back-door project to restore health to the people of the Allina neighborhood and to end heart attacks in New Ulm, MN.
An unusual man who, with his wife Karen, will maintain a home in downtown Minneapolis and another a mile from our second home in San Rafael, CA. He'll teach leadership at Harvard and in September bike from Vancouver, B.C. to the Mexican border with California. He also plans to make a difference in health policy - probably by taking the "community benefit" focus on community health to an entirely new level nationally. Or something like that. We just know he can.
GORDON MOSSER, M.D.
Founding director of the Institute for Clinical Systems Improvement (ICSI) in Minnesota retired a couple years ago to take up residence at the UMN's School of Public Health's Health Policy and Management Division. To his pleasant surprise at the end of this year of teaching, Gordon was named the "Teacher of the Year" by students in the MHA program. Quite an accomplishment in a place where time invested in research grant solicitation is valued more highly than time invested in graduate health care education.
CINDY MANN WILL SUCCEED DENNIS SMITH
Georgetown University's Cindy Mann took over the Center for Medicaid State Operations at CMS last week. She's a D.C. policy pro, having also served in HCFA under Clinton. She replaces Dennis Smith who tilled the same soil for Bush 43. They couldn't be more different. Both are good at what they do and are very principled. Smith believed that the growth in Medicaid is not justified and that moving responsibility for funding to the states could change its course. Mann's the opposite and takes pride in how well the program has done in filling gaps in insurance coverage for low income persons and those with disabilities.
ST. CLOUD, MN TO SET ANOTHER RECORD
Minnesota's "Granite City", the birthplace 75 years ago of one Dave Durenberger, is also the home of CentraCare Health System. Its foundation's health and wellness program has been trying for some time to get into the Guinness Book of Records with the biggest bicycle parade ever. On June 27th, organizers hope to break the record of 2,152 bikes set in Taiwan. Immediately at the conclusion of the two-mile bike parade, participants will head for St. Cloud's many saloons to get ready for the Granite City Days parade which used to be called the Wings, Water and Wheels Festival.
A THEOLOGIAN AMBASSADOR FROM THE U.S. TO HOLY SEE
Miguel Diaz does not remember his family's flight from Castro Cuba to Spain. He was five when they moved to Miami where Miguel's father worked as a waiter to support his family and to see his kids had something no one could ever take away - a first rate education. Miguel earned his way into Notre Dame where he met Marian Rukavina from Winona, MN and discovered both shared a love for philosophy and theology. They married sixteen years ago and have three sons and a daughter between 5 and 15, the first three 18 months apart and little Miguel "our Florida child".
Miguel and Marian were new to St. Cloud and his faculty appointment at the College of St. Benedict and St. John's University's theology department, when they watched the 2004 Democratic convention speech of an Illinois candidate for the Senate named Barack Obama. Miguel turned to Marian and said "There is so much to this man. We are watching a future president." Four years later Miguel volunteered to work for Obama in St. Cloud and then, with Senator Patricia Torres Ray of St. Paul, became active as Latino Catholics for Obama.
When Obama cinched the nomination and appeared in St. Paul June 4, 2008, the Diaz family stood in line with 35,000 others to see Barack and Michelle. He was recruited by Mark Linton for the Catholics for Obama and went to Denver for the Democratic National convention and became active in recruiting Cuban, Catholic and Latino votes. In late November he was at a party at St. John's neighbor Rob Culligan's home when Mark Linton called to tell him he would be asked to be U.S. Ambassador to the Holy See and he needed to think about whether he would accept.
It took the better part of a week to recover from the call, realize what it meant, and accept. He and his family have been thoroughly vetted (including brother George who was a strong Hillary Clinton supporter in south Florida) and Miguel is waiting for a Senate hearing. It may come soon because Obama wants to meet with Pope Benedict during the G-8 meetings in Rome July 20th and he needs an ambassador to arrange the meeting. The Vatican was quick to acknowledge Miguel Diaz' as an appointee. Maybe because the nominee and the Pope have a favorite German theologian in common, Karl Rahner. Miguel speaks fluent Italian and German as well as Spanish. He is also waiting for his first meeting with that 2004 convention speaker he knew could be President of the United States.
AFFIRMATIVE ACTION
Judge Sonia Sotomayor's journey to the U.S. Supreme Court is an interesting and important test of "change we can believe in." Much of it has to do with how well those of us who have benefitted from being an immigrant nation act on our beliefs that all people "created equal" do not have equality of opportunity in this country. Clarence Thomas and Sonia Sotomayor have different views on affirmative action. I voted for both of them. Many Americans believe that opportunity must be earned, not bestowed on the basis of race, gender or other forms of indisputable traditional bias and opportunity denial in this country. A majority of these people are Republicans. I know that from my 1980s efforts at civil rights restoration, economic equity for women, the Americans with Disabilities Act, the Voting Rights Act, and much more.
Until we live in a country whose laws and governance are truly blind to judging people by race, sex, and other "identities", there is still room for government acting to advance that cause. Senate Republicans objected to having "only 72 days" from nomination to confirmation to look for Sotomayor shortcomings. Ellen Goodman put it well recently: "The very fact that she has to prove her impartiality to a Senate that is more than three-fourths white and male is a bit bizarre. But let us dedicate these hearings to the memory of Ginger Rogers. As the late Ann Richards once said, Ginger had to do everything Fred Astaire did, only she had to do it backward and in high heels. Sonia Sotomayor is going to have to do this dance forward and on crutches."
GINGRICH vs. PALIN
Every year the Republican Senate and House election campaign committees join in one big fundraiser at a Washington convention center. This year the headline speaker was to be Sarah Palin. When the Alaska Governor wouldn't commit, they invited Newt Gingrich. Palin changed her mind at the last minute, showed up, and had to listen to Newt give a one-hour "state of the union" address on every policy issue under the sun. A Senator who was there told me "It was exactly what you don't want at one of these events - a long windy speech." But it was just the contrast some Republicans needed to hear between the two faces of the Republican Party today. Policy v. 'Issues.'
What we are for and what we are against.
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Illustration from the Star Tribune |
PEGGY NOONAN AND FRANK RICH
Are conservative and liberal political commentators. This week they wrote on the same subject. She in the Wall Street Journal and he in the New York Times. They connected the shrill screed of right wing radio in America with the rise of "hate mail (e or otherwise)" and suggested it might carry the power to acts of violence against consistent targets of right wing radio.
Right wing conservatives will respond by saying the liberal left is simply getting a dose of its own medicine. Republicans like Noonan and me will attribute the gradual erosion of public support for the party's candidates to the impression these Radio Republicans in Name Only (RRINOs) give most Americans. Simply countering the screed with appeals to Sam's Club moms won't do the trick.
WHAT IS A MINNESOTA REPUBLICAN
Not since Harold Stassen came one Oregon primary from taking the GOP Presidential nomination from Tom Dewey has Minnesota had a Republican Governor with the potential that Tim Pawlenty has to be our candidate for that office. After finishing another legislative session in which he balanced the state budget all by himself, Pawlenty announced he will not stand for a third four-year term in 2010. He said he'd made no plans for another future in politics and departed MSP for Washington, DC to speak to three national GOP organizations and hang out with a group of former John McCain staffers and political consultants.
Tim Pawlenty is John McCain on skates. He knows what he believes, he doesn't suffer fools, he chooses his fights, he loves the competition. He's not a great hockey player, but he's willing to put on pads and get out there with the best. Tim loves politics and service, loves his wife, and believes he will be led where he may not have expected to go. So he'll respond to invitations to share his thoughts and maybe, now, his experiences, with his party. Because the party that elected and re-elected him and the one that might have endorsed him in St. Paul last year if Sarah Palin hadn't come along, is no more the party of Pawlenty than it is of McCain.
OR A REPUBLICAN GOVERNOR
It didn't take more than an hour after Pawlenty's announcement for two dozen Minnesota Republicans to call somebody in the media to say they might be interested in being Governor. The list includes Congress member Michele Bachmann, former Senator Rod Grams, and former Congress members Mark Kennedy (he didn't call), Jim Ramstad, and Gil Gutknecht. Lots of legislators and former legislators. Former Senator Norm Coleman, who was on his way to being elected Governor in 2002 until Karl Rove and Dick Cheney made him into a senator, may have the most potential. Norm will have to climb out and over the mess created by the election recount, and whatever comes of an investigation of the role a supporter played in landing a job for his wife Laurie. But Norm's beaten bigger odds before.
SIGNS OF CHANGE
President Obama's efforts to find the moderate middle in national policy have been rejected by the radio-right that controls how much of the current Republican establishment thinks. It is also a bitter pill to swallow for liberals in his own party. Watch the DFL endorsing process for governor in Minnesota this year to see whether a non-Wellstone/Franken candidate can make it onto the ballot. Or watch the election campaign for Governor of Virginia, where a centrist state senator named Creigh Deeds beat out two high-powered, highly financed primary opponents.
Remember Obama supported the election of Virginia's current centrist Governor Tim Kaine to be the leader of the national Democratic Party. Former Reagan political adviser, Governor Mitchell Daniels (R-IN), tells national Republicans they need to stop comparing themselves with Ronald Reagan, a president they know only selectively, and chart their own conservative course for the future. Maybe that's where Tim Pawlenty, Daniels, and Governor/Ambassador Jon Huntsman come in?
TONY KUSHNER DOES POLITICS IN MINNEAPOLIS
The celebrated New York playwright is fulfilling a commitment to Guthrie Theatre artistic director Joe Dowling with a popular new play he keeps writing while it plays. From April 18th through June 28th at the Guthrie. The Intelligent Homosexual's Guide to Capitalism and Socialism with a Key to the Scriptures is the title. It's pure Kushner - taking on all the forces in our lives and setting it in the context of an Italian family in Brooklyn. Dowling likes it because "Tony uses theatre to make a stink, to make us feel." I like it because it because, as New York Times critic Andrea Stevens says, "it is a continuation of Kushner's surgery on the American body politic...he wants his listeners to think hard about the world and their place in it." I did, and I hope he keeps working at making it just that.
GEORGE H. W. BUSH
Chose once again to celebrate his birthday parachuting out of a plane with a member of the Army's Golden Knights. This is the former president's third birthday jump. Announcing he is already planning to jump on his 90th birthday, Bush challenged those of us who are old enough to retire to "get a life" and avoid "sitting in a rocking chair drooling." If you are my age and want to learn how - or whether - to ask his advice, I suggest you go see the latest Disney movie UP which I did with my granddaughter Emily and her friend on Emily's birthday.
DICK CHENEY
Says he has no problem with same-sex marriage. Thus joining a lengthening list of people whose sons and daughters are teaching them something about homosexuality, parenting, and marriage that in the stereotypes of our youth we found impossible. Thank you Dick and Lynne. My Rainy Lake fishing buddy Howie Hanson was taught the same lesson by his son and has turned the evangelism he usually devoted only to oppose gill-netting of Minnesota fish and the injustices of Native American "tribal justice", to penetrating the pale of religion's condemnation of homosexuality as a punishable sin.
SENATOR JIM INHOFE (R-OK)
Is known as one of the most conservative members of the Senate and a non-believer of every theory about environmental degradation. I know him to have a very human side and an adventurous one as well. I knew he was a flyer because he told some fascinating tales of his 1991 solo flight around the world in 16-days including some hours "lost" over Siberia. There was the time in 1999 when the prop dropped off in mid-air and he landed the plane without a propeller. On May 26th the 74-year old Inhofe logged his 10,000th hour since being licensed.
WEETCONGRESS.ORG
Senator John McCain has more Twitter followers (687,910) than any other Senator. Chuck Grassley (R-IA) is fourth with 9,327. This despite no obvious efforts on McCain's part to recruit "followers." Minnesota's own Michele Bachmann is no. 8 in the House at 4,702 followers compared with 4, 243 for Democratic presidential candidate Dennis Kucinich (D-OH). GOP leader John Boehner's 11,181 leads Speaker Nancy Pelosi's 10,135.
Soniasotomayor.com is up for auction by an anonymous cyber squatter for $5,000. According to the seller's page on godaddy.com the auction ends August 25.
AARP SELECTS AFRICAN-AMERICAN BUSINESS EXECUTIVE ITS NEW CEO
A. Barry Rand made history in 1999 when he was named the CEO of Avis and became the first African-American to run a Fortune 500 company. That came after 31 years at Xerox. When Avis was acquired by Cendant in 2001 Rand became chair and CEO of Equitant which he left in 2005 when it was acquired by IBM. He is currently Board chair at Howard University. Neither Howard nor AARP seem in any danger of being acquired so, at 64, Rand seems sure of a longer tenure as Bill Novelli's replacement at the influential senior's organization, than in his last two jobs.
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Illustration from the Star Tribune |
KIM JUNG UN
Is the number three son of Kim Jung Il, the "Dear Leader" of North Korea, and about to succeed his father as CEO of the cult posing as a country. Because it claims nation status, the fact that it's post-WW II "founder" passed leadership to his son who is about to do the same, does not make it a kingdom - like the many Arab states, or a dictatorship like some in Africa. It is a cult of personality. If the world doesn't treat it that way we are in for a big surprise.
Edward Luttwak is one of the wisest students of international security. His latest book: Strategy:The Logic of War and Peace. Ed suggests we cool it with North Korea. The very best strategy today - despite the serious provocations including trial and imprisonment of two American reporters - is the diplomacy of silence. Just don't talk to them. Forget the UN resolutions and the embargoes and the negotiations and all the other stuff that hasn't and won't work. Just shut up and drive them crazy, or crazier.
CAM AND BONNIE BLODGETT
Bonnie is one of St. Paul's best gardeners, writes a garden column for the local daily, and publishes the nationally known "Garden Letter." She and Cam live at 1 Crocus Hill making it the oldest home on our one-block street in which house numbers are sequenced by age. I'm not sure what husband Cam does besides write a humor column at the end of each Garden Letter. Last week Bonnie built him a wine cellar and stocked it with gifts from friends and neighbors as a 60th birthday present. On his birthday they mounted bicycles and made an 80 mile visit to Lake City for dinner at The Harborview. Bonnie's written a book on smell and what it's like to lose it. She's also trying to get her recent Wisconsin grad daughter to help her put up a humorous video blog of her - gardening!
UST Executive Education for Physician Leaders
2009 Physician Leadership College
University of St. Thomas
Minneapolis, MN
For ten years, the University of St. Thomas, through its Physician Leadership College, has been "Developing a community of physician leaders capable of directing current and future healthcare organizations to maximize their success." The next Physician Leadership College cohort begins September 20, 2009. Get more information and register> or contact Marlin Meendering at 651-962-4614 or marlinm@stthomas.edu. Applications must be submitted by June 30, 2009.
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