New Tennessee telemedicine law grows health care access

I am convinced that telemedicine is a crucial part of the solution for delivery of healthcare in the United States–care that isn’t yet affordable or accessible for all. Tennessee has made important steps toward ensuring telemedicine is an option for our citizens, but there’s more to do.

Telemedicine is in its infancy in Tennessee. Specialists at our university medical centers provide remote consultations and conduct virtual patient examinations. School nurses in rural counties use secure telemedicine links for consults. But it is vastly underused where the need is the highest: in the delivery of primary care.

Telemedicine can prevent an ER visit on a Saturday night and keep a busy Monday morning on track. Patients can avoid travel time, last-minute child care arrangements and a lengthy stay in the waiting room.

Telemedicine does not replace the need for a relationship with a family physician, but it does serve as a convenient, affordable and high-quality alternative to an unnecessary ER visit.

Last year, Tennessee became the 21st state to enact “telemedicine parity” legislation requiring that insurers reimburse licensed health care providers for services delivered remotely just as they would for in-person visits.

The legislation removes the wasteful financial incentive to having patients make a trip to an emergency room when a telemedicine consult would suffice. In both cases, the reimbursement to the provider would be the same. Tennessee’s parity law also includes TennCare, the state’s managed Medicaid program. The law was signed by Gov. Bill Haslam in April and became effective Jan. 1.

It’s a good first step, but Tennessee must go further. We need two additional assurances.

Read more at The Tennessean.

The Physician’s Role and End-of-Life

Over the past several months, I’ve been championing a revolution in end-of-life care. The care models need to change. Reimbursement strategies need to change. The way we think and talk about end-of-life needs to change.

And physician education needs to change. We, as doctors, need a new perspective on our role as healers and what that means when our patients can no longer be healed.

In the March issue of Academic Medicine (preprint available now), I look at the history of end-of life care, and consider how we should incorporate palliative care into our evolving healthcare landscape. As a preview to the academic paper, I’ve written a column at Forbes on some of the challenges.

This is a topic that deserves much thoughtful attention. I’d love your input.

Recent thoughts on end-of-life and palliative care:

Palliative Care: More than just end-of-life planning, Morning Consult, September 2014
Palliative Care: We know we need it, but how will the system pay for it?, National Institute for Health Care Management, September 2014
The Landscape of Long-Term Care, Aspen Ideas Festival session, June 2014
Bipartisan Policy Center Long-Term Care Initiative Launch, April 2014
NIC for Seniors Housing & Care Executives keynote, event preview interview, February 2014
Digitize your own advanced-care plan, The Hill, December 2013
End of life stories give us impetus to learn, Tennessean, December 2013
End-of-life care plan can ensure wishes are respected, Tennessean, November 2013
2013 Health Care Investors Conference report, November 2013
Elderly need options for palliative care, Tennessean, October 2013
We often avoid important conversation, Tennessean, October 2013
It’s never too early to discuss your final wishes, Tennessean, September 2013

Real Conversations: You and Me

With WK “Big Kenny” Alphin and Dr. Randy Wykoff, I am launching #Conversation2015, a look at the opportunities we have to make dramatic changes through compassion and caring. Read the introduction to the project here, the overview of you and me here, and the conclusion. Then join the conversation on Twitter and Facebook: #Conversation2015

At the end of the day, everything on our list comes down to a simple question that we all have to ask ourselves: Do we care enough about each other – the health of our nation and our world – to commit to making a difference? Do we believe that compassion for those less fortunate is, or is not, a fundamental part of who we are as a people?

It can be argued that compassion once defined who we are as Americans. You can, if you wish, define it in terms of religious faith. You can call it social justice. Or you can simply describe it as true patriotism. But no matter how you define it, let’s start with a return to a fundamental and basic principle—that we care. We care enough about each other to not let children die because they can’t have access to a basic medication. That women and girls anywhere should not be put at risk simply to find safe drinking water. That we care enough to not allow our fellow citizens to die young because they are poor. That we care enough to make a commitment to protect our environment as the future home of our children and their children—even if it means less economic benefit can be derived from it.

I’m looking forward to 2015 as we dig deeper into these issues. Merry Christmas!

Real Conversation on Democracy

With WK “Big Kenny” Alphin and Dr. Randy Wykoff, I am launching #Conversation2015, a look at the opportunities we have to make dramatic changes through compassion and caring. Read the introduction to the project here and the overview of the right to vote here. Then join the conversation on Twitter and Facebook: #Conversation2015

Hand in hand with freedom of the press is the right to vote. We learn about each other by expressing our opinions and allowing both small and the large voices to be heard. Many of our most pressing problems are problems of the majority, but the majority often needs to spend its day performing sustenance activities, instead of advocating for its needs. The right to be heard has never been more imperative.

Today, only about one third of the world’s population lives in countries with full and free democracies. The majority of countries in Africa and Asia—the very parts of the world facing some of most pressing challenges to human health and welfare—are not included in this list.

Those of us with “the vote” must recognize that the process of voting is only a small part of the democratic process. But it is emblematic of personal freedom and should be the instigator of our conversations about these very real issues.

We must protect and exercise our own right to vote, and become champions for that same right for people living around the world.

Water for the World

Back in 2003 I was traveling in Mozambique with a delegation of Senate colleagues to take a closer look at U.S. policy on HIV/AIDS.  We found an HIV emergency, but we also identified a health need even more fundamental: access to clean water.

That was the trip that prompted PEPFAR, President George Bush’s unprecedented commitment to address the HIV crisis. But it was also the trip that spurred advocacy for the dire need for safe drinking water, sanitation and hygiene (WASH).

At Forbes on Thursday I wrote a bit about the history of U.S. water legislation.

On Friday, the President signed into law the  the “Senator Paul Simon Water for the World Act of 2014”. It’s been a long time coming: the result of the work we started in 2003 as well as the tireless advocacy of so many other lawmakers and champions since that trip.

I’m thrilled to see the hard work of so many people come to fruition!

 

Real Conversation on Creative Freedoms

With WK “Big Kenny” Alphin and Dr. Randy Wykoff, I am launching #Conversation2015, a look at the opportunities we have to make dramatic changes through compassion and caring. Read the introduction to the project here and the overview of creative freedoms here. Then join the conversation on Twitter and Facebook: #Conversation2015

Creativity and freedom of expression are essential to dialogue and truth, and these are essential to democracy. The ability to express your ideas, critiques and concerns should be a basic right, but even in 2013, 70 journalists were killed and over 200 were in jail—murdered or imprisoned because their free thought represented a threat to those in power. Over the past five years, over 400 journalists worldwide were forced into exile.

Fear of expressing an opinion—for whatever reason—threatens the very fabric of our world.

Real Conversations on Population

With WK “Big Kenny” Alphin and Dr. Randy Wykoff, I am launching #Conversation2015, a look at the opportunities we have to make dramatic changes through compassion and caring. Read the introduction to the project here and the overview of population here. Then join the conversation on Twitter and Facebook: #Conversation2015

Almost all of the problems of the world today either stem from, or are worsened by, overcrowding. In October, 2011, the world’s population passed the 7 billion mark. And this has happened quickly. There are twice as many people on the earth today since the end of the Baby Boom.

We value life and want to prolong and enhance it, but given the issues previously discussed, the reality of population growth is something we cannot continue to ignore. A scientific and compassionate approach to education around and provision of acceptable birth control methods has never been a greater imperative. We need to move past the political barriers in the area to do what needs to be done.

Real Conversation on Children

With WK “Big Kenny” Alphin and Dr. Randy Wykoff, I am launching #Conversation2015, a look at the opportunities we have to make dramatic changes through compassion and caring. Read the introduction to the project here and the overview of children here. Then join the conversation on Twitter and Facebook: #Conversation2015

Over six million children die per year before they reach their fifth birthday, which is over 750 children per hour. And half of these deaths are preventable – and cheaply preventable. They include pneumonia, for which we need generic antibiotics, diarrhea due to unclean water, malaria preventable by mosquito nets, and measles for which we have a vaccination that costs $1.

Half of the over six million children who die every year are dying not because they have diseases that can’t be cured or prevented, but because they have diseases that we are not curing and preventing.

Then consider statistics on maternal and newborn health. Hope Through Healing Hands is leading an awareness and advocacy initiative to promote education and action for maternal and child health, with a special emphasis on healthy timing and spacing of pregnancies.

Healthy timing and spacing of pregnancies saves lives. We know that if young women in developing countries delay their first pregnancy until they are 20-24 years old, they are 10-14 times more likely to survive than those who have babies when they are younger.

If these women are able to space their children every three years, their newborns are twice as likely to survive their first year.

#Conversation2015

I recently got together with a couple of friends, entertainer WK “Big Kenny” Alphin and Dr. Randy Wykoff to talk about American compassion and to make a list: a list of things we should really care about. We wish to start a national conversation to identify and address some of the greatest threats to our global community. We are too privileged and have the advantage of too many lessons from history to continue to ignore our current trajectory – to continue to let another Ebola epidemic unfold as it did.

For my part, I frame the conversation in terms of changing health. American rhetoric regarding our national pride and values has taken many forms over the years, and until recently, health has not been a part of that conversation. But a focus on the social determinants of health, the basic tenants of our societal infrastructure, is imperative if we ever hope to build a society that can deftly and efficiently respond to and survive crisis.

This month, Big Kenny, Randy and I launched a conversation for caring, for change, for action. #Conversation2015 will focus on twelve issues for the next year. Picking twelve items was a daunting task, but we looked for opportunities where a little progress aided by a lot of compassion could make a big difference. To do that, let’s focus the dialogue on identifying those challenges threatening people’s health around the world, and how we can work together to address them. Join the conversation. Research these issues yourself and learn as much as you can and share what you learn with us.

Are you ready to take your place? Are you ready to care?

Read  my introduction in the Morning Consult

#Conversation2015 Issues (Links will update as we move through the list)

Safe Food and Water
Environmental Damage
Poverty and Inequality
Natural and Man-Made Disasters
Epidemic Diseases
Children
Population
The U.S. Criminal Justice System
Education
Creativity and Freedom of the Press
The Right to Vote and the Democratic Process
You and Me

 

Real Conversation on Disaster

With WK “Big Kenny” Alphin and Dr. Randy Wykoff, I am launching #Conversation2015, a look at the opportunities we have to make dramatic changes through compassion and caring. Read the introduction to the project here and the overview of natural disasters here. Then join the conversation on Twitter and Facebook: #Conversation2015

Natural disasters are a threat in and of themselves, and my friends and I have all witnessed first hand the destruction caused by hurricanes, earthquakes with tsunamis, and famine. As a society we are good at reactionary assistance – sending in the dollars and aid workers after the disaster strikes.

But many disasters are slow to occur and all disasters in an unprepared community – one with the issues of clean water and poverty to begin with – will wreak infinitely more havoc than they would on a well established community.

When an earthquake hits Haiti, when flooding overruns Bangladesh, or when famine starves the Horn of Africa, the impact is often magnified because of the challenging conditions in which the people were living before the disaster struck.

Lack of food, lack of economic opportunity, lack of education—all contribute to a much worse impact from any natural or man-made disaster. These are the “slow motion” disasters—just as devastating, but taking place over a longer period of time.

Can we as a society respond to both the “fast” and “slow” disasters with the same level of compassion and commitment?

 

Real Conversation on Poverty

With WK “Big Kenny” Alphin and Dr. Randy Wykoff, I am launching #Conversation2015, a look at the opportunities we have to make dramatic changes through compassion and caring. Read the introduction to the project here and the overview of poverty here. Then join the conversation on Twitter and Facebook: #Conversation2015

Poverty is inextricably tied to poor health. The world’s least healthy people often live in the poorest countries. Even in the U.S., a person in the lowest income bracket is about three times more likely to die before the age of sixty-five than someone in the wealthiest bracket. Poorer Americans are more likely to suffer from asthma, diabetes, high blood pressure, obesity, and heart disease and cancer.

But in the four decades since the war on poverty began, the gap between the richest Americans and the poorest Americans has actually grown. This is detrimental to the fate of our society because of its impact on children. Children born into poverty often remain there. Breaking the cycle of poverty by creating real opportunities is necessary to allow these children to become contributing members of our national family.

If we aren’t addressing poverty, we can’t improve health. If we aren’t thinking about poverty, we aren’t really considering the staggering level of injustice and inequality in the world.

 

Real Conversation on Environmental Damage

With WK “Big Kenny” Alphin and Dr. Randy Wykoff, I am launching #Conversation2015, a look at the opportunities we have to make dramatic changes through compassion and caring. Read the introduction to the project here and the overview of environmental damage here. Then join the conversation on Twitter and Facebook: #Conversation2015

Whether we are talking about global warming, strip mining or natural habitat destruction, the tension between economic interests and environmental concerns are becoming more tangibly apparent. We can now see the destructive impact our predecessors have had on the planet. Given this trajectory we know an uninhabitable world will be our fate in only a few more generations.

We can argue about the details, but the facts cannot be ignored. For example, the world is losing forests at a rate of about 120 square miles per day and as many as 3 million people, mostly in poor and developing countries, die each year from outdoor air pollution related to exhaust and emissions. Almost half that many are dying from indoor air pollution.

So it is not a matter of when our environmental destruction will impact our health, it is a question of when will it be a non-compatible threat? When will we reach the tipping point, beyond which we may not be able to return?

I liken our behavior to the smoker who says he will quit next week. At some point that is also the week he is diagnosed with a fatal illness. We have to change our habits before the earth develops its cancer.

Real Conversation on Safe Food and Water

With WK “Big Kenny” Alphin and Dr. Randy Wykoff, I am launching #Conversation2015, a look at the opportunities we have to make dramatic changes through compassion and caring. Read the introduction to the project here and the overview of safe food and water here. Then join the conversation on Twitter and Facebook: #Conversation2015

For many Americans it is a shock to realize there are still more than 2 billion people without access to clean water and 40% of the world population is without access to a toilet. The daily chore of securing clean water – clearly a necessity of life — can take up to eight hours a day and quite frankly be a life threatening endeavor in itself. As a result, over 3 million people a year are believed to die from water-related diseases.

Access to clean water, and the ability to keep it clean by not having it contaminated with human waste, industrial by-products, mining effluents, or other pollutants, is absolutely essential to improving health.

Even in the absence of significant famines, it is estimated that each year over half of all deaths of children under five are associated with malnutrition. This translates into almost 20,000 deaths per day.

As the world’s population grows, there will be a growing tension on the supply of food and water. Furthermore, regional disruptions in the food supply—from hurricanes, fires, earthquakes, or man-made disasters—will impact increasing numbers of people. For locations that are already without a supportive infrastructure, their communities are one natural disaster away from desolation of their community.

My global health organization, Hope Through Healing Hands, works with some excellent organizations addressing these issues. How can we all help?

 

 

Time to advance a new oversight framework for health IT

By former Sen. Bill Frist (R-Tenn.), MD

(The Hill; December 11)

Innovations in digital technology have changed the way we live our everyday lives, and we are finally, just now, seeing them change the way that we deliver health care and manage our own health.

Now new technology makes it possible for us to track and improve our health and wellness by logging our personal habits like physical activity, food intake, and sleep, as well as helping us keep track of important health information like medications and blood pressure. Americans are also using social networks for much more than socializing. Through online communities patients and caregivers are sharing their stories and advice, getting emotional support, and even logging and sharing side effects of specific treatments and interventions. In addition, price transparency tools are emerging to help the consumer-patient make better informed decisions about the quality and costs associated with many medical choices.

Given the pace of technology in every other field, it is embarrassing to report that we are just now seeing a significant penetration of online communication between doctors and patients. However, it is imperative to the efficient delivery of modern medical care. In addition to moving medicine into the 21st century with online portals and secure emailing, we are also seeing the rise of telehealth. Telehealth or connected health has been aided by the slow but eventual uptake of electronic health records by the nation’s physicians and hospitals. We can now access patient data and support on best practices at the point of care between physician visits. As we combine this type of health information access with genomic information, we move one step closer to truly personalized medicine.

However, new innovation is always met with the age-old problem of existing regulation. Laws are understandably written with existing technology in mind and without flexibility for an evolving and unforeseeable landscape. What Congress envisioned 40 years ago is simply no longer relevant. To support invention and innovation we need a flexible, risk-based oversight framework that protects patient safety and reduces regulatory duplication.

To address this need the Bipartisan Policy Center has engaged hundreds of stakeholders and experts to develop a set of principles and recommendations for a new oversight framework for digital technologies in health care. The BPC framework—reflecting agreement among leaders across every sector of health care—calls for higher risk health information technology (IT) to be subject to oversight via public-private partnerships promoting adherence to a set of voluntary consensus standards and patient safety reporting. This framework would better support rapid response, learning, and improvement. Advancing and implementing this framework was discussed during an event I kicked off at the Bipartisan Policy Center last week.

The good news is this is on the radar for Congress, the administration, and the private sector alike, with everyone agreeing we need a risk-based framework for health IT.
Just last week during BPC’s event, Representative Marsha Blackburn (R-TN) confirmed that an updated version of the Sensible Oversight for Technology which Advances Regulatory Efficiency (SOFTWARE) Act of 2013, which has 38 co-sponsors on both sides of the aisle, would be part of the 21st Century Cures package scheduled to emerge from the House Energy and Commerce Committee in January. Also last week, Sens. Michael Bennet (D-Colo.) and Orrin Hatch (R-Utah) introduced the Medical Electronic Data Technology Enhancement for Consumers’ Health (MEDTECH) Act, which provides greater certainty regarding regulatory expectations, limiting the Food and Drug Administration’s role related to low risk medical software and mobile apps in alignment with the BPC framework.

And the administration is also onboard with the release in April 2014 of the FDASIA Health IT Report: Proposed Strategies and Recommendations for a Risk-Based Framework, which reflects many of the principles and recommendations outlined in the BPC report.

With growing agreement among and action by Congress, the administration, and the private sector we are on the cusp of evolving a regulatory environment that would reward innovation, protect patient safety, create jobs, and improve health and health care in this country. But we cannot stop now.

We demand online and digital access 24 hours a day to most of the other information in our lives and employ digital technologies and devices to make frictionless our daily business and leisure activities. Why should something as important as our health be any different? Sure there are barriers and privacy considerations, but we can overcome them. We know how right now. So, it is time to move on bringing health information technology up to speed with the rest of our lives. No more excuses.

Frist was senator from Tennessee from 1995 to 2007. He was Senate Majority Leader from 2003 to 2007, and is currently senior fellow at the Bipartisan Policy Center.

This article originally ran online: http://thehill.com/opinion/op-ed/226680-time-to-advance-a-new-oversight-framework-for-health-it

Building Companies that Change Medicine

I am a partner at Cressey & Company, a health care focused private investment firm, where I serve as chairman of the company’s Distinguished Executives Council.  Yesterday, we announced the closing on a new fund that totals $615 million. Health care in America is changing so rapidly and I believe health-IT is an essential part of that. That’s why we are building high quality, value-driven companies that are centered on better care of the patient and prevention of disease.

It’s clear that government is not in a position to move as quickly as the market demands, but the innovation I’ve seen in private companies is astounding. Technology will change the face of medicine for the patient, the physician, and the payer, and we specialize in eliminating gaps in health care delivery so the patient sees better access and improved care.

It’s such an exciting time to watch to the health care industry change to deliver better care in better ways than ever before.

Read more about our news at:
Nashville Business Journal

November Update

The fall has been exceptionally busy around here with several international trips and speaking engagements, but I was able to be home for Thanksgiving and got to enjoy some of the beautiful autumn color that Middle Tennessee has to offer.

I hope you all had a happy Thanksgiving holiday. Here’s an update on some of what we’ve been up to.

Hope Through Healing Hands (Global Health)

We are very glad that some of the panic associated with the Ebola outbreak has calmed. Infections in the U.S. have been few and none of those healthcare workers who were infected here have succumbed to the disease.

But in Africa, the problem is still very real. Last month there was a panel at Vanderbilt University on U.S. leadership on Ebola in West Africa and at home. My notes from the event were published at Forbes. Now is the time to think carefully about what we are learning from this outbreak. Not only how do we best help and treat those sick with Ebola, but what can we learn about how our country responds to international health crises? What can this virus tell us about other hospital-acquired infections? What are containment best practices?

We must also remain aware that the countries battling the worst of Ebola are facing many other health challenges as well. The infrastructure questions for these health systems are complex and many. Foreign aid will still be needed after this outbreak is contained.

With foreign health systems at the front of mind, I had the opportunity to twice visit Cuba over the past six weeks. They were powerful trips. Cuba is a fascinating country, rich in culture and art despite severe and widespread poverty. Immediately after returning I got my first impressions down in a blog post. I was struck by some of the strengths of the primary care system—a system that in many ways reminded me of my father’s medical practice. But at the tertiary care level, the system falls apart to the detriment of the Cuban people. As we always find with international travel, Cuba yielded observations that will shape and inform thinking.

SCORE

Falling between the two trips to Cuba was one of my favorite dates all year: the annual SCORE Prize event. We awarded three $10,000 awards to individual schools and one $25,000 award to a school district for outstanding work with Tennessee’s students.

It is always an honor—and such fun!—to be a part of this night. Congratulations to Dresden Elementary School; Hillsboro Elementary/Middle School; Covington High; and Kingsport City Schools.

Also last month our friend Touch left for new horizons. Touch the Dog was auctioned off to benefit the Old Friends Senior Dog Sanctuary at the beginning of October. His new home is in South Carolina, but he’s sure to keep spreading his message of compassion, healing, and connection.

Domestic Health Reform

We’ve noted over the past several weeks the challenges that still lie before the VA. Congress wisely passed bipartisan legislation in July to bring greater accountability, transparency and patient choice to VA. Additionally, a new VA secretary, Robert McDonald, was appointed who will hopefully implement real change. As a former VA staff surgeon, I’ll be closely watching the progress.

But it’s not only our veterans who are faced with ongoing health challenges. The nation as a whole is struggling to reconcile our health goals and our realities. There have recently been great strides forward for the 86 million adults who have diabetes. The U.S. Preventive Services Task Force last month proposed new screening guidelines aimed at reaching a greater percentage of individuals at risk for diabetes. It’s a step in the right direction.

But really it’s up to all of us to take control of our health for ourselves and our communities. Yesterday we encouraged everyone to take a look at the Robert Wood Johnson Foundation County Health Rankings. You—like me—may be surprised and dismayed by what you learn. It’s time for us all to take action!

Finally, if you’re struggling with how insurance works, can we suggest the YouToons? The Kaiser Family Foundation’s series of animated videos is an amazing resource, and the latest short gets to the heart of the insurance structure. Maybe you’ll even recognize a voice there?

The Way Forward for Ebola

Thankfully—and appropriately—the panic surrounding Ebola in the United States has waned over the past weeks. But the calm doesn’t mean it’s time to move on, though the news cycle may have. All major crises can be teachable moments and now is the time to carefully consider our response to the Ebola outbreak and what we can learn to prevent these types of outbreaks in the future.

Last week I sat on a panel hosted by the Center for Strategic and International Studies (CSIS), the Vanderbilt Institute for Global Health, and Hope Through Healing Hands, the global health nonprofit for which I am founder and chairman.

I shared some notes from the discussion at Forbes.

2014 SCORE Prize Awards

Patricia Stokes, CEO of Urban League of Middle Tennessee; Spencer Beckman, Rise to the Challenge Winner; myself

Patricia Stokes, CEO of Urban League of Middle Tennessee; Spencer Beckman, Rise to the Challenge Winner; myself

Each year in late October I have the privilege of hosting the Annual SCORE Prize celebration. Every year just gets better and last night was no exception! We had a great time with school representatives from across the state and country music artist Dustin Lynch.

The SCORE Prize celebrates success in Tennessee’s schools, and this year we had much to celebrate! We awarded three $10,000 awards to individual schools and one $25,000 award to a school district for outstanding work with Tennessee’s students.

We also rewarded the students themselves. Students were invited to submit videos, essays, and creative writings that documented their experiences in classrooms and schools that have helped prepare them for their future through our Students Rise to the Challenge campaign. Last night we gave $250 college scholarships to three creative students for their entries.

The competition this year was fierce; I’m proud to say I think it gets tougher each year! Choosing the winners is the task of the SCORE Prize Selection Committee. They serve as crucial partners in planning and designing selection criteria for the SCORE Prize, and they give their time examining data and visiting schools and districts across the state. They’ve done great work this year, and we are grateful!

The 2014 winners are:

  • Dresden Elementary School
  • Hillsboro Elementary/Middle School
  • Covington High School
  • Kingsport City Schools (district award)

The Students Rise to the Challenge winners are:

  • Katie Workman, a third-grader at Foothills Elementary School of Maryville City Schools
  • Vincent Gould, a sixth-grader at Robinson Middle School of Kingsport City Schools
  • Spencer Beckman, a 12th-grader at Central Magnet School of the Rutherford County School District

You can get all the details on the 2014 SCORE Prize finalists and winners at the SCORE website, and be sure to look for upcoming case studies of best practices gleaned from these winners.

Congratulations again to SCORE, the winning schools, and all of the educators who are working so hard for excellence in Tennessee schools. I’m so proud of all you’ve accomplished, and I can’t wait to see what you do in this coming year!

 

Notes From the Road: A Big Picture Impression of Cuba

Two weeks ago, I was in Cuba as part of a healthcare delegation to learn more about the country as a whole and its healthcare system in particular on a “people-to-people” trip.

Cuba is a land of heterogeneity and chaos: an amalgam of cultures, colors, tastes, and textures. Wifi access there is severely limited, so I wasn’t able to blog from Havana. Since I returned, I’ve been focused on Ebola at home and in Africa, but I have had time to reflect a bit more on the trip.

I’ll dig into healthcare more soon, but first here is an overview of the biggest challenges for Cuba.

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Increasing social inequity. Twenty percent of Cubans live below the poverty line. It’s inconsistent with socialist values, but that’s the reality today. The socialist program is failing.

To be poor in Cuba is different from being poor in the rest of the world. This really struck me in comparison to what I’ve seen in Ethiopia, Kenya, South Sudan, and Bangladesh. The poor in Cuba don’t starve because everybody receives food rations—beans, rice and chicken—every week. The poor don’t die of curable diseases because the primary care system offers everyone free early treatment and prevention. Children are not forced to work.

But almost everybody works for the State, and their incomes are not high enough to match the free market prices, some of which is driven by the strengthening black market. As money starts to flow in Cuba, it aggravates the inequality and shows failure of the socialist system.

Low political participation. The decision-making process in Cuba is highly-centralized and far removed from the average person. The average Cuban feels like he has no voice in government. The people don’t feel like they can change things. They don’t elect their representatives. They’re just told what to do by the State. There’s declining political participation and people are very passive.

The State is overextended. Published numbers from the 1990s show that 95% of the labor force is employed by the State and 85% of the productive land is owned by the State. In the past, the State could support that burden with foreign money, but now the Soviet Union money has disappeared and the Venezuelan money has disappeared. There isn’t an influx of money with which to support the people. The Cuban government is looking mainly to Brazil to be their economic savior.

Too much bureaucracy. For the past decade, bureaucracy and government by very ineffective administrative control has been increasing. Leaders don’t have management techniques. Small businesses are buckling under bureaucratic regulations, and too many prohibitions stifle innovation.

Corruption. There seems to be corruption everywhere at every level with a general attitude of: “We need it; we take it.” For example, someone works at a restaurant not for pay, which is paltry, but so they can steal food and take it home to their family. Waitresses I talked to explained that salaries were miniscule, and patrons don’t tip. But by working in a restaurant, she can take a bit of food off the stove home to her family.

That kind of corruption is caused by unfilled consumption demands. People want more and there is no way to get it, so they take it. There’s no social contract. The whole concept of taxation is so foreign to them, because the federal government simply gives them everything. When that model begins to fall apart because of a lack of resources, the corruption and the stealing increases.

Media Policy. All media is party media—government media—of poor quality. For most Cubans, the internet does not exist. Access is severely restricted. Wifi is generally available only in big hotels, and then bandwidth is limited.  There’s been an explosion of cell phones in the last two years and people do have computers, but they can only download their news once a week from a memory stick.

Embargo with the United States. As the embargo approaches its 54th anniversary, it continues to have a major impact on nearly all aspects of Cuban life, and makes economic recovery and structural changes difficult. Even though there has been foreign investment, I believe things are not really going to improve in Cuba without a change from the United States.

Helping VA Do Better

(Military Times, October 15, 2014)

By Bill Frist

In his second inaugural address, President Lincoln articulated a clear principle to guide our nation’s commitment to military veterans. The goal, he said, should be “to care for him who shall have borne the battle and for his widow and his orphan.”

That sentiment still resonates a century and a half later, and the Veterans Affairs Department adopted Lincoln’s formulation as its motto. Yet as a string of VA scandals have come to light exposing shoddy patient care and bureaucratic malfeasance, it’s fair to ask, what happened to that mission?

Like all government-sponsored health care, VA is largely run by political appointees and bureaucrats, rather than professionals with specialized training in health care administration and management. The government approach to fixing a problem is usually to add a new regulation or yet another policy, when sometimes the cleaner solution would be to de-regulate and simplify.

Unfortunately, VA has suffered from this practice, resulting in an increase in middle managers and regulations that drive up costs, stifle innovation and make the system less responsive to the veterans it aims to serve.

The obstacles to timely care have been apparent to those working in the VA system for years. Indeed, I have experienced firsthand the challenges in that system; I served as a VA staff surgeon in Nashville, Tennessee, an experience that informed my approach to veterans’ issues when I later served in the Senate. I realize that VA simply must do better.

The patient scheduling scandal that arose in Phoenix this spring was simply the last straw. What made the revelations most appalling was the falsification of wait time records to ensure bonuses to administrators. That story suggests VA has lost sight of its true mission of service to veterans and their families.

In response, Congress wisely passed bipartisan legislation in July to bring greater accountability, transparency and patient choice to VA. Additionally, a new VA secretary, Robert McDonald, was appointed, with hopes that his fresh approach would lead the department in a new direction and institute some real change. Those were positive steps.

But those steps are only the beginning. The department has a long way to go both to restore the trust of our veterans and transform the current system into one that can deliver the timely, quality health care our veterans deserve.

So what next? The VA reform bill that passed earlier this year established a commission that will make independent recommendations that are due in early 2016. While this a worthy idea, we cannot continue to tell our veterans they will just have to wait.

It is essential that new ideas and fresh proposals, from outside VA and from all perspectives, be brought to the table for consideration. And we needed that to happen yesterday. Therefore, I am pleased to announce the formation of the Fixing Veterans Health Care policy taskforce, of which I will serve as one of five co-chairs.

My co-chairs on this taskforce, sponsored by the veterans advocacy organization Concerned Veterans for America, are Jim Marshall, a former Georgia congressman and Army Ranger, and two distinguished health care policy leaders — Dr. Mike Kussman, who served as the VA under secretary for health from 2007 to 2009, and Avik Roy, a health care scholar with the Manhattan Institute.

The goal of the taskforce is simple: Isolate existing challenges to veterans’ health care, identify systemic solutions, and propose concrete reforms to improve care delivery for our nation’s veterans. We will consult with the foremost health care management experts, former and current VA employees, members of Congress, and — most importantly — veterans and their families.

Through the submission portal on our taskforce website, we are actively seeking stories from veterans to get the most accurate story about what is going horribly, or well, in the VA system. We will then release a set of concrete recommendations in December that we hope will serve as the basis of reform legislation in the 114th Congress.

This taskforce will seek to think outside the box, challenge assumptions, and ask hard questions regarding the best possible way to deliver timely, efficient and effective care to our veterans. It seeks both short-term changes as well as systemic reform. And most importantly, the welfare of the veteran will be at the center of the coordinated patient care model we hope to recommend.

With politics, someone always disagrees, and we anticipate pushback from those who benefit from the status quo. But the status quo is unacceptable, and something has to change. It is on issues like these that we must employ bipartisan efforts and meet in the middle.

VA has changed before and they can do it again, which is why this taskforce is immensely important. Join us as we help the VA achieve the quality product our veterans deserve and we know they can deliver.

This article originally ran online: http://www.militarytimes.com/article/20141015/NEWS05/310150055/Opinion-Helping-VA-do-better

New Horizons for Touch!

If you follow me on Twitter or Facebook, you have probably seen Touch mentioned several times. He’s a new friend of mine with a fascinating story, and today is a very big day for him!

A few months ago, the Old Friends Senior Dog Sanctuary in Mount Juliet contacted me about their annual fundraising auction on Oct. 10 at the Omni Nashville. They invited several individuals to contribute dog statues, and I was intrigued.

The sanctuary houses and places older and disabled dogs who otherwise would be euthanized. Michael and Zina Goodin, who founded the sanctuary, believe older dogs make particularly calm and loving companions, and they are committed to finding homes for as many as they can.

These older dogs have touched many lives in their time. The old adage about man’s best friend means something! I started researching the role dogs play in healing and communication, and I’ve been fascinated by what I’ve learned. (I wrote about therapy dogs at Vanderbilt in this Sunday’s Tennessean.)

I worked with Tracy Roberts, an education specialist and therapy dog certifier from Virginia, and Charlie Buckley, a Mississippi landscape artist, to create Touch, a dachshund statue.

Touch visited a girls’ camp in Mississippi to start his journey; we visited Sam Houston Elementary School at this beginning of the school year to get some help and guidance from the students there; and many more have contributed along the way.

He wears a particularly special collar—a collar passed down from two hard working therapy dogs who taught empathy and compassion. A dog’s work is to be both a sponge and a rock: sometimes solid to hold on to, and sometimes absorbing all the sadness and fears in the world.

Touch has been exposed to so many wise and loving people since his birth and he’s learned a lot! He’s up for the challenge.

Today he starts the process of moving on: the online portion of the fundraising auction begins today!

After the online portion of the auction closes on October 6, Touch and other dogs will be auctioned off on October 10 at a fundraiser for the Old Friends Senior Dog Sanctuary. Until then, you can keep up with Touch and his adventures through his Facebook page. He loves hearing from other dogs about how they help their people and their communities.

 

Opportunity to Act for Maternal and Child Health

I just welcomed my second grandson, and the dichotomy between the health care we enjoy and the realities in the developing world is never more stark than when I visited the proud new parents and their precious little one in the hospital—everyone  healthy and well.

The biggest killer of women between 15 and 19 in many developing countries is pregnancy and childbirth complications. Enabling women and couples to determine the number of pregnancies and their timing is critical.

Contraception is a pro-life cause.

I believe equipping women to use voluntary methods for preventing pregnancy not including abortion, that are harmonious with their values and beliefs, can make a dramatic  improvement in that number and have lasting benefits for the women, the children, and their communities.

Empowering women to plan and space their pregnancies increases their survival and that of their children by 50%. It means they can nourish and raise their babies. It means they can heal after childbirth and contribute to their families and their communities.

Letting women space their own pregnancies means they can stay in school longer. Did you know up to one in four girls in Sub-Saharan Africa drops out of school because of an unintended pregnancy?

These are important issues—critical ones! Will you join me to discuss maternal and child health?

On September 24, I’ll be giving the keynote address at a conference in Nashville looking at these very issues. I’ll be joined by speakers from the Bill & Melinda Gates Foundation, Lwala Community Alliance, Live Beyond, World Vision, Compassion International, Food for the Hungry, Hope Through Healing Hands, and Living Hope.

We need your voice!

For more information & to register.

 

An Ebola Turning Point: An Early Diagnosis?

Read my earlier Ebola primer and a look at what we know about how the virus behaves.

As the Ebola situation in West Africa progresses, we are dealing with increasingly complex medical and cultural challenges. I addressed some of the cultural issues in a Morning Consult column last month, and highlighted the importance of identifying infected patients:

The only solution is prevention, which relies on containment and isolation. The sick must be rapidly identified and contained. Their contacts must be followed for 21 days so they can be rapidly isolated, should they develop symptoms. Their care must be delivered in a hazmat suit. If the patient dies, and [50%] do, the body must be properly disposed of because a recently deceased Ebola victim is actively shedding the virus from his skin.

But thus far, identification has not been straightforward. In its earliest stages, Ebola looks like other diseases: malaria, typhoid fever, cholera. It’s clear that these patients are sick, but it’s not clear that they are infected with Ebola virus. During the incubation period, the infected individual may not show any symptoms at all.

Currently, public health workers try to work backwards from a very sick patient. Who lives with them? Who is in their community? Where have they traveled? Who may they have had contact with over the past month? Find those individuals. Follow their health for the next month. If anyone gets sick, the process starts over.

An early, precise diagnosis would be a game changer for this process.

  1. We could separate infected from uninfected patients immediately—before they are contagious. Even in locations without sophisticated quarantine facilities, physical separation of Ebola patients from others would cut down on cross contamination within clinics and communities, and better protect one of the hardest hit groups: health workers.
  2. We could dramatically decrease the virus’s geographic spread. Incubation takes 2 to 10 days, and usually that means the person is positive but not yet symptomatic. We believe that a patient isn’t contagious until the fever starts, but a rapid diagnostic test could identify a carrier before symptoms appear, and before they travel and risk spreading the virus.
  3. We could focus on post-exposure drug development. Identifying carriers before they feel ill would let us treat them early. Some drugs have already shown great efficacy if they are given immediately. Zmab is a drug designed as a prophylactic. It’s shown to be 100% effective in primates if given within 24 hrs of exposure and 50% in 48 hours. Other similar treatments could be extremely effective if we know who to give them to.
  4. Health care workers that have been exposed to Ebola can be quarantined for up to 21 days, and often they have not been infected. In an area with a severe shortage of trained medical personnel, the loss of any workers is disastrous. An early diagnostic test would let those medical professionals continue to safely treat their patients if they have not been infected.

The situation in West Africa is complex for so many reasons, and a rapid diagnostic test would not be an ultimate solution, but it could be the tipping point we need to stem the tide of new cases.

Join me to Discuss Palliative Care: We know we need it, but how will the system pay for it?

UPDATED: If you missed the event, the entire webinar broken down by speaker is archived online.

On September 10, 1 pm EDT, I and some friends will be speaking at a live, free webinar sponsored by the National Institute for Health Care Management (NIHCM) on palliative care. We certainly need it, but how will the system pay for it? I’ve outlined some of my thoughts below, but we need your voice too! Please join me!  

http://www.nihcm.org/improving-access-to-integrated-palliative-care

Palliative care is one of the fastest growing specialties in American medicine today. This growth is driven not only by our aging population but also by the cultural and financial shift in medicine from fee-for-service to value-based care. However, when we talk about value-based care in the palliative care setting what we really have is a chicken-and-egg problem.

Value-based care is traditionally thought of as pay for outcomes. A hospital reduces hospital re-admissions, or a primary care physician achieves blood pressure goals on 80% of his patients and their reimbursement is higher. However, the important question is, How do you even achieve those goals in the first place? And in the palliative care setting—chronically ill patients who are not going to get “better”—What is an improved outcome?

The answer to the first question is a “medical team” model. Keeping patients well, especially the chronically ill, is all about care coordination. In the primary care setting, this means a team may have a physician, a nurse practitioner, a social worker, a registered nurse, a dietician, a psychologist and others all working together to meet the needs of a patient. A patient is not a single illness.  Each patient is a person with a family and possibly a job living in a community and dealing with many life stressors of which their illness is only one. You have to address the whole patient with all of their non-medical issues to reach success on their health outcomes.

In a palliative care setting, taking a medical team approach is even more imperative. The goal in palliative care is improved quality of life, which means better symptom management, reduced episodes of acute illness and overall better patient well-being. For chronically ill patients, coordinated care is the only way to achieve this.

If value-based care in the palliative setting means coordinated care, and the outcomes achieved can be cost saving, why isn’t everyone moving to this model? The reason is always the same: current reimbursement models do not support it. We bill for procedures, not outcomes, and even the shift to paying for outcomes is physician-centered. Chaplains and social workers are imperative, but they do not generate revenue under the current model.

We want the outcomes palliative care can offer. We want the cost-savings palliative care can generate. But to do that the payment model has to change, which requires proving to payers that the a medical team approach works, and finding people brave enough to venture into the palliative space when payment is not guaranteed.

The good news is healthcare systems and providers are changing. In Oregon and Colorado Medicaid reimburses for end of life discussions. Palliative care companies and programs within hospitals are springing up around the country. But the system is in transition and we need a more cohesive solution.

 

Why the VA Should Look Toward Proven Health Care Solutions

By Bill Frist and Tom Daschle

While it is not a secret that the Veteran’s Affairs hospital system has had inefficiencies for many years, the recent spotlight on veterans’ long wait times for basic medical attention has made headlines for good reason.

Long wait times are dangerous and extremely costly, resulting in unnecessary emergency room use, advancement of medical illness, and possibly even death, when early intervention would have been life and cost saving. In short, we are failing our veterans.

The confirmation of former Procter & Gamble chairman Robert McDonald to lead the VA is a step in the right direction. The bureaucratic entanglement from which the VA has suffered will potentially benefit from a leader with private industry experience. The bipartisan legislation recently enacted by Congress is another key step and will help ensure the VA has critical additional resources to eventually hire more personnel and open new facilities. But we still need more.

Delivering high-quality care for veterans will mean going beyond our national status quo, because inefficiency and waste are unfortunately part of the fabric of U.S. health care. Just consider appointment timing.

Nationwide, a patient faces an average of an 18-day wait for a doctor’s appointment. If the need for care is acute, that delay of preventative care means that a problem that could have been prevented yesterday is today out of control.

These problems are not novel. We have seen advances in health care technology making sense of these issues. Companies offering online appointment scheduling, patient adherence apps, telemedicine, and more are already easing the strain such that some Americans can get the care they need when they need it. In these models, we have seen tools for strengthening and modernizing our health care infrastructure being polished, tested, and refined by real-world patient use. The VA could be an easy adaptor given the VA electronic medical record system was one of the first in the country and continues to be the largest integrated system. We are encouraged that the bipartisan legislation enacted by Congress takes this practical approach and sets up a task force to look at existing solutions that can be deployed at the VA.

The message is that Veterans need health care now, which means the VA needs infrastructural improvements yesterday. There is no valor in reinventing the wheel when solutions already exist. Veterans, and frankly all Americans, cannot afford the delay. Models that can be implemented quickly and efficiently already exist. We should, and we must, avail ourselves of those opportunities. These options are ready for adoption and will help ensure our veterans are able to quickly access the care they deserve.

Tom Daschle is a former Senate majority leader and a senior policy adviser at DLA Piper. Bill Frist is a former Senate majority leader and a cardiothoracic transplant surgeon.

This article originally ran in Roll Call on August 19, 2014: http://www.rollcall.com/news/why_the_va_should_look_toward_proven_health_care_solutions_commentary-235759-1.html?pos=oopih

Ebola: Contagious vs Infectious

Read my earlier Ebola primer.

As the CDC treats the nation’s first two Ebola cases there are a lot of questions and concerns about the disease in America—Could it become an epidemic here? How contagious is it? How is it caught?

Although my medical specialty is cardiothoracic surgery, I have spent a good deal of time working on global health issues in Africa and elsewhere, and I have been in close contact with the CDC over the past week. I thought it might be useful to highlight some of the features of Ebola that make it more—and less—dangerous.

As a viral disease, Ebola follows a fairly predictable timeline.

Incubation: the time between when a person is exposed to the virus, and when symptoms start. In Ebola, that incubation period can be between 2 and about 21 days. During that time, the patient does not feel sick and research suggests that they are not contagious. (see doi:  10.1016/j.phrp.2011.04.001) There’s been concern about infected travelers spreading Ebola to other parts of the world after traveling from West Africa. That is certainly possible with a long incubation period.

Onset of Symptoms: However, once an infected person starts to feel sick, they are quickly seriously ill. There is sudden onset of fever, intense weakness, muscle pain, headache and sore throat. This is followed by vomiting, diarrhea, rash, impaired kidney and liver function.

Unlike a cold, when you could be spreading the virus and not really feel that unwell, Ebola patients know that they are sick. This is actually a good thing, because sick patients are easy to identify, isolate, and treat. Other diseases still need to be ruled out—malaria, typhoid fever, cholera—but it’s clear that the patient has a severe illness.

Transmission: Here is perhaps the scariest part. How do you get it? How did Dr. Brantly get it? How is the virus spreading between people?

Some diseases are infectious, but not contagious. Lyme Disease or Rocky Mountain Spotted Fever are transmitted from ticks to humans but cannot be spread from human to human.

Contagious diseases can be spread from person to person, but not all equally well. Chicken pox, small pox, and measles, for example, are airborne spread—meaning the virus spreads very well with each exhale. These diseases are highly contagious.

Ebola, on the other hand, is only spread through direct contact with the bodily fluids of infected patients—blood, semen, sweat, urine and other secretions. And then, that fluid needs an easy entry into the body: a shared needle, an open cut, an exposed mucous membrane. It could possibly be spread through a cough or a sneeze, but that would require a fairly large drop of mucous to be coughed into another person’s face and get into their mouth or nose or eye.

For healthcare workers in West Africa, this could be possible. With limited supplies, perhaps there is a tear in a glove, or there aren’t enough goggles to go around, or bedding is reused because there isn’t an adequate way to clean it.

If patients are being cared for at home—either because they are too far away from a medical facility, or there’s some cultural distrust of foreign aid workers—caregivers in close physical contact with sick loved ones would have no medical or cleaning supplies. There are also vast cultural issues that influence the virus’ spread, and I’ll touch on those soon.

But with supplies, knowledge, and fully-equipped medical centers, these circumstances would be much less likely to happen. For these reasons, the Centers for Disease Control (CDC) is not concerned about an outbreak in the United States.

The situation is certainly serious—and will continue to be very serious in West Africa. But although we don’t know everything about how this virus behaves and changes, we do have quite a bit of useful knowledge about how to keep it contained, and how to keep our healthcare workers at home and abroad safe.

Ebola Primer and Liberia

As I hope you’ve heard, there is an outbreak of the Ebola virus in Western Africa right now, particularly in Liberia. Two American aid workers, Dr. Kent Brantly with Samaritan’s Purse and Nancy Writebol, a volunteer working with the faith group Service in Mission, were recently infected.

I’ve been discussing the situation with the Centers for Disease Control, and I wanted to write a little bit about the transmission and natural history of the virus.

Ebola is a type of viral hemorrhagic fever (VHF). Four families of viruses cause VHFs, and Ebola is from the family Filoviredae. Dengue fever, Yellow fever, Crimean Congo fever, Hantavirus and Lassa fever are other types of VHFs you may have heard of.

Humans are not a natural vector for the Ebola virus, so outbreaks occur after a human comes in contact with an infected animal such as a monkey, pigs or especially bats. Human-to-human spread then occurs through contact with bodily fluids such as urine, secretions, blood, stool or contaminated medical equipment.

Ebola is not technically contracted by respiratory contact with an infected individual, but aresolization of secretions—for example, a coughing patient—can cause spread of the virus. Therefore, barrier precautions like gloves and gowns as well as airborne precautions like masks and goggles (to prevent absorption through the cornea of respiratory droplets) are necessary to prevent transmission. For healthcare workers, infection is almost exclusively the result of a tear or other weakness in their protective barriers.

VHF viruses are dangerous because they are highly contagious, have a high rate of infectivity with low doses of exposure and high rates of complications and death. Therefore, it is important to recognize the signs and symptoms to quickly isolate potentially infected individuals. First, the individual’s travel history is important if not already in an endemic area. Second the timing is helpful to raise suspicion. The incubation period is a few days to weeks. The illness begins with fever and muscle soreness, low blood pressure, red eyes and a rash (specifically, petechial hemorrhages).  The constellation of these symptoms with potential exposure is enough to warrant immediate quarantine.

The virus then attacks blood vessels all over the body and increases vessel permeability resulting in fluid loss and bleeding. The fluid and blood loss causes shock and disorders of the clotting system resulting in hemorrhage from mucous membranes as well as in internal organs such as the gastrointestinal tract and lungs. While there are experimental drugs under research and being used in Liberia today, the only known available treatment at this time is supportive care.  Supportive care includes fluids, blood products, blood pressure and respiratory support and possibly comfort measures.

The key to survival of Ebola is immediate and sufficient isolation of infected individuals and treatment with aggressive supportive care in an intensive care setting. Once patients have stabilized they are no longer infectious and can be taken out of quarantine. The virus is so rapidly fatal that naturally occurring outbreaks can be contained if patients are quickly isolated and effective barrier and airborne precautions implemented.

There are some experimental drugs for Ebola, but none have completed clinical trials and some have only been tested in lab animals. Many are arguing that the most advanced of these treatments be made available to the sick, even though they haven’t been fully tested yet. One such serum was administered to Ms. Writebol. Dr. Brantly has had a blood transfusion from a boy who survived the virus, in hopes that some antibodies to the virus may be transferred.

Much of the outbreak problem in West Africa can be attributed to lack of knowledge about the virus to recognize and immediately quarantine the sick, as well as the cramped facilities where the healthcare workers were operating. West Africa has never seen Ebola before, and most healthcare facilities are not properly equipped to handling the kind of quarantine needed.

The Centers for Disease Control is currently working to send in personnel and supply support to help contain the virus. Dr. Friedan, the director of the CDC, has little fear of spread to the U.S. due to quarantine posts at all points of entry. He also predicts it may take up to six months to completely contain the virus in Liberia, but he’s confident of eventual success.

Join me in praying for all of the infected individuals and the healthcare workers on the ground and abroad that are making efforts to help contain the outbreak.

What’s next?

 

 

Healthy Timing and Spacing of Pregnancies: My Conversation with Melinda Gates

Yesterday morning, I had the privilege of sitting down with Melinda Gates, Scott Hamilton, Jenny Eaton Dyer, and a room full of caring people to talk about Hope Through Healing Hands’ Faith-Based Coalition for Healthy Mothers & Children Worldwide.

Chatting with both Melinda and Scott is always such a pleasure—especially about such an important issue as this!

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Maternal and child health is a huge problem and the numbers can seem horribly daunting:

  • The biggest killer of women between 15 and 19 in many developing countries is pregnancy and childbirth complications.
  • One in every 39 child-bearing women in sub-Saharan Africa dies in childbirth.
  • Up to one in four girls in Sub-Saharan Africa drops out of school because of an unintended pregnancy.

But the exciting thing is, we know the answer! Empowering women to plan and space their pregnancies, dramatically increases their survival, and that of their children by 50%.

Women in the developing world want the power to choose. Melinda talked of her experiences visiting with women all over the world, and hearing them ask for more information and more resources. They want to understand their own fertility and their natural options; they want access to contraceptives.

Letting women space their own pregnancies means they can stay in school longer. It means they can nourish and raise their babies. It means they can heal after childbirth and contribute to their families and their communities.

Empowered women tend to have fewer babies, because their children survive. Couples make difference decisions when they can count on their children living. And these women have a long term plan: their daughters are twice as likely to be educated if the mother was able to complete her own education.

Do you know what else goes down when women have the information they need to time and space their pregnancies? Abortion rates plummet. Dramatically.

Even in the face of cultural norms that push women to have as many babies as possible, these women see how much is at stake. They see vastly better lives for themselves, their families, and their communities.

By 2020, helping the 120 million women who want help planning their pregnancies will result in: Over 50 million fewer abortions ; Nearly 3 million fewer babies dying in their first year of life; and 200,000 fewer women and girls dying in pregnancy and childbirth.

Healthy timing and spacing of pregnancies is a pro-life, pro-family message.

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But this isn’t just a great theory. We closed yesterday with a few challenges, and I’d like to extend them to you as well.

  1. Go to www.hopethroughhealinghands.org and sign up for our newsletter. Keep in touch, and stay plugged in.
  2. Write your Congressmen. In Tennessee, we live in a state where we do have two moderate-pragmatic Republicans who want to, and do lead on global health issues. But in this political climate, knowing they have your support so that they can offer strong leadership on these issues is so helpful. Send them an email!
  3. Talk about this issue in your social groups, in church, with your friends. Where we’re born is not up to us; we could have been born into these statistics. Jena Lee Nardella of Blood:Water Mission is a partner with HTHH on this, and she put it so well yesterday. This must be personal.

If you want to read more about our conversation and the effort, check out:

The Tennessean article that ran yesterday, including video from the conversation.
The Christian Post covered our conversation, and got some great quotes from our faith partners at Brentwood Baptist Church and Blood:Water Mission
The Time article that Jenny Dyer and I wrote a few months ago.
HTHH’s Toolkit with more information and resources

 

 

Retrospective on Rwanda

I’ve been home from Rwanda and Kenya only a few days and I’m already on another flight, heading back to Aspen, this time for the Aspen Ideas Festival Spotlight: Health, co-sponsored by the Robert Wood Johnson Foundation.

It’s on flights that I have time to reflect on a few takeaways, drawn from the myriad impressions and experiences I gathered in Rwanda. I tell everyone that journeys to Africa are life-changing and indeed this one was for me, and hopefully those who joined me.

  • Partners in Health—that unique Boston-based nonprofit global health organization—is uniquely positioned in Rwanda to develop research-based health service models that can be applied around the world. In fact, we in the States have much to learn from these. It’s well on its way to doing innovative, PROVEN programs of science-based health delivery; creating disciplined training programs; and even taking aggressive cancer therapy to the rural poor in a way that is economical and effective.
  • Paul Farmer should get the Nobel Prize. He has demonstrated in Haiti and Rwanda and around the world that health care can be brought to the people who need it. He has shown the world that therapy once regarded as too expensive to buy and deliver—like HIV treatment—can be effectively and inexpensively administered to the poor and rural. And now he is addressing cancer treatment in rural Rwanda.
  • Gorilla health is like human health. My work with the gorilla health began at the National Zoo in Washington. Some mornings I would scrub in at 6 am over in Rock Creek Park to take care of a sick gorilla before opening the Senate as Majority Leader. My interest in gorilla health continues, and that is why I introduced our group at the base of the Virunga Mountains to the vets with the Mountain Gorilla Veterinary Project, on whose board I served for years. The upland gorilla, whose march toward extinction was reversed by Dian Fossey, has grown in number from 750 to 880 just over the years I have been involved. Animal conservation working hand in hand with animal health makes a difference. As an aside, I want to raise a red flag to the rapidly growing problem throughout Africa of elephants being massacred for ivory.
  • ONE health is a concept and a movement I hope others come to understand. It gives name to my conviction of focusing time and energies on human health, animal health, and environmental health. Health and healing applies to all—in Rwanda to the land around us, the farmers, the cows and buffalo, all interacting integrally with each other, as so clearly manifested at the base of the Virunga Mountains. Living side by side with mutual respect for each is the only answer. Gorillas are extremely susceptible to human-borne illness. Crowding brings buffalo in close contact with the gorillas, contaminating waterholes and leading to disease and death. Too many people still rely on bush meat for food, killing gorilla and monkeys. Gorillas are also threatened by hunters trying to trap antelopes for holidays and celebrations, unintentionally ensnaring baby gorillas. Health for one is health for all.
  • The HRH program in Kigali blew me away. It will work and I predict become the model of the future where governments are not corrupt. It is built around partnerships. Twenty-six US universities partner with USAID, the source of $33 million, to deliver and improve health services in Rwanda. The process through which the money flows goes like this: the American taxpayer gives his money to USAID who channels the money to government of Rwanda led by Paul Kagame who channels the money through the highly respected Minister of Health Dr. Agnes Binagwaho. Dr. Binagwaho distributes the money to the sites; 86 health professionals on the ground lead large programs to improve health service delivery. An orthopedic surgeon from the Brigham in Boston or a hospital administrator from Yale may then come to introduce systems to the Rwandan hospitals and district pharmaceutical distribution center. Over an eight year period, the goal is to train Rwandan workers with the skills and knowledge to build and sustain their own programs over years to come. It is working and it is a wise and smart use of the taxpayers’ dollars.
  • Paul Kagame is the man for the times. He has courageously taken a country that in 1994 was deeply divided by genocide, which claimed the lives of 20% of the population, and deeply divided by artificial colonial convictions, and though strong leadership has reconciled the people, formally achieving forgiveness in the immediate aftermath of neighbor-killing-neighbor, and establishing and maintaining remarkable peace. At the same time his belief in markets and investment has led to 20 years of annualized growth of 8% and is greatly expanding the middle class. His leadership is dramatic. He leads from above but implementation begins at the village level. When the president says thatched grass roofs lead to poor health and suggests replacement, it is each neighborhood that comes together every Friday over a two year period to assist in replacing the grass roofs with metal ones. When it is identified that wearing no shoes, the African custom, allows parasites to enter the body leading to disability and death, a proclamation from above to wear shoes was implemented at the community level almost immediately. The New York Times and New Yorker don’t like him, but I think he is an amazing man who has saved his country of 11 million people.
  • Journeys to Africa by Americans are a good thing. Our group of 10, half of whom had not been to Africa, bonded and shared our own perspectives in a close, personal, and intimate way. Africa touches one’s heart. It inspires. It cause one to dream. It changes your life.
  • Health care is improving fast in Rwanda. Vaccinations far surpass those in the US. Childhood mortality has been cut by 2/3. The basic district health clinics are accessible to all and they place a heavy emphasis on family planning, healthy pregnancies, and early childhood health and nutrition. Maternal, newborn, and child health are the foundations of strong communities. The fledgling national health insurance system is solid and growing fast and has been received well. The system gets by with MRIs and CT scanners. It has only one urologist in the country and five pathologists. Heart surgery is rarely done. But all that will change as the economy improves. The new cancer center at Butero, established at the district hospital as a brainchild of Paul Farmer and the Ministry of Health, will greatly expand cancer therapy the county, heretofore lost in all of the attention on infectious or communicable diseases like HIV, malaria, and tuberculosis.
  • On my return journey, I stopped in Nairobi, Kenya. Crime in Nairobi is high—street crime and home invasions with burglary and carjacking. Al-Shabaab, the al-Qaeda-affiliated Somali terrorist group, is increasingly threatening the city. Tourists are not coming and hotel census is down. Corruption rules the government and police, it seems. But commerce continues and I spent a day in a wonderful market and had top notch service at the Tribe Hotel, where Jonathan, my son, introduced me to the wonderful family who has developed it.

Bipartisanship saves lives

(The Hill, June 24, 2014)

By former Sens. Tom Daschle (D-S.D.) and Bill Frist (R-Tenn.)

When parents in America think about their children turning five, sending them off to kindergarten for the first time can be stressful. But if you live in the developing world, your biggest worry is whether your children will even live to see their fifth birthday.

But that is changing, and this year six million fewer children will die before their 5th birthday than in 1990. To put that in perspective, that’s 2 million more children than are even in kindergarten in America today. Driving that change is an unparalleled reduction in deaths and sickness from pneumonia, diarrhea, measles, HIV/AIDS, malaria, polio and neglected tropical diseases.

This is a global sea change, and if it surprises you, you are not alone. Relatively few Americans are aware of this remarkable story, much less the role the United States and many other global actors played in making it happen.
Americans can be proud that these unprecedented advances would not have happened without our involvement as the largest single donor to global health and working in historic collaboration with the other governments, multilateral institutions, local entities, NGOs, civic groups, faith and business communities, universities and philanthropies.

As the majority and minority leaders of the Senate in 2003 when the President’s Emergency Plan for AIDS Relief, or PEPFAR, was created, we know firsthand how pivotal the U.S. role was in one of the biggest pieces of the global health puzzle.

Through PEPFAR – which President George W. Bush initiated with vision and strength, and President Obama has worked hard to continue – the U.S. led the international community by providing tens of billions of dollars to stop the spread of HIV, giving appropriate care to the millions ravaged by AIDS and keeping them alive with anti-retroviral and other interventions.

PEPFAR is one of the crowning examples of how American resolve and leadership can bring about an enormous impact with a relatively small portion of our national budget. It shows that Democrats and Republicans can actually agree on historic health initiatives, not only on HIV/AIDS, but also in tackling malaria, vaccines, clean water and other smart and effective interventions. That same collaboration of compassion can continue to save millions of lives in the future.

The improved child survival rates are so startling they are hard to believe at first glance. According to a 2013 UNICEF report, the global mortality rate of children under five years old dropped by 47 percent, from 90 deaths per 1,000 live births in 1990 to 48 per 1,000 in 2012. In some regions, the decline in under-five mortality was even steeper– as high as 65 percent in both the East Asia and Pacific and the Latin America and Caribbean regions.

A large portion of the progress came in much of the last decade, not coincidentally after the historic international commitment to the Millennium Development Goals. UNICEF estimates that, as compared to 12 years ago, today 700,000 fewer children die of pneumonia, and 600,000 fewer children die of measles.

Not only did deaths decline, so did sicknesses. Polio cases have decreased by more than 99 percent since 1988, when the disease was endemic in 125 countries. Today, polio is in only three countries. That is nearly all-out eradication of a dreaded malady that it seemed would never go away.

Encouraged as we all should be about the successes so far, there remain 6.6 million children under five who will not reach their fifth birthdays this year, dying mainly from preventable diseases. That is just not acceptable. Without a similar commitment by the U.S. and other international partners in the foreseeable future, we risk squandering the gains of the last 25 years and missing the opportunity to go even further in the next 25. We must keep driving the momentum that got global health to this point.

Some worry the commitment could wane, as Congress has struggled of late to achieve bipartisan consensus on much of anything and, according to a recent Pew Research Center study, a majority of Americans prefer to limit our international engagement to take care of problems at home.

Based on our experience with PEPFAR and other global health initiatives, we are convinced members of Congress from both sides of the aisle remain united around the small, but smart, investments in global health that have historically yielded extraordinary results.

And this week, businesses, NGO, faith, civic and philanthropic leaders are increasing their own investments, coming together to affirm their commitments of more than $2 billion of private resources to invest in ensuring children survive and thrive beyond their fifth birthday.

The world knows what works to increase child survival rates, and we can do this. But doing it will require continue bipartisan cooperation and the energetic grassroots efforts that made the last 25 years of progress possible.

Daschle served South Dakota in the U.S. Senate from 1987 to 2005 and was the Majority Leader from 2001 to 2003. Frist served Tennessee in the U.S. Senate from 1995 to 2007 and was Majority Leader from 2003 to 2007.

Read more: http://thehill.com/opinion/op-ed/210305-bipartisanship-saves-lives#ixzz35Z9818Nt

Watching Global Health Diplomacy in Action: A Week in Rwanda

(Morning Consult, June 23, 2014)

One week ago I had dinner in an open air restaurant overlooking Kigali, Rwanda. It was a beautiful night, and the almost-full moon illuminated Kigali and the land of a thousand hills.

As we were leaving, one of our hosts approached me. A formal and reserved woman, she quietly told me that at the end of her medical school education—about 1999—she almost walked away from the career she’d been building. All of her patients were dying of AIDS; the virus seemed unstoppable. There was nothing she could do to help them. There was no hope.

In despair, she told her Canadian advisor that she was ready to quit medicine. He encouraged her to keep working. “There are therapies to treat this virus in the world. They are young, they are very expensive, but there is reason for hope and optimism,” he told her. “These patients who have led you to despair have a treatment. And someday, if we all work hard, that treatment will be here.”

She had tears in her eyes when she looked up.

“And then,” she said, “you came.”

The “you” was the United States President’s Emergency Plan for AIDS Relief—PEPFAR. PEPFAR initially committed $15 billion starting in 2003 to fight the global HIV/AIDS pandemic. Rwanda was one of the original focus countries.

The United States and PEPFAR turned around a country that had been destroyed, indeed a continent that was being destroyed, by your generosity and your commitment, she said. Drugs that were out of reach, all of the sudden were being distributed to patients.

PEPFAR changed this woman’s life personally too. She stayed in medicine. She became active in public health issues. Today Anita Asiimwe, MD, MPH, is the Minister of State in Charge of Public Health and Primary Care.

I wiped away tears at the earnestness with which Dr. Asiimwe spoke. I looked at Dr. Paul Farmer, who led last week’s Rwanda trip with me, and he was emotional too.

I’ve long believed that health and medicine are the most powerful currency for peace and healing. Public policy matters. The United States is generous and it really affects people’s lives, both patients and providers.

Dr. Asiimwe’s story set the stage for a humbling week.

Dr. Paul Farmer, representing Partners in Health (PIH) and Harvard Medical School, and I, representing Hope Through Healing Hands, led a small coalition to learn more about health care in Rwanda and the progress being made there in the past 20 years.

In 1994, twenty percent of the Rwandan population—about a million people—was murdered in a genocide against the Tutsis over a 100 day period. I have studied the origin of the genocide, visited the memorials, talked with the survivors, read the explanatory books and made multiple journeys to Rwanda ­—but it is still hard for me to fathom. We in the US stood idly by when this happened.

The genocide was rooted in a deep-seated post-colonial divide coupled with eugenic constructs of race grounded in the previous century. All social order was destroyed. HIV infection rates skyrocketed. Child survival plummeted. And health care delivery capacity was nonexistent.

But the people of this country came together and began to rebuild. Formalized programs of reconciliation were embedded in every village and in every place of worship. The government began to plan an equity-oriented national policy focused on people-centered development.

The results speak for themselves. Life expectancy has doubled since the mid-1990s. Premature mortality rates have fallen dramatically in recent years

In 1998 the government released a national development plan based on a comprehensive consultative process coupled with long-term visionary thinking called Vision 2020. The plan involves the principles of people-centered development and social cohesion. Central to the vision is health equity. The government understood that prosperity would not be possible without substantial investments in public health and health care delivery.

In the early 2000s, I visited President Kagame in Rwanda and observed over the course of the day the inclusive consultative process, which brought experts and stakeholders from around the country together to plan for the future. I was impressed, and remember thinking at the time that we in the US should be doing a lot more of this strategic sort of planning.

In 2003 the Rwandan constitution formalized the inalienable right to health. The Rwandan people made the commitment—in contrast to the violence which led to the 1994 genocide—to commit to, and invest in life.

Their work is bearing fruit.

Initially, PIH was a health care provider in the hospitals and health centers it started. But increasingly, PIH has transitioned into more of an advisory role. PIH now supports the Rwandan government in providing services to more than 865,000 people at three district hospitals and 41 health centers, with the help of 4,500 community health workers.

The Rwanda Human Resources for Health (HRH) Program was launched two years ago in collaboration with Harvard Medical School, USAID and other US government programs. About 70 to 100 clinicians, administrators, and planners from Harvard-affiliated hospitals work closely with the Rwandan Ministry of Health to develop the clinical service infrastructure and train healthcare providers.

These groups are laying groundwork that Rwanda is building on to establish its own mature health services. But that doesn’t mean the time for dreaming is over.

Paul Farmer’s next dream for Rwanda is to set up a major multidisciplinary research university in a rural area outside of Kigali. It’s part of his vision to move services, “out to where the people are.” It will train doctors, nurses, and community health workers; it will give broad practical instruction in the post-secondary space; it will give opportunity to people among the poorest regions of the country.

It’s a crazy idea, but—mark my words—you will see it alive in five years.

Farmer already has the Minister of Health and Rwanda’s President on board. He’s funded studies on long-term sustainability. He has initial planning money from two donors, and is working with Melinda Gates on development.

For having survived so much pain, Rwanda has proven itself extraordinarily resilient. Starting with PEPFAR’s HIV/AIDS relief and now the work being done by PIH Rwanda and others, investments in health truly are returning dividends in peace, growth, and healing.

It is global health diplomacy at its best.

Read more: http://themorningconsult.com/2014/06/watching-global-health-diplomacy-action-week-rwanda/

Notes from the Road: Mountain Gorillas

*I’m in Rwanda this week representing Hope Through Healing Hands with Dr. Paul Farmer, Partners in Health Rwanda, and Harvard Medical School. These dispatches from the road are my personal journal–recording what I’ve seen and learned on this trip. See my pre-trip thoughts, and blogs from Monday, Tuesday, and Wednesday

Today we went to see some of Rwanda’s natural treasures: mountain gorillas.

Rwanda has a long history of gorilla conservation. Dian Fossey, author of Gorillas in the Mist, founded the Karisoke Research Center in Rwanda in 1967 and studied gorillas in the Virunga Volcanoes until her death in 1985.

We were hosted by Gorilla Doctors, a mountain gorilla veterinary project supported by the UC Davis Wildlife Health Center and dedicated to saving the mountain gorilla species one gorilla patient at a time. Gorilla Doctors serve the mountain gorillas throughout the Virunga Volcano Mountain Range that spans Uganda, Rwanda, and the Democratic Republic of Congo (DRC).

With Gorilla Doctor guides, we spent six rainy hours trekking through Volcanoes National Park looking for the Titus family of 10 gorillas—including one silverback and one 3 month old newborn. We finally caught up with them at about 9,000 feet.

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These incredible creatures are monogamous vegetarians. Each mother has 4-5 children during her lifetime, starting when she’s about eight years old. They can live to be 43 years.

At one point, the gorilla population here was down to 250 animals. When I visited in 2008, there were 750. Today, Gorilla Doctors estimates that there are 880 gorillas.

But gorillas are not quite the departure from human health that they may seem.

Dr. Jan Ramer, regional manager of the Mountain Gorilla Veterinary Project, explained that Gorilla Doctors approach their work from the “one health” perspective, a belief that the health of one species is inextricably linked to that of its entire ecosystem, including humans and other animal species.

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It’s easy to see how closely the species connect.

The number one killer of gorillas is trauma. On our walk we came across three rope and wire snares. Though meant for antelope, gorillas, especially infants and juveniles, sometimes get caught in these snares. Gorillas may lose limbs or digits to snares, or die as a result of infection or strangulation. Gorilla Doctors respond to reports of gorillas in snares and work to treat their wounds and release them.

The number two killer of gorillas is infectious diseases, and humans and gorillas are susceptible to the same diseases. In fact, the most common infection in gorillas is respiratory disease, which can range from a mild cold to severe pneumonia, in individuals or in whole groups. These diseases are often passed from human to gorilla.

I’ve worked with these animals before, even doing some gorilla surgery, but seeing them in their homes never gets old. Amazing creatures.

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Notes from the Road: Building Infrastructure for Long Term Growth

*I’m in Rwanda this week representing Hope Through Healing Hands with Dr. Paul Farmer, Partners in Health Rwanda, and Harvard Medical School. These dispatches from the road are my personal journal–recording what I’ve seen and learned on this trip. See my pre-trip thoughts, Monday’s blog, and Tuesday’s notes.

This morning we met with patients and physicians at Centre Hospitalier Universitaire de Kigali (CHUK), the urban hospital equivalent. For the past few days we have explored Paul Farmer’s vision of taking health care to the people in rural areas, so often neglected around the world.  Today we looked at health care in the city.

CHUK is the primary teaching hospital, located in the heart of Kigali. With 25 departments—17 clinical and 8 administrative—CHUK provides training, clinical research, and technical support to Rwanda’s 39 district hospitals.

Again we were able to meet patients and hospital staff. I was particularly impressed with this three-year-old little firecracker. He fractured his hip falling out of tree, but that wasn’t keeping him down! I also had the honor of meeting this dedicated woman. She’s served as a nurse in all of CHUK’s departments over the past 11 years.

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Over and over I’m impressed with how much Rwanda, with PIH and other groups, has accomplished.

For instance, Rwanda has one of the highest vaccination rates in the world—a status they have achieved through very hard work over the past eight years.

Vaccines for children here are a series of six individual vaccines that begin at birth over the first two years of life. In a country with about 11.5 million people—the majority of whom are very poor, a 94% vaccination rate has been achieved through national campaigns centered in communities. The vaccines are administered through community health centers in each of the villages. This is really, truly remarkable.

Breast and cervical cancer have been on the rise in Rwanda, so in 2010, a national campaign to vaccinate schoolgirls against HPV began that is gradually making it across the country through community health centers. The hospital at Butaro—where we were yesterday—is participating in research and the collection of data around this vaccine.

It works; it’s a great vaccine. For cervical cancer it’s very important. And Rwanda is taking a leadership role. As you can imagine, cancer is not treated well in the developing parts of the world. So it’s pretty remarkable that both a vaccine program and cancer care are coming together here.

Of course Rwanda’s remarkable progress is contrasted by the genocide that took place here 20 years ago.

This afternoon we visited the moving Kigali Genocide Memorial, where the history of genocide worldwide is powerfully presented. It was a return visit for me, but no less humbling.

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Last time I was here, a bipartisan group of Senators laid a memorial wreath. This time, I considered what Rwanda has accomplished in those 20 years:

  • a dedicated nurse spending 11 years caring for the sick;
  • Partners in Health Rwanda’s work over the past nine years;
  • a nationwide vaccine program against polio, tuberculosis, and measles, for the past eight years; and
  • the PIH Women’s and Girls Initiative training women for the past six years.

But these are only the beginning.

Maybe the most hopeful thing I saw today was the work of Human Resources for Health (HRH). We had the privilege of meeting physicians from this innovative Rwanda-U.S. joint partnership to strengthen the Rwandan health care system.

Harvard Medical School, USAID and other US government programs are funding about 70 to 100 clinicians and administrators and planners through the Rwandan Ministry of Health to develop the clinical service infrastructure.

These are inspiring mid-career physicians from Harvard-affiliated hospitals who are changing the world. Our tour was conducted by an American orthopedic surgeon who is dedicating a period of her life to serving the hospital and the training program of young Rwandan physicians.  They are all heroes.

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The program, funded by the American Taxpayer and in its second year of an eight year commitment, is a tremendously powerful and smart investment in the future.

What is needed in Rwanda—and globally!—is a long term plan. HRH is building up infrastructure which is so badly needed to lift up the health sector here. But equally importantly, their work will make health care in Rwanda sustainable and prepared for the future.

Notes from the Road: Cancer Care in Rural Africa

*I’m in Rwanda this week representing Hope Through Healing Hands with Dr. Paul Farmer, Partners in Health Rwanda, and Harvard Medical School. These dispatches from the road are my personal journal–recording what I’ve seen and learned on this trip. See my pre-trip thoughts, and Monday’s blog

Who says you can’t treat patients suffering from cancer in the poorest, most rural parts of the world?

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I’m writing on my iPhone on a bumpy dirt road that I am told will be paved next year. It winds for two hours through gorgeous green mountains sculpted with terraced plots of land and scattered homes stepped up and down the hillside.

But 30 minutes ago I was on a mountain top in a cancer ward listening to the heart sounds of a 6-year-old boy with leukemia and examining the slowly disappearing lumps on the chest of a 20 year old man with non-Hodgkin’s lymphoma—both being treated with state of the art intravenous chemotherapy.

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Butaro Hospital, based in Burera District, Northern Province, is a PIH-supported facility and home to the Cancer Center of Excellence, a cancer-referral site for all of Rwanda. The cancer ward was opened up in this rural district hospital two years ago. As we toured the wards, we saw children with leukemia, women with breast cancer and men with bowel cancer.

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Paul Farmer introduced to the world the fact that HIV treatment does not have to be expensive and that it can be successfully treated in the poorest parts of the world. No one believed him at first. But he proved them all wrong.

Now he is doing the same for cancer diagnosis and treatment. If it can be pulled off in rural, mountainous, and hard-to-reach Burera, it can be done anywhere.

One third of the patients come from the local district, a third come from outside the district, and a third from around the country and even neighboring countries.

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The hospital has only the essentials: a simple plain film x-ray machine, one ultrasound machine, and basic blood chemistries but nothing like blood cultures. There are no pathologists there—photographs or iPhone pictures can be sent to partner hospitals in Boston, Brigham and Women’s and Dana Farber Cancer Center, when needed.

But the staff is Rwandan and they have been trained in concert with Partners who place a heavy emphasis on fact-based science, research, and clinical training with certification. Pride among the staff bursts forth. People are living and have hope where they were dying in despair.

It’s truly an amazing thing to see.

Notes from the Road: Rwanda and Health Diplomacy in Action

KIGALI, RWANDA | Why are we in Rwanda? What makes it a unique place to learn about health policy, and health care delivery? What will we learn that can make us smarter as we address health issues back at home?
I thought through these questions on the flight to Rwanda, and I had plenty of time. It’s been a long series of flights—Aspen to Denver to Chicago to New York to Amsterdam to Kigali. But the real journey began today as we saw our first health facilities.

Today (Monday), the delegation piled into a Land Rover after breakfast for the 2.5 hour drive to our first stop: the Partners in Health (PIH) headquarters at Rwinkwavu. We toured the Rwinkwavu District Hospital & Health Center, which was funded in part by the Rwandan government, PIH, and Bill & Melinda Gates.

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Formally, I’m here as the Chairman of Hope Through Healing Hands, the global health nonprofit I founded. Having been both a surgeon and a public servant, I am convinced that health and medicine are the best currency for peace and healing worldwide. I started Hope Through Healing Hands to put that belief into action.

It’s a vision that is shared by Dr. Paul Farmer, PIH’s founder and director. Paul has been a friend and like-minded champion for global health for years. He has always had the vision to see things that others could not, the audacity to dream big, and the commitment, dedication, hard work to make his visions–whether a nursing school, hospital, outpatient clinic, or even an entire medical school–a reality. It’s an honor to tour Rwanda with him, and see the progress being made.

When I was last in Rwanda, in the summer of 2008, I was impressed to see how diligently international funds were used (in that case, PEPFAR funding focused on HIV, malaria, and tuberculosis care and prevention). I said then, I wish all Americans could join our delegation to see how wisely their contributions have been spent, and with accountability.

I have seen the same today in the Rwinkwavu District Hospital.

When Rwinkwavu District Hospital first opened, Paul planted several trees there on the property. Standing in their shade today, they are a visual reminder of the growth and progress that PIH—and Rwanda as a whole—has made.

With Paul Farmer under the trees he planted.

With Paul Farmer under the trees he planted.

The district hospital is in Southern Kayonza District, one of three that PIH serves. The 110-bed Rwinkwavu District Hospital and its eight health centers are in remote, rural area, and yet it is delivering care to the poor with both compassion and excellent science.

The highlight of my day was meeting the young researchers at Rwinkwavu who were learning how to conduct sophisticated clinical studies that are and will continue to be published in peer-reviewed journals. They are pushing medicine forward not only in their hospital, but globally as well!

Increasingly the hospitals in Rwanda are seeing surgical disease including cancer. For so many years, the African continent has concentrated on infectious diseases. Now that most of those are under control, the most dramatic emergence is of chronic disease of the heart and lung. In addition, there is a huge need for trauma treatment centers, which are generally nonexistent.

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After our hospital tour, we visited the PIH Women and Girl’s Initiative, a wonderful artisanal cooperative that had been started specifically for teenage girls, ages 12 to 18, an age group that has been neglected a bit in Rwandan society. The 20 young women that we met had dropped out of school for various reasons, but had banded together to start a cooperative and learn about small business. They manufacture purses, robes, aprons, gloves that are truly magnificent. (Yes, I bought an apron.)

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While the medicine being done compels the surgeon in me, from a global health perspective, the most exciting thing about PIH’s work in Rwanda is that it truly is being taken up by the Rwandan people.

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Initially, PIH was a health care provider in these hospitals and health centers. But increasingly, PIH has transitioned into more of an advisory role. PIH now supports the Rwandan government in providing services to more than 865,000 people at Rwinkwavu District Hospital and two other hospitals and 41 health centers, with the help of 4,500 community health workers.

At dinner I had the opportunity to sit beside Dr. Agnes Binagwaho, Rwanda’s Minister of Health. Dr. Binagwaho and I have met several times on my previous trips. She’s been championing public health in Africa since 1994. Tonight she, I, and David Vreeland, discussed the role of information technology in healthcare and the transformation it promises. Rwanda has made outstanding progress implementing health IT to support clinical decision making–a challenge we struggle with in the US as well.

This is the power of global health diplomacy—empowering a community to achieve health, healing, and peace, and seeing incredible gains for the entire global community.

Tomorrow we head North to another province, another hospital, and a cancer center of excellence. I’m excited to see what we learn there.

Off to Rwanda: Considering Child Nutrition

I was in Aspen earlier this week working on some of the challenges facing healthcare and the health industry in the US, but it’s time to switch gears.

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From my 2008 visit to Rwanda with the ONE Campaign.

Sunday, I leave for Rwanda to lead a one week group trip with my friend Dr. Paul Farmer to see some of the work being done by Partners in Health (PIH) in the country. I haven’t been in country since 2008, and I’m anxious to see the progress PIH and other groups are making in health.

Since the spring of 2005, Paul’s PIH organization has been in Rwanda working closely with the government and the Ministry of Health to reach the rural, underserved areas of the country. PIH began by focusing on HIV/AIDS work, but has now expanded to full healthcare offerings. Today, over 800,000 people are served by PIH’s 40 health facilities.

But the health challenges in Rwanda are still vast! Next week with PIH we’ll be considering many aspects of health in Rwanda, but one in particular that I’ll be looking at while I’m there is nutrition.

I firmly believe–and have seen firsthand!–that global health diplomacy works as a real and powerful currency of peace worldwide. And a healthy start to life–a mother enjoying a safe and healthy pregnancy leading to a safe birth and healthy infancy–is crucial to building a foundation that leads to stable communities and global peace.

Food insecurity and malnutrition account for more than half of the deaths of children under 5 in developing countries, and Rwanda has had its fare share of nutrition challenges. In 2005, 18% of children in the country were underweight.

But Rwanda’s government has made real progress in child nutrition since 2009. That year, a Presidential Initiative launched to address malnutrition. The country also joined forces with the US in the Feed the Future initiative.

A 2010 health survey showed that chronic malnutrition and stunting affect 44% of children under the age of 5 in Rwanda.

In September of last year, the Right Honorable Prime Minister, Dr. Pierre Damien Habumuremyi launched a 1,000 Days Campaign, focusing on food availability and a balanced diet for pregnant women through the first two years of life of their babies.

The first 1,000 days may seem like such a small window of opportunity for global change, but the data are clear that childhood undernutrition has long-lasting consequences.

WHO models estimate that over half of adults in the prime working age group–20-29 year olds in Rwanda–have been affected by childhood stunting. Many of these adults wear the visible badges of malnutrition: shorter height or lessened muscular development. And for just as many, malnutrition has exacted a mental toll as well, diminishing the cognitive function of the working age population.

Along with the rest of what we’ll see–including a bit of gorilla trekking and possibly gorilla surgery–I’m anxious to see what progress Rwanda’s 1,000 Days Campaign has made, and the returns realized on nutrition investment.

I’ll be sure to keep you updated.

Call to action on global nutrition

(The Hill, May 28, 2014)

The United States has shown courageous leadership over the last decade on global health. Earlier this year, Congress once again voted to protect the budget for those critical investments that we make to save lives, prevent the transmission of diseases and end preventable child deaths. During my time in Congress, we fought hard for life-saving global health programs. We were able to work together with both Democrat and Republican presidents to launch and implement historic health initiatives in priority areas such as HIV/AIDS, malaria, vaccines, and clean water. These programs have saved millions of lives, and proven that health is the best currency for peace.

But even as funding for global health soared, foundational programs promoting maternal and child nutrition were largely overlooked. Yet the need for greater leadership and investments in nutrition could not be more clear. Across the world today, 162 million children—1 in 4 children under 5 years of age—are physically and developmentally stunted, and 80 percent of those live in just 14 countries. The combination of physical limitations and reduced cognitive development directly linked to poor nutrition sentences these children to lives of unfulfilled potential, and it creates a severe drain on their communities and countries. A 2013 report from the UN Food and Agricultural Organization (FAO) estimates that the social and economic costs of malnutrition are unconscionably high, amounting to as much as $US3.5 trillion per year or $US500 per person globally.

Thanks to U.S. leadership on global health, child death rates have been cut in half over the last 20 years from 12 million to 6 million per year. With continued investments and unwavering leadership, child death rates could be cut in half again over the next decade. We must not save these children, only to abandon them in their most crucial developmental years.

Providing the right nutrients is fundamental to health, particularly during the first 1,000 days from a woman’s pregnancy to her child’s second birthday. In the 2012 Copenhagen Consensus report, an expert panel of economists concluded that every $1 invested in nutrition generates as much as $138 in better health and increased productivity. Yet despite the severe costs associated with malnutrition and the extraordinary returns on nutrition investments, the world spends less than 1 percent of development aid on life saving, basic nutrition solutions.

The tide is turning. In the 2014 budget, Congress provided a funding boost to the global nutrition account, signaling strong bipartisan support to combat malnutrition. President Obama has committed to developing a global nutrition strategy, and USAID Administrator Dr. Raj Shah, who has taken the lead on this initiative, just announced the completion of that strategy and the effort underway to develop a coordination plan across all agencies and programs that contribute to improved nutritional outcomes.

Moreover, in June 2013 at the Nutrition for Growth event in London, the U.S. joined other world leaders and signed a global agreement that will boost global prosperity, prevent millions of infant deaths, and unlock greater human potential by working in partnership with developing countries to tackle malnutrition. This commitment is reflected in the Global Nutrition for Growth Compact, which has been endorsed by over 90 stakeholders.
Governments from Scaling Up Nutrition (SUN) countries and their development partners are also taking nutrition seriously. A total of 50 countries have joined the SUN movement to date, committing to driving forward their national nutrition plans at scale.

These plans and commitments are encouraging, but we must sustain and build upon the momentum that has been created over the last year on global nutrition. The president and Congress must remain resolute in their support for strong global health and nutrition funding in the FY15 budget and in prioritizing nutrition as a critical pillar in our foreign assistance investments. They must work together to oversee the implementation of the new strategy, and to provide the increased resources that are necessary to reach the millions of children who continue to suffer needlessly from poor nutrition.

Investments in maternal and child nutrition build the foundation for the next generation to survive and thrive, and serve as a shining example of U.S. global leadership at its best.

Frist, an acclaimed heart transplant surgeon, served Tennessee in the U.S. Senate from 1995 to 2007. He was Senate Majority Leader from 2003 to 2007. He is chairman of Hope Through Healing Hands and Tennessee SCORE, a professor of surgery and author of six books. Learn more about his work at BillFrist.com.

This article originally ran in The Hill: http://thehill.com/blogs/congress-blog/healthcare/207271-call-to-action-on-global-nutrition#ixzz332ggJvaJ

Happy Memorial Day

Maura C. Sullivan is a former U.S. Marine Corps Captain, Iraq War Veteran and graduate of Harvard Business School. She is a Commissioner, American Battle Monuments Commission– managing America’s overseas WWI & WWII cemeteries.  

Maura has demonstrated exemplary service to this country, continued commitment to public service, and an unusual breadth of experience. I’m proud to call her a friend.

She’s been in France this week welcoming American families who have traveled to spend Memorial Day honoring their loved ones who died abroad for the cause of freedom in World War II. She shared some of her thoughts with me, and I’m honored to share them with you.

I hope you’ll join me in thanking Maura, our other servicemen and women, and the Gold Star Families today.

Bill Frist

I’ve been afforded an incredible honor this year to spend Memorial Day with a Marine Corps “Gold Star” Family at Rhone American Cemetery in France, but I recently realized that many Americans aren’t familiar with the term, Gold Star Family, the honorific we bestow on families when one of their members has died while in uniformed service.

During World War I, families hung banners in their windows with a blue star for each service member.  If their service member was killed, they would replace the blue star with gold.  The tradition continued in WWII and beyond.  Today across America, more than 8,000 families of the Iraq and Afghanistan fallen bear this burden as do countless more from wars dating back to WWII. You can often recognize a Gold Star family member by the simple gold star lapel pin they proudly wear in memory of their loved one.

I am encouraged to see organizations like The American Battle Monuments Commission and The Franco-American Society honoring the sacrifice of our Gold Star Families and ensuring that the legacy of their service is passed down to future generations.  They join President Obama, who called upon the nation to honor Gold Star Families by issuing a Presidential Proclamation in 2010 declaring the last Sunday in September to be Gold Star Mothers’ and Families Day.  Additionally, The Marines’ Memorial  Club in San Francisco hosts an annual Gold Star Parents Honor and Remembrance  Weekend and the U.S. Army announced this past February that it will release three public service announcements over the next year to increase awareness of Department of Defense-issued Gold Star and next-of-kin lapel pins

Freedom is not free.  Many families paid dearly for it.  Let us cherish them this Memorial Day and hold them close to our hearts.  If you have the honor of meeting a Gold Star family member, thank them for their sacrifice and perhaps inquire about their loved one who died fulfilling the most fundamental and sacred obligation of our nation.

 

The Case For Global Health Diplomacy

(Health Affairs Blog, April 14, 2014)

At the end of February, I had the pleasure of speaking about global health diplomacy at the Nursing Leadership in Global Health Symposium at Vanderbilt University. Nurses are one of the specialties that we support in the Frist Global Health Leaders program facilitated by Hope Through Healing Hands, a nonprofit dedicated to advancing peace by supporting health care services and education in some of the world’s most vulnerable communities. Nurses, including the men and women I met at Vanderbilt, have an enormous opportunity to affect health and global health diplomacy. Indeed, everyone in the medical profession can play a crucial role in health diplomacy.

Global Health Diplomacy And Foreign Policy

For several years now I’ve been thinking about—and speaking about—global health diplomacy. The term started appearing around 2000 and has many definitions, representing the complexity of the issue itself. Diplomacy, at the simplest level, is a tool used in negotiating foreign policy. Health diplomacy is different, though. As a physician, the overall goal of health is clear: improve quality of life by improving health and meeting overall patient goals of care. As a diplomat and policymaker, the goal is more complicated.

The full text of this story is available for free at the Health Affairs Blog at http://healthaffairs.org/blog/2014/04/14/the-case-for-global-health-diplomacy/

 

Contraception Is A Pro-Life Cause In Developing World

(Time Magazine, March 21, 2014)

By Bill Frist, M.D. and Jenny Eaton Dyer, Ph.D.

When it comes to the health of children and mothers worldwide, there are immense challenges yet many signs of hope.

Over 6.9 million children die every year in the developing world from preventable, treatable causes. While the loss of these children is a tragedy of epic proportions, the good news is that over the last six years, this number has been lowered by 35%. We know we can combat newborn mortality and enhance child survival. Simple, low-cost measures are being taken to ensure better health for these children around the world. Measures like oral rehydration therapy, bed nets to prevent malaria, and access to immunizations have accelerated the rate of reducing child mortality in developing nations.

With an increased focus on maternal, newborn, and child health over the past few years, the global community has seen real progress against daunting challenges. An underappreciated part of that story is healthy birth spacing and timing, or family planning, which has a profound effect on the survival and quality of life of both mothers and children. As Michael Gerson, former speechwriter for President George W. Bush and Washington Post columnist, puts it, “family planning is a pro-life cause.”

When we talk about voluntary family planning in the international context, what do we mean? The definition I use is enabling women and couples to determine the number of pregnancies and their timing, and equipping women to use voluntary methods for preventing pregnancy, not including abortion, that are harmonious with their values and beliefs.

It shocks Americans to learn that one in every 39 child-bearing women in sub-Saharan Africa die in childbirth. However, when a woman delays her first pregnancy until she is at least 18, her chances of surviving childbirth increase dramatically. If she can space her pregnancies — through fertility-awareness methods (sometimes called natural family planning) or modern contraceptive tools — to at least three years between births, she is more likely to survive and her children are more than twice as likely to survive infancy.

The Center for Strategic and International Studies (CSIS) hosted a delegation in February for congressional staff, foundation, and nonprofit leaders, including Jenny Eaton Dyer, to see the emerging success of family planning in Ethiopia. With the infrastructure of their path-breaking Health Extension Worker (HEW) program, training 38,000 women as health workers in just a few years, women in the most rural communities now have access to antenatal care and family planning. With a Health Post designated for every 5,000 people, women have access to tools for healthy timing and spacing of pregnancies without having to walk for miles to a higher level health facility. In less than a decade, since 2005, Ethiopia’s contraceptive prevalence rate has nearly doubled, from 15% to 29%.

Healthy timing and spacing of pregnancies, alongside an increase in births taking place in Health Centers with skilled care during delivery and post-partum care, offers a strikingly successful model to reduce maternal mortality and improve child survival.

In addition to expanding access to voluntary family planning information and services, Melinda Gates, co-chair of the Bill & Melinda Gates Foundation, has also focused on healthy timing and spacing of pregnancies as a critical factor for global health and development. Hope Through Healing Hands, with support from the Gates Foundation, is promoting awareness and advocacy among Americans to support maternal, newborn, and child health. We are highlighting the crucial role that voluntary family planning is playing in nations such as Ethiopia.

Healthy timing and spacing of pregnancies does more than save lives from health risks: it also allows girls to stay in school. In Ethiopia, where the average age of marriage is just 16 (with many girls married as young as age 11), girls are often forced to drop out of secondary school to begin families. If girls can delay their first pregnancy and stay in school, ideally until the university level, they will be better equipped to partner with their husbands to meet their children’s needs, in a more stable family economic environment.

And as First Lady Roman Tesfaye of Ethiopia stated, “When a mother can contribute to her own life and family, she contributes to the nation as a whole.” Moving beyond the national level, healthy timing and spacing of pregnancies is also a key to other global health goals, like combating hunger and improving the status of women and girls. Family planning is a key, often hidden, engine for additional global health achievements.
Family Planning 2020 is a global partnership of more than 20 governments working with civil society, multilateral organizations, the private sector and others. Created at a 2012 London summit, it represents a commitment to meet the needs of an additional 120 million women who want to delay or prevent pregnancy but lack access to information and tools.

With a focus on healthy timing and spacing of pregnancies, we can make major strides in just a few years. That’s great news for mothers, children, and our entire world.

Bill Frist is a former U.S. Senator from Tennessee. Jenny Eaton Dyer, Ph.D., is the executive director of Hope Through Healing Hands.

This article original ran in Time Magazine: http://time.com/33905/bill-frist-contraception-is-a-pro-life-cause-in-developing-world/

Building a Healthier America

Last week I joined the Partnership for a Healthier America (PHA)’s Building a Healthier Future Summit. It was a fun meeting with lots of good food and guest appearances by Sesame Street’s Abby Cadabby and Doug E. Fresh.

I’m a firm believer that we must make the healthy choice the easy choice to change behavior and improve health. I was happy to see that a lot of other people are working toward that as well.

If you want to scan the live comments, follow the #PHASummit hashtag, but here are just a few of my notes and thoughts from the event…

Michelle Obama spoke and I was happy to hear her encouraging home cooking as a solution to childhood obesity. It’s a message she says she’ll continue to champion after the end of this presidential term. Cooking at home and eating as a family promotes better nutrition and cost savings, Ms. Obama said.

PHA announced several new partners: Dannon, Del Monte, Kwik Trip, Sodexo, Nutri Ventures, Knowledge Universe, FirstBIKE, UnityPoint Health-Trinity, Eskenazi Health, Meridian and St. Luke’s Hospital all made commitments to making healthier choices more accessible and affordable for busy parents and families.

In particular:

Dannon committed to improving nutrient density and reducing sugar and fat in its yogurt products. Dannon will also invest in education and research focused on healthy eating habits.

Del Monte Foods committed to improving the nutrient density of what it sells through marketing and new product innovation. It also is donating more fruit and vegetable products to anti-hunger efforts.

Kwik Trip, a family-owned business that runs more than 400 convenience stores and other outlets in Wisconsin, Minnesota and Iowa, committed to improving healthier food access and implementing a new EATSmart program and other policies that promote healthy habits among consumers. Kwik Trip will also start a Healthy Concessions Program that allows organizations to purchase healthier items at discounted prices to use in their fundraising efforts.

FirstBIKE is committing to donate balance bikes to the YMCA and similar organizations in order to provide increased physical activity opportunities for children in early childcare environments.

Knowledge Universe is implementing specific standards that promote healthier behavior at its KinderCare, CCLC and Champions centers, focusing on limiting screen time, providing ample opportunities for physical activity, healthy food and beverage choices, accommodating mothers who wish to breastfeed and offering engagement and nutrition education for parents.

Nutri Ventures committed to use its multi-media entertainment to promote healthy lifestyles and nutritious foods to children across the country.

Sodexo committed to implement healthy dining programs in 95 percent of its food service accounts, expand healthier food choices in hospitals, offer more free breakfast meals in schools and increase the selection of healthier, more nutritious options in its vending and K-12 lunchroom programs.

Eskenazi Health, Meridian, St. Luke’s Hospital and UnityPoint Health – Trinity have joined nearly 400 hospitals in PHA’s Hospital Healthy Food Initiative in a commitment to offer more healthy options throughout their facilities over the next few years. These hospitals will implement PHA’s Hospital Healthy Food Initiative guidelines, which include improving the nutrition of patient meals as well as that of the food options in on-site cafeterias.

All of the companies set specific benchmarks for their commitments, and you can read those at the PHA website. Dannon, Del Monte and Kwik Trip and FirstBIKE, Knowledge University, Sodexo, Nutri Ventures, and the hospitals.

Investing in Healthy Mothers and Children Worldwide

Earlier this week, a project we’ve been working on for months finally came to fruition! Hope Through Healing Hands announced a partnership with the Bill & Melinda Gates Foundation to launch the Faith-Based Coalition for Healthy Mothers and Children Worldwide.

Since 2004, Hope Through Healing Hands has made investments to support infrastructure, sustainable health development, education, healthcare, and emergency relief in developing nations.

We’ve sponsored the placement of over 75 medical, nursing, and public health students as well as medical residents in underserved clinics around the globe to bolster health care support and provide training to community health workers. We have invested in the education of young health professionals to help stem the global health worker crisis.

HTHH’s newest initiative, with the help of the Bill & Melinda Gates Foundation, might be our biggest effort yet.

  • Every year, complications from pregnancy and childbirth claim the lives of nearly 287,000 women and permanently disable many more, mostly in developing countries.
  • Children born to women younger than 18 years have an excess mortality risk of about 40% and are more likely to be stunted and anemic than children born to women over 18 years of age.
  • 42 million unplanned pregnancies worldwide end in abortion. 67,000 women die because of abortion-related injuries and millions more suffer complications and long-term injuries.

Yet if 120 million women get access to information on the healthy timing and spacing of pregnancies, 200,000 fewer women and girls will die in childbirth by 2020 and 3 million fewer babies will die in their first year of life by 2020. Fifty million abortions will be avoided by 2020.

The impact will be incredible.

The savings is not only counted in lives of women, girls, and newborns. Every dollar spent in family planning in a developing nation saves the country $4 in needed government services and support down the road. Healthy women can better care for themselves, their families, and build their communities.

How do we do this? By educating women in developing countries about the safest ages for pregnancy (between 18 and 34). By offering women contraception options (NOT including abortion) to help them space their children 2-3 years apart so that mothers can fully heal, and babies can get more of what they need that crucial first year.

Our work at HTHH is to spread the word, to build a coalition of faith-leaders and conservatives to promote awareness and advocacy for maternal, newborn, and child health with a focus on healthy timing and spacing of pregnancies. We’ve got several great initiatives planned. The Faith-Based Coalition for Healthy Mothers and Children Worldwide will offer education and advocacy support. There are opportunities to join us on our website.

This is an opportunity to profoundly impact future generations, and I’m so thrilled Hope Through Healing Hands will be leading the charge on behalf of these little ones and their families!

The Cadillac Tax: Implications and a Potential Silver Lining?

(Forbes, February 26, 2014 )

Like much of the Affordable Care Act, the Cadillac tax—Obamacare’s solution to a tax subsidy created during World War II—offers a solution to an important problem, but is fraught with unintended consequences. Ideally, the tax would prompt employers to offer more cost-effective plans, with some shift of risk to employees along with mechanisms to help employees spend healthcare dollars wisely. For many reasons, that is not likely to be the reality.

The Cadillac Tax was designed to raise revenue for the ACA and it will. But we cannot continue to be the little Dutch boy with our finger in the dam. There is an opportunity here to allow the impact of the Cadillac tax to be positive and encourage real restructuring of healthcare spending.

Most economists thinking seriously about the depth of our deficit agree that the Employer Sponsored Insurance (ESI) tax subsidy is a significant part of the problem. ESI subsidies date back to the freeze on wage increases during World War II. To offset the freeze, the ESI allowed companies to use pre-tax dollars to pay for generous health benefits tax-free.

Of course that was nearly 70 years ago. Today, wages are free to rise, yet the ESI subsidy still costs $250 billion a year. What’s more, that cost only benefits about half of Americans: those with employer-sponsored health insurance.

Today, the ESI subsidy encourages overspending in health care by allowing money to be taken out of the normal wage tax structure and put into a safe haven if spent on health plans. The tax structure encourages the misappropriation of fund towards bloated health plans and is regressive.

The ability to funnel wages into health benefits is not just the purview of the wealthy. State and local government workers often find much of their compensation tied up in health benefits. Governments and many unions use the subsidy to compensate middle-income workers at a lower cost to the employer.

Rather than simply repealing the old tax structure, the Obamacare solution is an additional tax, a penalty imposed on “Cadillac” or very high cost health plans. It calls for a 40% excise tax on employer-sponsored plans spending more than $10,200 per employee (or $27,500 per family). This number includes employer and employee-paid premiums and employer contributions to Health Savings Accounts (HSAs) or Flexible Spending Accounts (FSAs). There will purportedly be some adjustment for areas where healthcare is more expensive and for employees in high-risk jobs, but the regulations have not yet been promulgated.

The purpose of the Cadillac tax is threefold: to address cost of the ESI, to help finance the Affordable Care Act (ACA), and to reduce employer incentive to overspend on health plans and employee incentive to overuse services encouraged by these high-cost plans.

The Congressional Budget Office (CBO) originally projected the tax would raise $137 billion over the first decade starting in 2013. However, due to effective lobbying by pro-union groups and others, the tax is delayed until 2018 and CBO expects it to raise $80 billion between 2018-2023. Other experts estimate as much as $214 billion raised by 2023 based on indirect revenue from wage increases.[1] But beyond its role as a funding mechanism, the Cadillac tax could have significant unintended consequences for employees and the health system as a whole.

Based on the plan size defined by the tax, in 2018, about 16% of employer-sponsored plans will be affected. However, if healthcare spending continues to exceed inflation, a greater percentage of plans will qualify as “Cadillac plans”—spending more than $10,200 per employee or $27,500 per family— each year. The tax is tied to the Consumer Price Index (CPI) +1% for the first 2 years of implementation but then just the CPI. If healthcare spending continues to grow at approximately 6% per year (the historic average, though it has grown at a lower rate in recent years), the Cadillac tax will swallow 75% of employer-sponsored plans by 2029.

This should be a significant enough impact to change employer behavior, but will the change be positive or negative? I can see at least three major potential impacts of the incentive created to slim down “bloated” health plans.

First, employers will move toward reducing the cost of plans to avoid the tax, but not to curb overall health care spending. A 2013 survey by the International Foundation of Employee Benefit Plans[2] revealed that of the 879 single-employer plans they surveyed, 40% of employers responded that they were currently making changes in their insurance plans to avoid the tax and 16.8% stated they were seriously considering it.

The most obvious strategy for lowering employer contribution is to pass costs to employees, either as higher employee premiums, higher deductible plans, removing employer contribution to HSAs and FSAs, increasing co-pays and coinsurance, or just decreasing covered services. While these changes may avoid the tax, they will only decrease the healthcare costs of an employer’s work force if the employee then turns around and spends their healthcare dollars wisely. Alternatively, if employees just avoid healthcare they need due to cost, it could result in more expensive hospitalizations and sick days down the road.

Second, “high-cost” plans are not necessarily “benefit-rich” plans. Sicker populations, including the elderly and chronically ill, and populations with more women are simply more expensive to insure. Despite attempts to tailor their plans, employers will not be able to decrease their community rating if they have large numbers of older employers and women. Especially considering the ACA requires more comprehensive coverage for some areas like preventative and obstetrical care, creating a “bare bones” plan is actually antithetical to the rest of the ACA. To dodge this internal inconsistency, workers will likely find themselves in the exchanges. While these workers will still have a health insurance option, if it happens in great numbers it will affect the cost of premiums in the exchanges. In other words, the exchanges will take on the risk and cost of insuring older and sicker workers without the balance of the young-healthy population to share the cost.

Finally, given that state and local employers frequently use benefits to make up for lower salaries, the tax will likely affect your garbage man and your child’s teacher. This may result in increased salary, but will definitely result in decreased benefits, higher premiums, and more cost sharing. Due to the misalignment of inflation and the cost of healthcare—healthcare costs rise faster than inflation—a subtle whittling of plans each year to avoid the Cadillac tax will eventually lead to an underinsured work force. We are already hearing stories about people taking on higher deductible plans where the deductible exceeds their ability to pay. In other words, the Affordable Care Act will result in unaffordable plans and an underinsured workforce.

On the bright side, the Cadillac tax could have a positive impact on the pricing of healthcare if employers take into account the long-term effects of their immediate maneuvers to avoid the tax. Rather than scheming to avoid the tax at all costs, employers can accept some portion of increased tax while instituting cost-sharing mechanisms that use consumer shopping and market forces to drive down overall healthcare prices. For example, employers can employ strategies like referenced-based pricing and consolidation of services with specific providers to allow for lower contracted costs. Creative solutions like these will actually decrease the cost of care, not just move money around on the balance sheet.

We need to attack the cost of healthcare at its source: level of use and initial pricing of services. Simply adding another tax that will indeed raise money but will not change cost is just biding time. Employers have an opportunity here to be pioneers. While the Cadillac tax may change some with revised legislation, it is an idea that has stuck and it addresses a problem that needs solving. This is an opportunity for innovation and change in the private market that can truly impact healthcare behavior and habits.

This story originally ran in Forbes: http://www.forbes.com/sites/theapothecary/2014/02/26/obamacares-cadillac-tax-could-help-reduce-the-cost-of-health-care/

 

[1] B. Herring & L, Korin Lentz (2011) What Can We Expect from the “Cadillac Tax” in 2018 and Beyond?. Inquiry: Winter 2011/2012, Vol. 48, No. 4, pp. 322-337.

[2] International Foundation of Employee Benefit Plans. 2013 Employer-Sponsored Health Care: ACA’s Impact: Survey Results, available at http://www.ifebp.org/pdf/research/2103ACAImpactSurvey.pdf

Connected Health and the Rise of the Patient Consumer

(Health Affairs, February 2014)

How to achieve better care at a lower cost? Two powerful new forces may hold the answer.

America’s health care delivery sector stands at a tipping point—a convergence of a growing, graying, and highly consumptive population with increasingly limited financial and human capital resources.

Policy makers naturally gravitate toward government to provide the framework for solutions to this worsening scenario in which demand outstrips available resources. I’ve spent about equal time in government and the private health sector, and I believe there are two other levers that are more likely to be effective.

The first lever is the rapid ascent of the newly empowered consumer, equipped for the first time with actionable knowledge that can affect his or her health. The second consists of magnificent advances in information technology (IT). The exponential growth and application of these technologies are revolutionizing, in a very short period of time, the automation, connectivity, decision support, and mining of health information and data, which together will radically transform and improve health care delivery.

These two forces are just beginning to come of age. Neither was a significant driver of health care value just three years ago. Today their potential is enormous. Together, the empowered consumer and rapidly advancing health IT will channel our chaotic, fragmented, and wasteful health care sector toward a more seamless, transparent, accountable, and efficient system. They will answer the underlying question of how we will get better care for less cost. They will be the primary keys for game-changing, value-driven reform, where provider compensation and payments are determined not by the type and number of specific services rendered but by the quality and outcomes of care provided.

The rest of this article is available for free courtesy of Health Affairs.

 

 

Tennessee at Crossroads: 2013-14 State of Education Report

When SCORE was launched in 2009, we identified a “once in a lifetime opportunity” for unprecedented growth in student achievement in Tennessee. In November, we have learned that the efforts of educators, policymakers, and other stakeholders have helped Tennessee become the fastest improving state in the nation – and 2nd overall behind the District of Columbia – in terms of student achievement according to the Nation’s Report Card.

It was a huge achievement for Tennessee. But it was only the beginning.

Tennessee is at a crossroad – a critical point – in its pursuit of a better public education system. Tennessee is still under the NAEP national average, and we can’t lose our sense of urgency.

At SCORE, we believe it is critically important for a non-partisan, non-governmental organization to examine our state’s progress, to identify promising practices as well as challenges, and to provide specific recommendations for how Tennessee can continue on the pathway of preparing all students for success in college and the workforce.

The 2013-14 State of Education in Tennessee Report reflects months of research and more than 500 interviews with educators, students, policymakers, and other Tennesseans.

This year’s report is grounded in five key areas that we believe are crucial to Tennessee’s work to improve student achievement in the year ahead: Maintaining a commitment to rigorous standards and assessments; Strengthening schools through effective leadership; Expanding student access to great teaching; Investing in technology to enhance instruction; and Supporting students from kindergarten to career.

Under these headings are many specific recommendations. Here are just a few that I highlighted this morning.

  • Tennessee must stay the course on the continued implementation of the Common Core State Standards.
  • Because measuring student success with higher standards is a precursor to informing effective instruction, Tennessee must continue its commitment to implementing the PARCC assessments.
  • Principal preparation programs in our state should have rigorous selection processes and curriculum requirements that prioritize the skills that instructional leaders need.
  • Teacher support is crucial. It is imperative that teachers are provided with the tools and resources that will enable them to be experts in their profession.
  • School districts should create, as well as protect, time and opportunities throughout the academic year for high-quality professional learning that increases educator effectiveness and results for students.
  • It is critical that public policy implementation enables the state to attract and retain the best teachers.
  • It is important to use technology as a vehicle for quality instruction and for individualizing student learning.
  • We must increase and expand opportunities for high school students to participate in rigorous coursework including AP, International Baccalaureate, dual-credit, and dual-enrollment courses.

These are just a sampling of the points from the full study. I encourage you to visit SCORE’s website to read the full report.

We have great work ahead of us, Tennessee. But we’ve proven that the stakeholders in Tennessee education–the teachers, students, administrators, parents, and policy-makers–are committed to excellence and growth.

Digitize your own advanced-care plan

(The Hill, December 18, 2013)

End of life planning is so important. It’s a topic I’ve spoken on frequently. But it’s not just a plan that you need. Your family members must be able to find it when they need it. That’s why free, online tools like the ones My Directives offers are so valuable! It makes your wishes available any time, anywhere. 

The holidays are here, and with them time to gather with family and friends. This year, as we gather around the holiday table, I suspect that healthcare will be a common theme.

I challenge you, though, to move beyond the politics to discuss a topic that really matters: you, your voice, your thoughts. Who do you want empowered to speak for you during a medical crisis if you can’t? What kind of medical care would you want, or want to avoid? What are your hopes and fears if you were in an emergency situation?

While some of us might have thought about if we would want life-saving measures used, such as CPR or a ventilator, not nearly enough of us have shared those preferences with our loved ones, and even fewer have documented them in an advance medical directive.

Now, here’s the kicker. For the very few who have created a directive, can we — or better yet, our future doctors — access it immediately if needed?

While you might feel powerless to affect health reform, you can take charge of your own care by using this holiday season to discuss your thoughts and digitize them so your preferences are known. Make your voice heard. Don’t wait for an accident or illness to strike — there’s too much else to focus on, and your decisions need to be clear.

As a transplant surgeon, I saw critical health situations every day. I know firsthand the emotions that accompany the time spent in emergency rooms and intensive care wings. I’ve walked that road with hundreds of patients and their families.

Consider that at the end of life, nearly all patients will lose the ability to make their treatment preferences known — some in their last days, others for weeks or months on end. In the absence of advance care planning, patients are much more likely to receive medical interventions that can actually prolong or worsen their suffering and will certainly increase expense for their loved ones.

For example, cancer patients without advance care planning are seven times more likely to be placed on mechanical ventilation, and eight times more likely to have emergency CPR prior to death. On the other hand, nursing home patients who engage in such planning are less frequently hospitalized, report improved patient and family satisfaction, and experience 33 percent lower costs of care.

I imagine some of you are thinking, “Yes, this makes sense for my parents or grandparents.” I can assure you this is not a topic just for the elderly or sick; this is a topic for all of us. Talk of “death panels” during the healthcare debate was a distraction — and a dangerous one, at that. The truth is that we all need to take personal responsibility for our own end-of-life wishes.

If you won’t create your directive for yourself, do it to relieve a burden on your loved ones. I’ve talked with patients and families across the country about their end-of-life experiences. Families report that facing a decision about a loved one’s treatment near the end of life is one of the most stressful life events. However, for families whose loved ones have prepared a treatment plan, the experience is more peaceful. These families are able to take advantage of precious time together, rather than worry about and debate the right course of action.

There’s no better time than during the holidays to start the conversation with your loved ones. MyDirectives.com, for instance, offers free digital advance medical directive forms online with instructions on completion and how to introduce the subject with family. The service helps ensure doctors can find your directive online during a crisis.

When a good advance directive is in place, providers can better do their jobs, and patients can be confident that their wishes will be part of the treatment process. Your doctors are medical experts, but only you are the expert on your hopes and preferences. An advance care plan relieves your family and physicians of the burden of having to guess your wishes.

These days, we’re hearing many voices in support of — or in opposition to — various parts of the healthcare law. But when it comes to one of the most important healthcare decisions you will ever make, the voice we really need to hear is yours.

Frist represented Tennessee in the U.S. Senate from 1995-2007 and was Senate majority leader from 2003-2007. He is a heart and lung transplant surgeon.

This story originally ran in The Hill: http://thehill.com/opinion/op-ed/193444-digitize-your-own-advanced-care-plan

End-of-life stories give us impetus to learn

(The Tennessean, December 1, 2013)

By Sen. Bill Frist, M.D. and Manoj Jain M.D.

Authors’ note: This is the final of six parts. We are honored and extremely grateful that so many shared their family stories with us. We have preserved the stories but have changed individuals’ names.

Over the past three months, as we have journeyed through the difficult topic of “end-of-life care,” we’ve had the privilege of hearing from many Tennesseans. You have shared stories of tender passings, tales of deep struggle, and accounts of sheer confusion and angst at the end of life of a loved one. The personal stories you’ve entrusted to us have renewed our passion and commitment to enable conversations in families, with doctors and in the community that will ensure loving and peaceful experiences at the end of life.

Milly described how this summer her husband suffered a massive stroke, which left him unable to feed himself and, even worse, unable to swallow food without aspirating. Milly and her husband had prepared for such a day because they had endured the painful death of her stepfather the previous summer: an experience in which he was left mute and paralyzed for months in the nursing home.

Include family in plan

Initially, Milly said, her children were alarmed and angered at the thought of forgoing more aggressive treatment in the hospital. While Milly and her husband had signed advanced directives together, they hadn’t shared their plans with the children. Thankfully, when they saw their father’s signature on the advance directive papers their anxiety was eased and they graciously accepted his wishes. Milly describes her husband’s last two weeks at home with hospice as “tough” but infinitely better than being in the hospital or the nursing home.

As with many families, it took a painful experience for Milly and her husband to realize the importance of planning for end of life. We encourage everyone to take the first step now, and not wait for a tragic experience to underscore the need for end-of-life preparation.

Once you’ve made your decisions, share your wishes with your loved ones. Knowing that the choice is yours relieves family of the burden of making difficult decisions.

Joe shared the medical journey of his wife, who was diagnosed with lung cancer and was told she had less than a year to live. She began chemotherapy and for four years enjoyed a good quality of life, able to care for herself and spend precious time with her family. When her tumor spread into her spinal cord, Joe’s wife wanted to continue chemotherapy and simultaneously begin hospice, yet hospice declined. Forced to choose, she ultimately returned home with hospice support and died surrounded by family.

Strings attached

Joe and his family experienced a sad reality in much of end-of-life care: Services are available, but they have strings attached. Hospice is a service offered to Medicare patients at no cost; yet, for patients to be eligible for hospice their life expectancy must be less than six months and they must no longer be taking any active treatments such as chemotherapy.

There is need for a sea change in end-of-life care, and models of palliative care are gaining ground in Tennessee. For example, Aspire Health aims to build a patient-centered comprehensive service that doesn’t demand a choice.

A final story: Grace’s parents’ health declined together over several months. While recovering from a heart attack, her father was diagnosed with rapidly progressing Lewy body dementia. Hospital social workers suggested a nursing home with physical therapy, but after family discussion and much prayer, Grace’s family decided to make the transition to hospice. Grace’s father died in his home surrounded by family.

‘See you soon’

Grace’s mother’s last words to her husband of almost 70 years were “I will see you soon.” She became ill the day of her husband’s funeral, was diagnosed with pneumonia and congestive heart failure, and died six weeks later.

For Grace, the tandem death of her parents seemed “surreal,” but the coordinated care from the primary care team, the hospice team and the home caregivers made it possible to endure those months and glean the best from them.

The experience was also made easier by her father’s meticulous preparations. He had carefully planned for the end of his life, even including a note reminding his family to “call the church sexton (during the funeral) so he’ll open the church so people can go to the bathroom.”

In sharing their stories, Milly, Joe and Grace have given all of us the impetus to learn from their experiences. Health care is complex. We are working within the medical community to increase the options for end-of-life care, but it is up to us all as individuals to initiate conversations about end-of-life wishes with our families.

If you’re still unsure where to begin, Alive Hospice, in Nashville, has launched The Gift Initiative this holiday season, encouraging all of us to give ourselves and our loved ones the ultimate gift of peace and preparation. Resources and free materials are available atwww.thegiftinitiative.org.

For many, the Isaac Asimov quote holds true: “Life is pleasant. Death is peaceful. It is the transition that is troublesome.” But we believe that with thoughtful preparation, peace of mind is available to us all at the time of transition.

Bill Frist is a heart transplant surgeon and former U.S. Senate majority leader. Manoj Jain is a Tennessee doctor who writes for The Washington Post.

Originally posted at: http://www.tennessean.com/apps/pbcs.dll/article?AID=2013312010072

Notes from the Road: Global South Summit 2013

NASHVILLE | At the Global South Summit last week, I moderated a panel on one of my favorite topics: transforming healthcare into health.

There is much discussion about how the current model of healthcare is “broken.” But the fact is, the system is producing exactly what it was designed to produce. The problem is that the current healthcare model was designed around brick and mortar buildings supporting the delivery of services and procedures. It is a sector with misaligned and misplaced incentives that leads to inefficiency and lowered productivity.

Calling it “broken” suggests that we need to return it to a previously working state. The truth is we need a radical redesign.

In tackling that question, I was joined by a panel of some of the top innovators in the country.

  • Jean Claude Saada, Chairman, Cambridge Holdings;
  • Dr. Clare Pomeroy, President and CEO, Lasker Foundation;
  • Dr. Jeffrey Balser, Vice Chancellor, Vanderbilt Medical Center;
  • Bill Gracey, President and CEO, Blue Cross/Blue Shield, Tennessee; and
  • Dr. Eric Bing, Director of Global Health, George W. Bush Institute, Southern Methodist University.

As Chairman and CEO of Cambridge Holdings in Dallas, Jean Claude Saada is launching a new strategic initiative to create “mindful living communities” and innovation hubs in major cities and research centers around the US and world: oneC1TY.

The idea, Saada said, came from speaking with his own grandmother. She lives in a small community surrounded by her friends and family. She walks to the market, to church, eats and cooks at home daily and grows her own produce. Her life and relationships are centered on a community within walking distance and includes everything she needs. The anecdote is backed by research into communities where people live the longest. Researchers found that they tended to have leaner diets and access to fresh food. They were active. They kept their minds active. They conversed more with family and friends and lived outdoors. Saada was inspired to deliberately build similar communities that enable healthy living.

Before Claire Pomeroy took her role as President and CEO of the Lasker Foundation, she served as Vice Chancellor and Dean of the UC Davis Health System. She knows that the mission—health—is often forgotten. When looking at the determinants of health, only 10% is actually health systems, she said. The rest is determined by behavior, genetics and social determinants. For example, the largest driver of children’s health is the educational status of mom!

Health outcomes just don’t improve unless you address the social determinants of health, and Pomeroy called for community partnerships to address the biggest needs, whether that’s violence, mental health, or dental care. We also have to address education, transportation and food deserts, she said. (Read a great article from the Washington Post on the food deserts in our country). The focus must shift and non-traditional partnerships must emerge. Pomeroy called for a culture change, a look at the big picture, and “health in all policies.”

I asked Jeff Balser at Vanderbilt Medical Center what role university medical centers should play in helping us move health and healthcare forward. He stressed the importance of research, and noted that it is changing as well. The system of doing research, publishing it and hoping it is impactful in 20 years is not the current case, he said. Now researchers could watch the discovery of a gene in their training lab actually guide drug design and make it to the market in a clinical trial within the time it takes to complete their PhD.

Big data, Balser said, is emerging both as a research resource and a care resource. For example, each case of diabetes is different with a different prognosis and outcome because the natural history of a diagnosis is patient specific. My mother’s diabetes is not my best friend’s diabetes, so offering them both the same treatment plan is not maximizing the impact of the health intervention.  Personalization of treatment based on not just genetics, but the social determinants of health can be a challenge but it is also an amazing opportunity.

Bill Gracey took on the questions of the financial and business model shifts as we change our thinking from “healthcare” to “health”. Bing echoed Pomeroy: To look at money, structure and lifestyle issues individually and not collaboratively is a road to nowhere. The health insurance industry, in an attempt to bring various aspects together, has invested several million dollars in wellness portals that incentivize wellness, Bing said. Not for having better health, he noted, but for doing the right things. Blue Cross Blue Shield has also focused on palliative care and chronic disease management as a space needing more integration but facing challenges in current payment models.

Eric Bing brought a global perspective to the topic. After the genocide in Rwanda, communities had massive health needs and minimum resources. So they innovated. Each community nominated health workers that were in charge of going house to house to determine issues as basic as “Who is ill here?” and  “Who is pregnant here?” and “Do they have a toilet here?”  This information was relayed to doctors using cellular phones to aggregate data so resources could be organized. There was also significant task-shifting to mid-level providers and non-medical professionals to save costs.  While these interventions may seem simplistic, they were lifesaving.  Simple needs assessment and allocation of resources in the most efficient way seems like a no-brainer, but in an economy where we have so much, we tend to forget these principles.  But in the circumstances of a crisis, they are the only hope.  As the U.S. approaches the rising healthcare crisis, though not as acute, we should consider these types of simple solutions.

Bing agreed with a tenet I’ve long believed to be true: disease knows no boundaries and health care is a great way to do diplomacy. U.S. leadership in HIV has made a huge difference across the board, Bing said. It has made a difference in maternal health and clean water and other issues. The US commitment is steady right now, but he challenged that it could be more.

Notes from the Road: 2013 Health Care Investors Conference

NASHVILLE | Last Wednesday, (Nov 13) I had the privilege of joining Bass, Berry and Sims and Deloitte at the 2013 Health Care Investors Conference. I sat down with Brad Smith, CEO of Aspire Health; Andrew Lasher, CMO of Aspire Health; and Anna Gene O’Neal, CEO of Alive Hospice, to discuss some of challenges and opportunities in end-of-life care today, and how we believe a new partnership can help.

End-of-Life care is positioned strategically for both the individual and the nation. Transitioning from a volume-based system to a value-based system requires a new model. We don’t have enough money to provide everything to everyone. At the same time, palliative care is needed at an intimate and chaotic time in people’s lives. Most people are not spending the last few years they way they want to—they don’t die the way they want to die.

Something has to change. Fee-for-service payment models will not sustain palliative care or even hospice. There has to be a forward-thinking to deliver these services in way that cost effective for the companies providing care. No one has been able to do this sustainably in the pure for profit or non-profit sector. The question that Smith, O’Neal, Lasher and I discussed is, “Can we meet this need by marrying for- and non-profit organizations with similar missions and goals?”

Andrew Lasher pointed out that palliative care is both a new field of medicine and the very oldest. In the past, it was the only thing medicine had to offer. Now we are good at managing chronic illness. We are prolonging life, but not comfortably. We need more physicians with training to merge the treatment of chronic illness with a palliative frame work. Currently, our teaching programs are not doing this quickly enough.

I agree. We have lost the connection between the physical, medical patient and the emotional, spiritual individual. Palliative care is what my dad used to practice in the mid 1900s. He used a holistic view of the patient to offer treatment and comfort as coinciding services –not separate options. In the current model, treatment and comfort are addressed as a decision point resulting in diverging paths where they should be travel companions.

Alive Hospice is striving to do end-of-life better, said Anna Gene O’Neal. The average daily census at Alive Hospice is more than 480 patients. Alive is the only hospice with both adult and pediatric services. They are front runners in the field in both their concept and their forward thinking. They focus not only on shepherding patient through the end of life, but also caring for families in the bereavement phase.

Alive is also taking on the responsibility of community education. They launched The Gift Initiative this month, a program to encourage everyone to have end of life conversations with their families. “Are we challenging ourselves to define what we want at the end of life instead of letting a fragmented healthcare system do it?” O’Neal asked.

Lasher pointed out that the biggest difference between hospice and palliative care is not the disease, but the patient’s preferences. Is the patient treatment-focused or comfort-only-focused? Does the patient still want chemo or dialysis? If so, they can’t go to hospice, but they are still hospice eligible and need 24/7 responsiveness, comfort support and spiritual support. Aspire seeks to remove the difficult choice and provide patients with both options as an integrated treatment plan.

There are people across the country doing palliative care the way we are describing it, but they are doing it on a small scale. There are several models. Large healthcare systems have done it because it is the right thing to do. Inpatient hospitals have also developed it because it is needed. And then there are some palliative care MDs who have built a private practice. However, these are all small scale, and cannot bear the volume of patients who need these services.

Aspire wants to partner with other groups like Alive Hospice and build a comprehensive service, said Brad Smith. 80% of the markets across the country have a person—not a company—doing this.

In O’Neal’s experience, there are lots of patients that are hospice-eligible but not hospice-ready. They have less than six months to live, but are not ready to withhold medical treatments. From Aspire’s perspective, the right thing was clear: serving these patients so they can get medical continuity of care, quarterbacking their resources—all the specialists—and giving them palliative care without using hospice specifically. But the current payment model is not sufficient to support this ideal and there is not enough volume to show the payers this. Right now these patients are just “dust on the balance sheet,” she said.

Providing this bridge service is the right thing to do, but it is causing a monetary loss. This is where I see a huge opportunity to lobby payers and push payment reform to support these services. Aspire Health and Alive Hospice together bring expertise to the table that will create value and show the payers they can make money.

The biggest issue is figuring out how to contract with the payers, said Smith. There are lot of unknowns about enrolling patients, volume and triaging patients, making it difficult to make a value-based argument to a health plan.

Partnering with Alive has allowed us to start answering these questions so we can better liaise with payors. Physicians are excited about delivering care in a more scalable way. If we can get the payors on board, we have a new business venture.

What does this new model look like practically? Andrew Lasher described a 65-year-old patient with heart failure and very advanced emphysema who was short of breath and in pain. The patient had been admitted to the hospital seven times in the six months before enrolling at Aspire. His wife, his primary caretaker, chauffer, and breadwinner, was exhausted. In his condition, serious problems emerged with no warning.

Aspire’s first step was to arrange 24/7 support. He has IV diuretics at home, and a physician network on call. In the three months since enrolling, he’s had one hospital admission.

Keeping patients out of the hospital prevents delirium and infections and decreases the strain on caregivers. The patient says he feels better. This is different from home health, Lasher explains, because home health is limited in time and the scope of issues they can address. However, Aspire is a physician supervised network that can diagnose and treat new problems as well as provide ongoing care of existing ones.

The cost model here is different. It truly merges quality of care with cost savings in a very tangible way. Decreasing hospitalizations is clearly cheaper than home based care to the system. The issue is that if there is a fragmented set of payors you may save a hospital money, but not the home health care company.

Brad Smith explained for a patient at the very end of life—two to three months to live—costs can be about $50,000. But Aspire’s approach can reduce those costs by $10,000 to $20,000. It hasn’t been as hard to sell this to health plans – groups that cover all aspects of a patients care under one roof – because when the health plans run the data they realize their potential cost savings!

The risk of this model is that this has not been done before at this scale, but as the healthcare sector changes, the bearer of that risk is changing. Governments and payors used to bear the majority of the risk, but that is shifting to providers and patients—the very people who most benefit from this model. Realigning the payor system to pay for this increased quality and merge the savings of a prevented hospital stay to cover the cost of in home palliative care and care coordination will make this model profitable and do what we all know is best for patients simultaneously.

Bloomberg: The Real Price of Healthcare

Nov. 21 (Bloomberg) — Bloomberg View columnist Lanhee Chen is joined by former U.S. Senate majority leader William Frist, Mayo Clinic CEO John Noseworthy, Boston Consulting Group partner Michael Ringel, John Hopkins Medicine CEO Paul Rothman, Thompson Holdings CEO Tommy Thompson, and Walgreen CEO Gregory Wasson to discuss the state of healthcare in the United States. They speak at Bloomberg’s The Year Ahead: 2014 conference at the Art Institute of Chicago.

Original Post

Child’s first 5 years hold key to success

(The Tennessean, Nov 14)

As a surgeon, I understand the exigency of a window of opportunity. In cardiac transplant, procurement of a donor heart starts a strict four-hour window until that heart needs to be beating in the chest of the accepting patient — a patient who is almost always a plane ride away.

Neuroscience research has revealed a similarly crucial window of opportunity. Between birth and 5 years old, 90 percent of a child’s brain development occurs, and at a lightning-fast pace. Every sight, smell, sound and sensation makes an impact. Long before most children step foot into a classroom, neurons are building networks, cognition is exploding, language is developing, and the foundations are being laid for a lifetime of learning.

Outside of that five-year window, you lose opportunities you may never get back. Children who don’t develop sufficient language skills in those first years are up to six times more likely to experience reading problems in school. When children fall behind in reading, every other aspect of education suffers.

The good news is that taking advantage of this window of opportunity is much easier than transplant surgery.

Every interaction a child has with his or her environment is an opportunity for learning. In the first five years, daily activities — talking, singing, reading, playing — stimulate brain development and dramatically influence future health, learning and behavior.

This message may seem simple, but many children do not start school prepared.

A new initiative called Too Small to Fail, led byNext Generation and the Clinton Foundation, is working to make sure parents and caregivers get this message so they can make the most of the first five years of a child’s life and help the child succeed.

The initiative focuses on educating parents that the most impactful thing they can do for language development is the most obvious: talking to your kids.

Children build their vocabulary by listening to and interacting with their moms, dads, grandparents and caregivers. Just as a healthy diet and physical activity help toddlers grow, reading and talking to them helps their brains develop and builds language skills that form the foundation for learning the rest of their lives.

The more words a child hears from caring adults between birth and age 5, the better he or she will learn over a lifetime. However, these words need to be delivered in face-to-face interactions. Passive listening — watching videos or having the TV on in the background — does not show a positive association with language development.

In my home state of Tennessee and around the country, families are stretched thinner than ever. We are juggling multiple jobs that barely cover the cost of child care. We are single-parent homes facing issues as complicated as health care and as mundane as daily transportation and grocery shopping. It can seem like there’s never enough time — or money — to do all the things you would like for your children.

However, the exciting news of Too Small to Fail is that there is an opportunity for every parent and caregiver to make a real difference in the lives of their children without an act of congress or new government initiative. In fact, it costs no money at all.

When preparing dinner, shopping at the market or even folding laundry, identify shapes, colors and numbers. Ask your child questions about the buildings you pass on the way home. Which are tall and which are short? Make mealtime a time for discussion about what’s on their plate.

Talking and singing to children from the day they come home from the hospital helps develop language skills. Reading to your child for 15 minutes a day can make a tremendous difference in his or her future success. These may seem like small steps, but they add up quickly.

Recent research in brain science is really just reenforcing the importance of doing what we already know is good for our children. Our parental intuition is more astute than we think.

But life can be busy and sometimes we forget. That’s why Too Small to Fail is bringing together educators, business leaders, physicians, community organizations — everyone from me to Hillary Clinton. We all have a role to play in making sure parents and caregivers know the simple things they can do to get their children off to a great start.

This is one instance where talk may be cheap, but it will prove invaluable.

This article was originally featured at The Tennessean: http://www.tennessean.com/apps/pbcs.dll/article?AID=2013311140028&gcheck=1

Tremendous Step Forward for Tennessee’s Children

Today the state of Tennessee has taken a tremendous step forward for our children and our future.  The Volunteer State has made more progress than any other state in the nation across 4th and 8th grade reading and math.

When I launched the State Collaborative on Reforming Education (SCORE) in 2009, we noted that “several factors are coming together to create a once-in-a-lifetime opportunity that could lead to unprecedented growth in student achievement within Tennessee.”  We outlined an ambitious plan for the state in our Roadmap to Success report that brought together key education stakeholders around four pillars of work – great teaching, high standards, strong leadership, and utilizing data to enhance learning.  And, we said we would monitor our progress by looking at key data, including 4th and 8th grade reading and math scores on the National Assessment of Educational Progress (NAEP) exam.

Today, NAEP released the 2013 Nation’s Report Card and the results are significant – Tennessee students grew more than students in any other state, making Tennessee the fastest improving state in the nation.  For example, in 4th grade reading, Tennessee jumped from 41st to 31st in the nation.  In 8th grade reading, we went from 41st to 34th.

There is certainly more work to be done, and we are ready for the challenge. But this growth means a big step toward a brighter future for our students and continued economic growth for our state.  It means that the goals we set for SCORE in 2009, while bold, are being achieved through steadfast, student-focused, and collaborative leadership.  It means Tennessee students are making dramatic academic improvements.

On behalf of SCORE, I must congratulate and thank our teachers, students, parents, business leaders, and elected officials – from Governor Bill Haslam to members of the Tennessee legislature – on a job well done.  Your passion and dedication are paying meaningful dividends.  Our hard work is paying off in what really matters – student success!

OTHER RESOURCES

statement from SCORE

A great chart comparing net score increases and declines across the nation.

A graph of Tennessee’s progress from 2005-2013

Washington Post’s coverage of the NAEP scores

Tennessean’s coverage of NAEP scores

The Commercial Appeal’s coverage of the NAEP scores

New York Times coverage of the NAEP scores

Why the U.S. must lead on Disabilities Treaty

(Reuters, November 5, 2013 )

By Bill Frist

In an HIV clinic in Africa, a man born deaf holds a single sheet of paper with a plus sign. He looks for help, but no one at the clinic speaks sign language. In fact, the staff doesn’t seem interested in helping him at all.

He returns to his plus sign. These are his test results. They dictate he should start antiretroviral drugs immediately and should also make changes in his sexual habits. But he doesn’t know this. He leaves the clinic concluding that the plus sign must mean he’s okay, that everything is just fine.

This scenario seems shocking. Yet it continues to play out around the world. The Senate will tackle this issue at the November 5th hearings on the Convention on the Rights of Persons with Disabilities (CRPD) — the Disabilities Treaty.

There are nearly 1 billion people worldwide living with a disability. For the sake of those individuals, the United States joined 158 other countries in signing the Convention on the Rights of Persons with Disabilities in 2009. The Disabilities Treaty was drafted to promote and protect the human rights and fundamental freedoms of persons with disabilities — modeled on our own Americans with Disabilities Act, but on a global scale.

Yet the Senate failed to ratify the United Nations treaty last December. As is often the case, a bit of politics and a bit of misinformation ruled the day.

First, the timing was bad. The vote was called in a lame duck session and many senators said this was an inappropriate time to ratify a U.N. treaty, signing a letter to that effect. But this was not the entire story.

Two larger political issues emerged. Republicans exhibited some squeamishness around the term “sexual and reproductive health” in the treaty. While the term is undefined, there were rumblings that it could create a global right to abortion.

The second issue was an impressive fear campaign launched by Michael Farris of the Home School Legal Defense Association to convince parents that the U.N. treaty would limit their ability to educate their disabled children at home.

The relevant provisions in the treaty regarding sexual and reproductive health demand nondiscrimination for persons with disabilities.

In many parts of the world, people with disabilities, regardless of age, are believed to be sexually immature or inactive. The assumption can make them targets for rape and other sexual crimes while, at the same time, gynecologic and obstetrical care are withheld and considered inappropriate and unnecessary. In other cases, they are forcibly sterilized or forced to have abortions, simply because they have a disability.

The treaty’s “sexual and reproductive health” language is a necessary provision to protect these people. It does not define services — a ratifying country’s existing law provides the definition. The agreement simply demands that those with disabilities not be denied any treatments based on their disability.

It does not create any new services not previously available or legally sanctioned in an adopting country.

For the home schooling debate, the story is more complicated. The Americans with Disabilities Act — on which the international agreement is modeled — has a strong history of Republican support.

Consider, the disabilities act was signed into law by President George H.W. Bush — passed with a 76 to 8 vote in the Senate. President George W. Bush negotiated the CRPD treaty in 2006. Senator John McCain (R-Ariz.) and former Senate Majority Leader Robert Dole, who had each suffered serious war injuries, were significant supporters. Senator Jerry Moran, a Republican from Dole’s home state of Kansas, also initially supported it.

The tide turned, however, at a Senate Foreign Relations Committee hearing on July 12, 2012. Farris, president of the home-schooling organization, claimed in testimony that the U.N. treaty was “dangerous” for parents who teach disabled children at home. He asserted that it will create a legal basis for the United Nations to infringe on the fundamental parental rights of parents of disabled children.

In a radio interview after the hearing, Farris stated “[t]he definition of disability is not defined in the treaty and so, my kid wears glasses, now they’re disabled; now the U.N. gets control over them.”

It sounded terrifying.

Then-Foreign Relations Committee Chairman John Kerry dismissed Farris’s argument out of hand. But the home-schooling organization has an impressive grassroots machinery.

Within a few weeks, Farris’s argument spread. Senator James Inhofe (R- Okla.) and then Senator Jim DeMint (R-S.C.) wrote an op-ed article for the Washington Times stating the treaty would infringe on U.S. sovereignty. Farris’s group began a phone campaign to all senators who might be potential nay votes — specifically targeting the Kansas senators. Senator Rick Santorum, a parent of a disabled child, adopted Farris’s argument as well.

The probable nail in the coffin was when Moran changed his position to align with the HSLDA.

But despite the successful political maneuvering of Farris’s home-schooling organization and its capture of many Tea Party senators, careful reading of the law reveals their arguments were a misinterpretation.

U.S. ratification of the treaty does make the agreement a U.S. law, along with the Senate’s reservations, understandings and declarations (RUDs). However, these RUDs make it clear that current U.S. law — the Americans with Disabilities Act — meets any U.S. obligation under the treaty. In fact, the ADA and related disability laws far exceed the standards set out in the U.N. treaty. Ratifying the agreement will not affect current enforcement of the ADA or create additional causes of action under the treaty. The Americans with Disabilities Act would remain the controlling U.S. law.

The U.N. experts committee cannot make international law and therefore cannot create new international obligations. The committee can make suggestions for improvement during a review process. But these recommendations are just that — recommendations. The United Nations will have no ability to swoop in and poach parental control over the education of children with disabilities in the United States.

Some still argue that the United States has no need to ratify the U.N. treaty. The Americans with Disabilities Act, they insist, already protects the rights of those with disabilities at home. But as a global leader, we must stand with those struggling for the rights that we hold dear.

These are complicated issues revolving around potentially esoteric points of international law. Given this complexity, many senators felt the previous hearings were rushed and that they did not have enough details to make an informed decision. The set of hearings scheduled for November 5 and 12 will be different. Both witness lists have a deep bench of experts — legal, administrative and activist alike. Now is the time to really unpack what this U.N. treaty would mean for Americans and the world.

Voting no to this treaty without a specific and compelling reason is saying that we do not think the global community deserves an ADA of their own.

U.S. leadership matters. We should be at the table. It is not just Americans who deserve healthcare and protection from discrimination. It is everyone.

The article was originally featured on Reuters: http://blogs.reuters.com/great-debate/2013/11/05/why-the-u-s-must-lead-on-disabilities-treaty/

 

 

End-of-life care plan can ensure wishes are respected

(The Tennessean, November 4, 2013) By Sen. Bill Frist, M.D. and Manoj Jain, M.D Fifth of six parts that will appear this fall

“I would never have my mother, who has cancer, go through this,” a hospital case manager in her 50s says. “I would never have her be strapped to the bed. Never have a feeding tube. Never have an endotracheal tube.”

The case manager is one of thousands of Memphis employees who are experiencing a paradigm-shifting training session on the importance of having an end-of-life plan.

This novel pilot effort is being led by Healthy Shelby, a public-private effort that is focused on better health, better health care and lower costs. End-of-life care is one of Healthy Shelby’s key areas of focus.

Jeri Ashley, the administrative director at Baptist Trinity Home Care and Hospice, is one of several trainers conducting the sessions. She is sharing the Five Wishes end-of-life planning tool with working adults across Shelby County and changing the dinner conversation about end-of-life care planning.

Experts have told us that if end-of-life care is to improve, whole communities need to change. This is what happened in La Crosse, Wis. The community took on a huge end-of-life awareness campaign, and now it has become the best place to die, because patients’ choices are known and respected. In La Crosse, 96 percent of all adults who die do so with an advance directive.

Can this happen in communities across Tennessee?

Changing the culture
Debra Bartelli, project director for Healthy Shelby, thinks it can.

“Today, only 20 percent of patients admitted to the four largest Shelby County hospitals have an advance directive or advance care plan,” she said.

To start a communitywide culture change, Healthy Shelby began by targeting those closest to the health care setting: hospital employees.

They launched an employee education plan in October 2012. About 20,000 hospital employees across the city have been educated on end-of-life planning using the Five Wishes resource, and 60,000 copies of the Five Wishes tool have been distributed to patients and their families.

The initial employee training showed great success, so a curriculum and resource booklet was developed for working adults. The training was expanded to physician offices, law firms, pastors and nearly 6,000 Shelby County employees, including representatives of the sheriff’s department and human resources groups from the University of Memphis.

An estimated 35,000 employees have been trained thus far by Healthy Shelby. Bartelli is ambitious. She hopes to reach 100,000 by the end of the year.

Healthy Shelby isn’t alone in its work. There are community campaigns across the state and the country that are changing the culture of how we talk about death, how we prepare for death and how we ultimately die.

The Tennessee End of Life Partnership holds statewide workshops to educate and empower patients, families, and health care and other professionals.

Nationally, Aging with Dignity designed the Five Wishes tool, which is used in 42 states. Death Over Dinner encourages individuals to host open conversations over a meal about the end of life — what they have experienced and what they want for themselves. The Conversation Project offers tools for starting an end-of-life discussion via free download. Communities are promoting end-of-life discussions.

“The process is life-changing for people,” Ashley says.

Of the Shelby County employees who have attended a workshop, Ashley estimates that 40 to 60 percent have completed or are working on their Five Wishes documents.

“That was profound to me! … People are getting it,” she said. “They are understanding the importance of preparing ahead.”

Personal stories
For the Healthy Shelby initiatives, one measure of success is tracking the percentage of patients who have an advance directive when being admitted to the hospital. In less than a year, Bartelli says, the numbers have risen from about 20 percent of patients with an advance directive to 26 percent of patients.

So what works? What motivates an employee, a patient, a family member or even a doctor to initiative the difficult conversation about end of life?

“One thing that comes up at every training is the stories,” Ashley says. “I could stand up there and talk all day long, but the one thing that changes it is the employee who says, ‘You know, I’ve been through this with my loved one, and it was horrendous. And yet this (other) person in my life had (an advance directive), and I can’t tell you how easy it was, how different.’ ”

For the case manager and her mother, a different experience is assured. Through thoughtful conversations, they are preparing an end-of-life experience that respects their choices.

Next: Stories from families about end of life.

Bill Frist is a heart transplant surgeon and former U.S. Senate majority leader. Manoj Jain is a Tennessee doctor who writes for The Washington Post.

Elderly need options for palliative care

(The Tennessean, October, 20, 2013)

By Sen. Bill Frist, M.D. and Manoj Jain, M.D.

A patient — we will call her Matilda — has thin, silvery hair, deep-set eyes and is in her mid-80s. She worked as a factory worker until she was widowed and now lives alone a few miles away from two working daughters.

Matilda’s swollen body reveals some of the health challenges she faces. She has congestive heart failure and recurrent blood clots, both of which cause swelling in her legs and led to a hospitalization a few months ago for a skin infection. She improved and went home and with help still managed her own care: orchestrating a dozen medications daily, including a blood thinner, her cooking and frequent doctor appointments.

A few weeks ago, she contracted pneumonia, probably caused by aspiration — food going down her windpipe rather than her esophagus — probably during a minor stroke. She was admitted to the intensive-care unit but just avoided intubation and being connected to a ventilator.

Now, Matilda is better. She does not want aggressive treatment such as a ventilator or life resuscitation. She does not want to be in a nursing home. She does not have a terminal illness. As the time for her discharge from the hospital nears, the question for her daughters, her doctors, the social workers is: Where should she go? Who will care for her? No model of care seems to work well.

Our present model of health care focuses on either providing life-prolonging aggressive care regardless of quality of life in the hospital and ICU setting, or providing hospice care when patients have a life expectancy of less than six months. For patients who are slowly declining, a nursing home may be their only option for getting the support they need.

Matilda and millions of other elderly Americans do not fit into these molds. They deserve better options than these.

A new option to consider

Palliative care is one such option that seeks to intervene early in the course of chronic illness; to ease the patient from a curative goal to a comfort goal; and to meet medical, social, psychological, spiritual and family needs. Over time, if the illness becomes terminal, the patient is moved to hospice care.

The palliative care model is still relatively new in the U.S. Under this model, Matilda’s primary care physician would work closely with a palliative care physician, nurse practitioner, nurse, social worker and even a chaplain. Together, the palliative care team would manage Matilda’s medicines, answer calls in the middle of the night and work to prevent hospital readmission. The team’s dual focus is on making her comfortable and continuing full medical treatment of her conditions.

A network of resources treats the progression of the illness while trying to avoid emergencies. Instead of jumping from one crisis to the next, leaving Matilda disoriented and fearful, palliative care provides her with continuity of care and support.

So why do we not see more health providers, hospitals and doctors offering palliative care services?

The major stumbling block is payment methods. The current structure of Medicare and Medicaid is fee-for-service reimbursement instead of focusing on the whole patient and providing care such as frequent home visits and 24/7 telephone support. Since most insurance plans take their cue from these federal programs, they don’t support palliative care, either.

There is one new piece of legislation that would begin to address this need: The Care Planning Act, S. 1439, sponsored by U.S. Sens. John Isakson, R-Ga., and Mark Warner, D-Va., and introduced in August. It would amend the Social Security Act, which encompasses Medicaid and Medicare, and it would provide specific compensation to physicians for one-on-one, end-of-life planning discussions with their patients. While this would certainly help encourage physicians to take the time to have these conversations, the services planned and needed still require support.

The bill supports pilot palliative care programs, which would deliver coordinated palliative care including an interdisciplinary team, 24/7 telephone support and home visits. Once a successful pilot emerged, then a systemwide solution could be implemented.

While The Care Planning Act is a step in the right direction, it still comes with a price tag. Yet, the financial benefits of a palliative care model with fewer hospital admission and ER visits would outweigh the costs. Given that these savings come with longer life expectancy and a better quality of life at the end of life, palliative care programs are not just a benefit, but also a necessary addition to our medical model.

Over the past several weeks, we’ve encouraged everyone to discuss end-of-life issues with their families and physicians. Initiating these conversations ensures that your family is aware of your wishes, and that hard decisions can be made with peace of mind.

End-of-life care is not only an issue facing us as individuals, though: The health care system also has reached a critical mass. High costs and low patient value are not sustainable. It’s time for a different model of care.

Bill Frist is a heart transplant surgeon and former U.S. Senate majority leader. Manoj Jain is a Tennessee doctor who writes for The Washington Post.

This article was originally featured in The Tennessean on October 20, 2013 http://www.tennessean.com/apps/pbcs.dll/article?AID=2013310200075

 

 

 

We often avoid important conversation

(The Tennessean, October 6, 2013)

By Sen. Bill Frist, M.D. and Manoj Jain, M.D.

When a patient’s lymph node biopsy came back as a rare form of lymphoma, he did not have long to live. In the six months before he died, he did not settle his family affairs or financial accounts. His doctors should have initiated a frank conversation to best equip him to plan for his remaining time.

End-of-life conversations between patients and their doctors are not happening often enough. A 2009 Archives of Internal Medicine study of patients with terminal metastatic lung cancer (the majority of whom lived only two months after they were interviewed) found that just slightly more than half of their health care providers had discussed hospice care with them.

Every patient will face the end of life. So why don’t all doctors discuss options for end-of-life care with their patients?

In this patient’s case, I know why his physicians did not push harder for such a conversation. They were hesitant to give him a timeline for the course of his illness. They were not ready for the final prognosis. They planned to talk about it later.

I (Dr. Jain) know this was the case because I was one of his physicians. And I wish I had pushed early for an end-of-life conversation.

Unready for prognosis

Doctors are conflicted because — in most cases — forecasting a timeline is hard to do, even among the most experienced clinicians. For a patient awaiting a heart transplant, the outcome without a donor organ is very clear. But several studies have suggested that when dealing with many terminal illnesses, especially cancer, doctors are usually incorrect in their prognosis, nearly always tending to believe that their patients will live longer than they actually do.

Harvard Medical School professor Jerome Groopman, a leading cancer and AIDS researcher, says that when he is really pressed, he will provide a likely timeline. But he adds, “You want to partner with (your patients), not be the presiding judge handing down a death sentence.”

End-of-life conversations between patients, families and the doctor require quiet time, in the clinic or the hospital, time found amid good days and bad days of chemotherapy, congestive heart failure treatment or progressive dementia. The right day for the conversation often never seems to come.

Many doctors, especially those trained more than a decade or two ago, have had no guidance on when and how to talk with patients about the end of life. We were trained only to prolong life, not help in its end. Our focus has been on quantity of life, not quality of life.

Patients also avoid the topic. In a 2005 AARP survey of Massachusetts residents over age 50, nearly 90 percent said they wanted honest answers from doctors, but fewer than 20 percent had discussed their end-of-life wishes with their physicians.

How do we overcome this twofold barrier? How can we encourage doctors to initiate the conversation, and patients and their families to ask for the conversation?

Trust is the fundamental basis of the doctor-patient relationship. The patient must trust the doctor and the plan of treatment — or lack of treatment.

Time to reflect

Conversations this important require time to reflect on the trajectory of treatment and the patient’s quality of life. Such conversations are best held in a noncrisis situation, before an ICU admission or emergency surgery.

The doctor can begin by saying something like: “I know this has been hard, but I want to take the time and discuss what your wishes are if the heart failure does not respond to stronger medications.”

Patients can also initiate the conversation with, “I know things are not going well with the treatment and I want to talk about some of my options for end-of-life care that would not involve more aggressive medicines or surgery.”

The Tennessee Department of Health website (health.state.tn.us/advancedirectives) and most hospitals provide a form for physician orders for scope of treatment, also known as the POST form. It is completed by health care professionals and provides a doctor’s order about a patient’s wishes.

For example, POST forms document if you do not wish to receive CPR, antibiotics or medically administered fluids and nutrition.

The POST form records the conversation between doctor and patient, just as an advance care plan (or living will) form records the conversation among families.

Stating your wishes does not mean the end of care. New areas of medical care, including palliative care, are focused on helping patients, families and doctors navigate the end of life in comfort and peace.

As doctors, we always hope to make the best decisions for our patients. In looking back over the care we’ve chosen for our patients, we don’t often question our choice of antibiotic or a surgical technique, but we do wish we had spent more time talking to them about planning for the end of life, before the end of life.

Manoj Jain is a Tennessee doctor who writes for The Washington Post. Bill Frist is a heart transplant surgeon and former U.S. Senate majority leader.

 

 

This article was originally featured in The Tennessean http://www.tennessean.com/apps/pbcs.dll/article?AID=2013310060057

It’s Common Sense to Come Together for Our Kids

(The Huffington Post, October 2, 2013)

By Sen. Chris Dodd and Sen. Bill Frist, M.D.

When we served together in the Senate, we found ourselves on different sides of a variety of issues. But when it came to common-sense measures that benefitted our country and our citizens, we pulled together.

We were proud to cosponsor the Organ Donation and Recovery Improvement Act because we knew its reforms would help save thousands of lives in America. Today, we’re pulling together to support another common sense measure — early education for all children in America.

There is little debate that education is key to a child’s future success, or that it is key to our global competitiveness as a nation. But one of the most overlooked ways to improving educational opportunities in America is reaching kids early enough.

Two out five children in America have had no preschool or kindergarten education by age 5. When these children do enter school, many are already behind their peers.

As science has clearly shown in recent years, most brain development is complete well before a child enters kindergarten. Without early learning opportunities, many children are entering school without the tools they need to stay on track and succeed.

Unfortunately, poor children in America are most likely to lose these critical opportunities. As a result, children from low-income families can easily fall 18 months developmentally behind children from middle-class families by the time they’re just 4 years old.

Let us share one anecdote from our friends at Save the Children, to show just what a difference early learning can make. The non-profit organization recently received a letter from the superintendent of an isolated, rural school district in Alpaugh, California.

Poverty, language and cultural barriers, and lack of parental engagement in the education system have long meant that children in the district enter school ill-prepared to succeed, he said.

But this year, he reported, the first group of children who had been through Save the Children’s early learning program entered the first grade. Every one of them is reading at grade level, he said, “something unheard of in past classes.”

This success is particularly significant because research is clear about the importance of reading at grade level by the time a student enters the 3rd grade.

Helping all families have access to children’s books and information on how they can support their child’s development goes a very long way. And giving more children the chance to attend high-quality preschool is the smart thing to do.

One study found that every public dollar spent on preschool returns $7 through increased productivity and savings on government assistance programs and criminal justice costs.

We all have a role to play in helping more children succeed. That can be through volunteering in our own communities, contributing to programs that make a difference, or voicing support for proposals to expand high-quality early education in America.

There is critical work taking place in our country to improve K-12 public education. However, there is more to do to ensure millions of children do not fall behind before they even reach school. Common sense tells us, investing in our children early is the right thing to do.

This blog post is part of a series produced by The Huffington Post and Save the Children, as part of the latter’s drive for universal early education, which is the focus of their gala on October 1 in New York. For more information about Save the Children, click here.

 

This article was originally featured in The Huffington Post http://www.huffingtonpost.com/chris-dodd/its-common-sense-to-come-_b_4031431.html

It’s never too early to discuss your final wishes

(The Tennessean, September 22, 2013)

By Manoj Jain, M.D. and Sen. Bill Frist, M.D.

A week before my (Dr. Jain) elderly parents came for a long visit, I asked them if they would be willing to have a conversation about end-of-life planning. But it wasn’t until the day before they left that we sat at the dining table with documents I had printed from the Tennessee Health Department website.

Too often among family, such end-of-life conversations do not occur. Studies show that 60 percent of people say they do not want to burden their families with difficult end-of-life decisions. More than 80 percent of people agree that it is important to have end-of-life instructions in writing. Yet less than 25 percent of people have followed through with written directions to ease the burden on their family members.

Why do we not have this crucial conversation? Talking about end of life is certainly uncomfortable. Yet, there may be an even greater fear. Talking about death may be akin to opening Pandora’s box, or being perceived as someone who is encouraging or wishing for our loved one to die.

But by having a conversation about death, we are not inviting or encouraging death for our loved ones, we are profoundly affecting how the end of life will be experienced by everyone involved — both the individual whose wishes are to be respected, and all of the family members who carry their memory forever.

I (Jain) feared that my parents might misunderstand my intentions. As we sat at the dining table, I broke the ice by talking about the death of my grandfather at 93, and how he was clear in his wishes not to go to die in a hospital. My father then told me how he spent the final day and hours with his father, sitting with him. As our conversation went on, I realized that my parents, too, had desired to have an end-of-life conversation.

Whether you are concerned about an elder family member, or preparing to share your own end-of-life wishes, there are resources and tips to make the conversation easier.

Starting the conversation

Approach the topic directly and gently. Start the conversation with plenty of time, on common ground, perhaps by discussing a shared experience. Confirm your desire for a family member’s wishes to be honored, for their dignity to be preserved.

The Tennessee Department of Health provides further guidance for this conversation in its “Five Wishes” resource. More than 18 million “Five Wishes” packets have been distributed.

A structured document called an advance-care plan, or living will, can help guide the conversation. While it is a legal document reflecting our wishes, an attorney is not required to draft it or sign it. In Tennessee, advance-care plans are available online: http://health.state.tn.us/advancedirectives/.

An advance-care plan requires three major decisions. First, an individual must name an agent. A health care agent is a person who will make health care decisions for you. You can make this effective at any time. An agent is usually a trusted friend or relative who you feel will make the best decisions on your behalf.

Next, an individual must determine how he or she defines quality of life in the final days. You decide which conditions are acceptable to you: permanent unconsciousness, such as in a coma; permanent confusion, like end-stage dementia; or dependency for activities of daily living. These are not easy decisions, and over time your opinions may change. Having a frank and thoughtful conversation about your wishes will empower your family if any of those situations arise.

Treatments and Interventions

Finally, individuals must decide which treatments and interventions they would like to take advantage of. At the end of your life, do you wish to receive CPR? Life support? Surgery? Tube feedings? Advance-care plans offer explanations and definitions of each option. If you have questions, your local doctor or nurse can help.

The final product — a two-page document — will be notarized or signed by two witnesses. Then copies should be shared with your physician, your health care agent and close relatives.

Culturally, it is hard for us to talk about and prepare for death, but taking the time to prepare now will be invaluable for you and your family later. Conversations about end of life do not need to be single, marathon affairs. Express your wishes, do your research, discuss again as circumstances change. It is never too early to agree together to a plan, but it could be too late.

 

Dr. Manoj Jain is a Tennessee doctor who writes for The Washington Post. Dr. Bill Frist is a heart transplant surgeon and former U.S. Senate majority leader.

This article was originally featured in The Tennessean http://www.tennessean.com/apps/pbcs.dll/article?AID=2013309220100

Health care group a guide in time of change

(The Tennessean, September 15, 2013)

By Larry Van Horn, Ph.d., and Sen. Bill Frist, M.D.

October 2014 is a month that our nation has eyed for more than four years. We will take a historic step to revamp our health care system by enrolling millions of Americans in federally mandated health insurance coverage.

At the same time, our city will take another critical step to ensure leaders from Nashville’s largest industry are poised for the future of health care as we plan for the second Nashville Health Care Council Fellows class.

For the nation, years — decades — of planning brought us here. We embark on this journey of health care reform knowing it is the most critical since Medicare and Medicaid started in the 1960s.

The impact of this work in five, 10, 30 years is unknown. Health care experts, economists, policymakers and clinicians have all opined, predicting the good and the bad. Their commentary shaped the Affordable Care Act and other seismic shifts in our health care system.

But in Nashville, we stand in a different position. Instead of commentary and law writing, we will execute changes at the bedside — in hospitals and health care facilities throughout the country owned by local companies. Today, and in the coming years, our work begins as we:

• Build networks of care across multiple settings for the benefit of patients.

• Manage the health of the populations, rather than just treat individual episodes of care.

• Discover measures of quality that result in a positive, more consistent patient experience and reward providers for quality.

• Use technologies under development in the nation’s most innovative companies.

• Create new models of care delivery that change the way, and the setting, in which patients receive care.

We will do this all while grappling with massive changes in reimbursement that prompt us to work smarter and more innovatively.

The practical work of implementation is hard work. But Nashville’s track record for innovation, entrepreneurship, partnership, collaboration and growth in health care positions us perfectly to take on this challenge.

One of the most promising demonstrations of the collective spirit and tenacity of our $70 billion, 250-company industry is the Nashville Health Care Council Fellows. This group of senior executives, chosen each year from every corner of the industry, is shaping the industry. With our inaugural class behind us, the 2014 class is poised to expand upon their work and develop ideas that will resonate in the boardrooms and C-suites of every health care organization in this city.

The Fellows recognize what we all must: We can no longer be slow to change. Disruptive innovation is rapidly opening doors for a new era, and historic months like October 2014 are only the beginning.

Bill Frist, M.D., and Larry Van Horn, Ph.D., are co-chairs of the second annual class of the Nashville Health Care Council Fellows initiative. Bringing together 30-plus senior industry executives over the course of eight daylong sessions in 2014, the group engages the health care industry in a collaborative experience that will guide it through an era of unprecedented change.

This article was originally featured in The Tennessean http://www.tennessean.com/apps/pbcs.dll/article?AID=2013309150014

Global Engagement Pays off for U.S.

By Sen. Bill Frist, M.D. and Gov. Phil Bredesen

During difficult economic times, there is a tendency for Americans to turn inward, to focus on domestic challenges, especially as this country emerges from a decade defined by two major wars and a crushing financial crisis. Though the urge to withdraw and retrench is understandable, it is shortsighted given the benefits that accrue to all Americans from our country’s continued leadership and engagement around the world.

While we come from different political parties, we are both committed to improving the lives of the people of Tennessee, a state to which we have both devoted much of our professional lives. And the record is clear that the U.S. government’s international development and diplomacy efforts represent a sound investment in our country’s prosperity and security.
Consider that more than 95 percent of the world’s consumers live outside of the United States and, in Tennessee alone, more than $30 billion in goods and services are exported overseas, supporting 1 in 5 jobs. Furthermore, foreign investment in this state has paid off for Tennessee working families, most notably from the estimated 12,000 jobs created across the state by Volkswagen’s plant in Chattanooga.

Going forward, expanding exports will be critical to this region’s economic recovery and continued job growth. The fastest-growing markets around the globe are in the developing world, where more than half of the country’s exports already go. The work of our diplomats and development experts enables U.S. businesses to prosper in these emerging markets by supporting stable and representative governments, encouraging economic reforms that promote competition, and fostering respect for the rule of law.

In addition to economic returns on investment, these programs keep Americans safer by ameliorating conditions that too often lead to crises requiring U.S. military intervention. Threats to America’s national security are evolving rapidly and are markedly different from the conventional, state-on-state rivalries and conflicts that defined the 20th century.

To address this century’s unconventional security challenges requires robust, well-coordinated and properly funded development and diplomacy capabilities, alongside defense. That is why America’s most prominent military leaders have been outspoken in their support of the International Affairs Budget. In March, Gen. James Mattis, who formerly commanded all U.S. forces in the Middle East and Central Asia, was asked how important funding was for our civilian foreign policy tools. His answer: “If you don’t fund the State Department fully, then I need to buy more ammunition.”
Investing in these programs is not only the smart thing to do, it’s the right thing to do. Countless lives have been saved and improved through the humanitarian and longer-term development assistance provided by the U.S. government working in partnership with private organizations. These efforts include combating HIV/AIDS, malaria and other crippling diseases as well as leading the international response to natural disasters like the Haiti earthquake and South Asian tsunami. Showing compassion for the neediest and most vulnerable people not only lifts their spirits, but also lifts the spirits of Americans, enhancing our nation’s reputation, credibility and influence in the world. It defines the best of who we are as a nation.

For these and many other reasons we are co-chairing the U.S. Global Leadership Coalition’s Tennessee Advisory Committee, a diverse association of community, business, military and faith-based leaders united in support of America’s tools of global engagement.

There is no question that in an era of high budget deficits, tough decisions must be made in Washington regarding the best use of taxpayer dollars. But contrary to what many believe, only 1 percent of federal spending goes toward the International Affairs Budget. And this modest investment yields enormous returns for the American people in economic growth, national security and international goodwill.

Even during these hyper-partisan times, it is important to remember that sustaining America’s global engagement and leadership has not traditionally been a Democratic or Republican issue. Nor should it be today. It is in the best interest of our state and our nation.

Phil Bredesen served as governor of Tennessee from 2003 to 2011. Dr. William H. Frist served as a U.S. senator from Tennessee from 1995 to 2007. They are co-chairs of the Tennessee State Advisory Committee of the U.S. Global Leadership Coalition.

This article was originially featured on 8.17.13 in the Tennessean http://www.tennessean.com/apps/pbcs.dll/article?AID=2013308180044

Technology And The Changing Business Of Health Care

Three years after the passage of the Patient Protection and Affordable Care Act, popularly known as “Obamacare,” scholars and political pundits have paid much attention to the macroeconomic effects of the law. Will Obamacare bend the health care cost curve? What will be its impact on the federal budget deficit? How will it affect the bottom lines of small businesses and the economic security of the middle class?

When it comes to these questions, one can find a wide disparity of opinions among analysts, physicians, and even the authors of this commentary. But when it comes to the microeconomic ramifications of Obamacare — the effects the law will have on the business of delivering health care, especially in the non-hospital setting — there is little uncertainty: change is coming. As tens of millions of previously uninsured Americans obtain coverage, thereby allowing many to shop for doctors for the first time, the health care market will grow dramatically. Physicians thus will need to find ways to extend their capacity so that they can take advantage of this unique opportunity to expand their practices.
As the fee-for-service model continues its decline — and physician reimbursements come to be based on the quality, not quantity, of care — providing preventive care and promoting wellness will become a business, and not just clinical, priority. Meanwhile, Americans will take more ownership over their health care as they obtain insurance, face higher deductibles, and gain more knowledge through newly available price and quality information. Physicians will need to foster closer individual relationships with patients and prioritize not only cost efficiency, but also customer service, much in the way other businesses have in increasingly competitive retail sectors.
In this post, we outline the upcoming opportunities and challenges Obamacare is likely to present for physicians. We describe how physicians might adapt accordingly and suggest an embrace of emerging technology as a key element of success in the post-Obamacare practice.

Changing Physician Reimbursement
A key concern of health care policymakers remains the skyrocketing cost of care. The leading target of reformers is the outdated fee-for-service model, which creates incentives for doctors to provide more costly — and sometimes unnecessary — care. Indeed, studies show that hundreds of billions of our health dollars are spent each year unnecessarily. The lack of adequate transparency, a volume-driven payment system, defensive practices, prohibitive administrative costs, and the lack of adequate chronic care coordination are some of the reasons why.
In March 2012, the National Commission on Physician Payment Reform (of which Sen. Frist was a co-chair) recommended the abandonment of the fee-for-service model. Frist argued that the model is “the major driver of higher health care costs in the United States [because it] contains incentives for increasing the volume and cost of services (whether appropriate or not), encourages duplication, discourages care coordination, and promotes inefficiency in the delivery of medical services.”

Policymakers encapsulated this perspective in Obamacare, and Medicare has joined the private sector in pursuing initiatives designed to improve efficiency. The Center for Medicare and Medicaid Innovation, for example, is poised to serve at the cutting edge of delivery models that will gradually erode the fee-for-service structure under Medicare. Already, according to the New York Times, “an estimated 428 accountable-care organizations now cover four million Medicare enrollees and millions more people with private insurance.” Indeed, evidence is mounting that payment arrangements that reward outcomes are already helping to slow the cost of care.

In time, we expect the fee-for-service model under which many physicians have worked their entire careers to no longer dominate, and for accountable care organizations and patient-centered medical homes to proliferate. The economic incentives that have guided physicians as they have built their practices will change dramatically. Instead of being rewarded for the quantity of care they provide, doctors will operate under a payment structure that emphasizes preventive care and patient wellness.

This era of “person-focused medicine” will require doctors to form closer, stronger relationships with patients — not only to tailor wellness plans to each individual, but also to ensure that patients are taking the steps necessary to enhance their own health, such as taking medications or following dietary recommendations. No longer will it be enough to simply see a patient once a year for a checkup.

Indeed, physicians will need to form these stronger relationships not only for the health of their patients, but also for the health of their own practices. As the prominence of employer-provided insurance continues to decline, and high-deductible and defined-contribution plans continue to grow in popularity, patients will inevitably become more price-sensitive. Americans are becoming more motivated to seek greater value in health care. With the implementation of Obamacare, they will become more informed about their options. This represents a potential challenge for physicians working under the ACO model, for whom doctor shopping represents a direct threat to the bottom line.

The Growing Demand For Care
At the same time, most models estimate that, with the help of government subsidies, some 7 million previously uninsured Americans will acquire coverage in the first year after health care exchanges launch in October, with tens of millions more to follow over the next five years. Groups like Enroll America, which Sen. Daschle is involved with, will help to usher the uninsured into the exchanges, providing them with information to help them pick the appropriate plan for their needs. With greater ability to afford regular health care, these new health care consumers represent an enormous opportunity for physicians to grow their practices.

Physicians would do well to respond to these changes by building deeper relationships with each individual patient and striving to deliver excellent customer service. But, at the same time, the entry of tens of millions of new consumers into the health care marketplace threatens to put a severe time strain on physicians.

Evidence suggests that the demand for physicians already outstrips supply. State-level studies compiled by the Association of American Medical Colleges (AAMC) found alarming doctor shortages across the country, a problem that is already worsening due to a growing and aging American population. Add in the expansion of the health care market brought about by Obamacare, and the AAMC estimates that the United States will likely face a shortfall of 63,000 doctors by the year 2015, and 130,000 doctors by the year 2025.

The challenge, then, is clear. Physicians will have to find a way to expand their practices to handle more patients, while at the same time forging closer relationships with them in order to improve the health outcomes upon which reimbursements increasingly will be based. Many health care experts argue that physicians can increase their patient load capacity through team-based organizational models; others have looked to the enhanced scope of practice approaches that have increased the roles of nurses, nurse practitioners, physician assistants and pharmacists.
Technology as a physician extender. These changes can help, but we believe that advances in smartphone technology, cloud computing, data analytics, and other innovations have put us in a place where technology can play a necessary and critical role in meeting these challenges. Unlike expensive new scanners and tests, the information technology required to meet patient demand is inexpensive and easy to incorporate into a physician’s practice. Over time, it should save money, not cost money.

For instance, technology can eliminate inefficiencies that plague physicians’ business operations (especially small practices). Online scheduling can help avoid revenue losses by filling appointments more efficiently. Physicians who regularly see 10 to 20 percent of their appointments turn into no-shows could make use of previously wasted time by putting appointment books online. Other advances in information technology can free up time currently spent on paperwork, patient follow-up, and other administrative tasks so that physicians can focus on the actual work of providing health care. And, as we have written, health information technology will be particularly important as physicians evolve their practices to account for new delivery and payment models.
From information technology that makes the operation of the physician’s business more efficient; to telemedicine that can allow physicians to assess a rash or read an MRI without scheduling a visit; to consumer electronics that allow patients to collect their own data and physicians to tailor care to each individual — these advances can serve as extremely effective “physician extenders” that assist physicians in expanding their capacity to match growing demand. They can help physicians build the kind of strong patient relationships that many thought would be impossible when the era of house calls came to an end.

Patients too are increasingly expecting these conveniences. Recent studies found that the majority of Americans plan to use social media and the Internet to find and review care providers, to check their symptoms, or to track their own health data. Mobile health and medical applications for smartphones are predicted to reach 142 million downloads by the year 2016. Large majorities of Americans report that they would like far more transparency, online scheduling, and email communication with care providers, as well as access to an electronic medical record to review information and email reminders when they are due for a visit. They also want the opportunity to receive diagnostic test results via email.

In addition, patients report that they will act on these preferences. A PriceWaterhouseCooper’s Health Research Institute study asked patients what would guide their choice between two physicians with equivalent reputations. The top answer was, unsurprisingly, cost, at 20 percent. But 19 percent answered that they would choose physicians whose offices were more technologically advanced. In particular, 59 percent of “Generation Y” patients say they would switch doctors for one with better online access.

Finally, as mentioned above, the movement away from fee-for-service will create a further need for physicians to use technology to efficiently forge a close relationship with patients. In many of these coming models of care, if a patient under a physician’s care decides to leave his or her medical home or accountable care organization to seek other care, the physician will be responsible for those expenses. Similarly, if a patient with a chronic condition does not follow practice guidelines to stay healthy, this could have financial (as well as clinical) consequences that the physician would have to face. In such a world, new advances in patient communications and health monitoring are critical for providers.

Change And The Need To Adapt
In sum, physicians need to expand their capacity in order to take advantage of the coming market transformation. They need to encourage patients to take ownership of their health care to secure outcomes under new reimbursement models. And in this era of doctor shopping, they need to provide the service patients are looking for.
Change is coming to the business of health care. In order to survive – and thrive – under Obamacare, physicians must adapt. And as they seek to do so, technology can be a critical asset.
Technology cannot eliminate all the uncertainty that comes with a major change in federal health care policy. Physicians must demonstrate resilience, innovation, collaboration, and leadership in the face of new developments. And they must remain engaged in the public policy sphere as the implementation of Obamacare proceeds.

But technology can play a critical role as physicians seek to adapt their practices to the new landscape. This entails delivering customer service that inspires patient loyalty, offering new options for partnering with patients to achieve better outcomes, and expanding physicians’ capacity so they can take advantage of the coming influx of new patients.
While physicians may be hesitant to embrace the emerging economic reality of health care in America, we urge them to embrace the technologies that will help them succeed in the new reality.
This article was originally featured on the Health Affairs http://healthaffairs.org/blog/2013/08/14/technology-and-the-changing-business-of-health-care/

European Summer Travels

Copenhagen, Denmark
The statue of the Little Mermaid who gazes longingly out to sea from her rock to the harbor. Copenhagen is one of the most historic cities in the Baltic region; loved exploring the 850 years of recorded history.

Helsinki, Finland
Missed the all-year round Igloo hotel, but did sit for a few minutes in the Rock Church, hewn from solid rock with a celling of copper. Rode bike out to Sibelius monument which honors the best-known Finnish composer Jean Sibelius (not related to out secretary of HHS in Washington I don’t think … but maybe). It has 600 steel pipes. Cycled through the small islands and past private homes and along the coast. Nokia’s main headquarters are over here.

St. Petersburg, Russia
I get confused on this history … it’s not hard; it’s just hard to remember. Catherine Palace is the estate presented by Peter the Great to his wife Catherine in 1710, and served as the Imperial family’s summer home until the time of the last tsar. Loved the romantic park with mysterious arbors and pavilions. The opulent Great Hall was huge and magnificent – over the top.
The Amber Room was just opened to public 10 years ago. German Emperor Frederick William I originally presented the 16-foot high mosaic panels of 100,000 perfectly fitted pieces of amber to Peter the Great. They were dismantled by German troops in 1941 and sent to Germany. What we see today is an exact reproduction by Russian craftsmen. (By the way, amber with a bug in it is worth more. It is soft. Would have loved to buy a piece of amber to give to someone.)

Pavlovsk Palace, St. Petersburg, Russia
Pavlovsk Palace is the formal royal summer residence of Emperor Paul I the only son of Catherine the Great.

Yusupov Palace is where one of the most controversial personalities in Russian history was mysteriously assassinated. The mystery haunts me, and it would you. Rasputin, a peasant who apparently had supernatural powers, counseled the Tsar’s family and naturally became quite powerful because of his influence over very important decisions. Thus, Rasputin was murdered on December 16, 1916, to eliminate the power of his potentially manipulative position. The story is full of twists and turns and is re-enacted in detail.

Church on Spoiled Blood is built on the site where Tsar Alexander II was assassinated.

At Pushkin Gallery I bought small Matroishka Dolls, Fabergé egg pendants and Russian boxes decorated by semi-precious stones from local craftsmen and some modern masters. I love the cupped puzzles that I will hand deliver to my grandson, “baby Harrison.”

The Hermitage
The Hermitage (not Andrew Jackson’s Tennessee plantation!): The Winter Palace makes up one of the buildings of the Hermitage. Considered to be the largest art museum in Russia and maybe in the world, it was founded by Catherine the Great in 1764. It contains 2.7 million works of art., a masterpiece of architecture and elegant interiors. The museum features incredible art collections of Italian, French and other European masters as well as one of the largest impressionist collections in the world.

The Peter and Paul Cathedral built around 1720 and designed by Peter the Great – has become the burial place of subsequent tsars.

Peterhof Palace.
Hydrofoiled to arrive to the former summer residence of the Russian imperial family located on the seashore of the Gulf of Finland, 18 miles from St. Petersburg. It is called the “capital of fountains” because of the 4 huge cascades and 150 charming fountains. There is a huge amount of water flowing through Grand Cascade, which goes downhill, spraying into the air, while water artistically splashes. splashing artistically, and a famous chess Cascade waterfall.. (Interestingly enough, the entirety of the falls is powered by gravity instead of a pump.)

Ate lunch at the Orangerie—Russian cuisine.

Houses in Estonia
View of Estonian architecture from bike ride with my sister and her husband

Tallin, Estonia
Rode bikes with Mary through Kadriorg Park, site of Peter the Great’s Summer Palace, and then went by the President’s Palace. Apparently he is a Princetonian but I did not see the orange and black flag flying that day (wonder if he was at reunions? Finally to romantic Old Town to see the beautifully preserved ancient walls and Medieval Towers. Rode by Fat Margaret Tower and St Olav’s church and then paid respect to the old drug store, the Town Council’s Apothecary, which dates back to the mid-1400s.

Stockholm, Sweden
Founded as a fortress where Lake Malaren meets the Baltic. Only a day here so once again on the bikes to tour with Lee. 14 islands, never realized so much water. St P is a third water, a third city, and a third parks. We rode the city and the parks. The waterfront has pillared arcades and of course we insisting on cycling past city hall where the annual banquet for the

Bike Ride Through Kadriorg Park, Estonia

Rode bikes with Mary and Lee through Kadriorg Park, Estonia, site of Peter the Great’s Summer Palace, and then went by the President’s Palace. Apparently he is a Princetonian but I did not see the orange and black flag flying that day (wonder if he was at reunions? Finally to romantic Old Town to see the beautifully preserved ancient walls and Medieval Towers. Rode by Fat Margaret Tower and St Olav’s church and then paid respect to the old drug store, the Town Council’s Apothecary, which dates back to the mid-1400s.

Health care system should focus on easing patients’ lives

Over the course of the past century, advances in public health and medical care have led to improvements in life expectancy that our ancestors would not have been able to imagine. Average life expectancy for Americans born in 2013 is approaching 80 years. While we now live longer and typically spend most of these years in good health, many live with advanced and complicated illnesses. Health problems that once caused death are now controllable as chronic conditions. With these chronic conditions comes the risk of chronic illness and chronic symptoms.

Our health care system is not well-suited to caring for the large and growing number of patients with multiple, complex chronic illnesses. The strengths of our system — the technology and expertise that have led to these amazing advances in survival — target specific diseases one at a time. For those of us who have a single curable or controllable disease but are otherwise healthy, this system works very well. But what about those with chronic health problems, especially when one person has multiple chronic diseases? Our current health care system is often too fragmented to be of substantial benefit for these patients.

The solution is a system of specialized, coordinated care focused on the needs of patients with complex and chronic illnesses, aimed at helping patients live as well and as long as they can, even when cure is not a reasonable expectation. This is palliative care.

The word “palliative” comes from a Latin word for a kind of cloak, so that palliation is properly understood as shielding and protecting patients from the suffering of illness. Palliative care is aimed at maximizing quality of life; minimizing suffering; and providing care, comfort, companionship and peace. Palliative care can be provided to patients at the end of life or to those who have years left to live and are receiving treatments aimed at cure and control of disease.

Patients with heart disease, lung disease, diabetes, cancer and other illnesses can live for years with controllable health problems. Palliative care uses a team of physicians, nurse practitioners and other professionals who collaborate with a patient’s other health care providers to deliver and organize care. This care is guided by the preferences and values of the patient and family and aims to help patients live as well as possible and avoid health crises that may lead to hospitalization. Care aims to minimize symptoms like pain and nausea; reduce worry, anxiety and depression; and maximize important relationships and finding peace of mind.

Palliative is provided at home and clinics, just in the hospital. Care is shaped to what patients need and want. When that care is moved to the patient’s home, complications and crises can be prevented. Patients feel better and spend more time out of the hospital, enjoying good quality of life. Health care costs go down when patients have fewer health crises that require trips to the emergency room or admissions to the hospital.

Making this care more widely available is an important step in improving our health-care system. In Tennessee, Aspire Health and Alive Hospice, the largest hospice in Middle Tennessee and one of the first hospices in the U.S., are forming a joint venture: Aspire Health Medical Partners of Middle Tennessee. We hope to bring the benefits of palliative care to more people in our community. This partnership will create a nationally scalable model for advanced illness care that can meaningfully improve the quality of care for patients facing a serious illness while simultaneously significantly reducing total medical costs.

Middle Tennessee is our home. We are proud to build this pioneering partnership here.

Dr. Bill Frist is a former U.S. Senate majority leader and currently the chairman of Aspire Health, a new palliative care company. Dr. John Shuster is a board-certified palliative care physician and the chief medical officer of Alive Hospice. Dr. Andrew Lasher is a board-certified palliative physician and chief medical officer of Aspire Health.

This article was originally posted in The Tennesseean http://www.tennessean.com/article/20130721/OPINION03/307210082/

Global Engagement Pays off for U.S.

(The Tennessean, August 17, 2013)

By Sen. Bill Frist, M.D. and Gov. Phil Bredesen

During difficult economic times, there is a tendency for Americans to turn inward, to focus on domestic challenges, especially as this country emerges from a decade defined by two major wars and a crushing financial crisis. Though the urge to withdraw and retrench is understandable, it is shortsighted given the benefits that accrue to all Americans from our country’s continued leadership and engagement around the world.

While we come from different political parties, we are both committed to improving the lives of the people of Tennessee, a state to which we have both devoted much of our professional lives. And the record is clear that the U.S. government’s international development and diplomacy efforts represent a sound investment in our country’s prosperity and security.

Consider that more than 95 percent of the world’s consumers live outside of the United States and, in Tennessee alone, more than $30 billion in goods and services are exported overseas, supporting 1 in 5 jobs. Furthermore, foreign investment in this state has paid off for Tennessee working families, most notably from the estimated 12,000 jobs created across the state by Volkswagen’s plant in Chattanooga.

Going forward, expanding exports will be critical to this region’s economic recovery and continued job growth. The fastest-growing markets around the globe are in the developing world, where more than half of the country’s exports already go. The work of our diplomats and development experts enables U.S. businesses to prosper in these emerging markets by supporting stable and representative governments, encouraging economic reforms that promote competition, and fostering respect for the rule of law.

In addition to economic returns on investment, these programs keep Americans safer by ameliorating conditions that too often lead to crises requiring U.S. military intervention. Threats to America’s national security are evolving rapidly and are markedly different from the conventional, state-on-state rivalries and conflicts that defined the 20th century.

To address this century’s unconventional security challenges requires robust, well-coordinated and properly funded development and diplomacy capabilities, alongside defense. That is why America’s most prominent military leaders have been outspoken in their support of the International Affairs Budget. In March, Gen. James Mattis, who formerly commanded all U.S. forces in the Middle East and Central Asia, was asked how important funding was for our civilian foreign policy tools. His answer: “If you don’t fund the State Department fully, then I need to buy more ammunition.”

Investing in these programs is not only the smart thing to do, it’s the right thing to do. Countless lives have been saved and improved through the humanitarian and longer-term development assistance provided by the U.S. government working in partnership with private organizations. These efforts include combating HIV/AIDS, malaria and other crippling diseases as well as leading the international response to natural disasters like the Haiti earthquake and South Asian tsunami. Showing compassion for the neediest and most vulnerable people not only lifts their spirits, but also lifts the spirits of Americans, enhancing our nation’s reputation, credibility and influence in the world. It defines the best of who we are as a nation.

For these and many other reasons we are co-chairing the U.S. Global Leadership Coalition’s Tennessee Advisory Committee, a diverse association of community, business, military and faith-based leaders united in support of America’s tools of global engagement.

There is no question that in an era of high budget deficits, tough decisions must be made in Washington regarding the best use of taxpayer dollars. But contrary to what many believe, only 1 percent of federal spending goes toward the International Affairs Budget. And this modest investment yields enormous returns for the American people in economic growth, national security and international goodwill.

Even during these hyper-partisan times, it is important to remember that sustaining America’s global engagement and leadership has not traditionally been a Democratic or Republican issue. Nor should it be today. It is in the best interest of our state and our nation.

Phil Bredesen served as governor of Tennessee from 2003 to 2011. Dr. William H. Frist served as a U.S. senator from Tennessee from 1995 to 2007. They are co-chairs of the Tennessee State Advisory Committee of the U.S. Global Leadership Coalition.

 

This article was originially featured on 8.17.13  in the Tennessean http://www.tennessean.com/apps/pbcs.dll/article?AID=2013308180044

 

Technology And The Changing Business Of Health Care

(Health Affairs, August 14, 2013)

By Bill Frist, M.D. and Tom Daschle

Three years after the passage of the Patient Protection and Affordable Care Act, popularly known as “Obamacare,” scholars and political pundits have paid much attention to the macroeconomic effects of the law. Will Obamacare bend the health care cost curve?  What will be its impact on the federal budget deficit? How will it affect the bottom lines of small businesses and the economic security of the middle class?

When it comes to these questions, one can find a wide disparity of opinions among analysts, physicians, and even the authors of this commentary. But when it comes to the microeconomic ramifications of Obamacare — the effects the law will have on the business of delivering health care, especially in the non-hospital setting — there is little uncertainty: change is coming. As tens of millions of previously uninsured Americans obtain coverage, thereby allowing many to shop for doctors for the first time, the health care market will grow dramatically. Physicians thus will need to find ways to extend their capacity so that they can take advantage of this unique opportunity to expand their practices.

As the fee-for-service model continues its decline — and physician reimbursements come to be based on the quality, not quantity, of care — providing preventive care and promoting wellness will become a business, and not just clinical, priority.  Meanwhile, Americans will take more ownership over their health care as they obtain insurance, face higher deductibles, and gain more knowledge through newly available price and quality information.  Physicians will need to foster closer individual relationships with patients and prioritize not only cost efficiency, but also customer service, much in the way other businesses have in increasingly competitive retail sectors.

In this post, we outline the upcoming opportunities and challenges Obamacare is likely to present for physicians. We describe how physicians might adapt accordingly and suggest an embrace of emerging technology as a key element of success in the post-Obamacare practice.

Changing Physician Reimbursement

A key concern of health care policymakers remains the skyrocketing cost of care.  The leading target of reformers is the outdated fee-for-service model, which creates incentives for doctors to provide more costly — and sometimes unnecessary — care. Indeed, studies show that hundreds of billions of our health dollars are spent each year unnecessarily. The lack of adequate transparency, a volume-driven payment system, defensive practices, prohibitive administrative costs, and the lack of adequate chronic care coordination are some of the reasons why.

In March 2012, the National Commission on Physician Payment Reform (of which Sen. Frist was a co-chair) recommended the abandonment of the fee-for-service model. Frist argued that the model is “the major driver of higher health care costs in the United States [because it] contains incentives for increasing the volume and cost of services (whether appropriate or not), encourages duplication, discourages care coordination, and promotes inefficiency in the delivery of medical services.”

Policymakers encapsulated this perspective in Obamacare, and Medicare has joined the private sector in pursuing initiatives designed to improve efficiency. The Center for Medicare and Medicaid Innovation, for example, is poised to serve at the cutting edge of delivery models that will gradually erode the fee-for-service structure under Medicare. Already, according to the New York Times, “an estimated 428 accountable-care organizations now cover four million Medicare enrollees and millions more people with private insurance.” Indeed, evidence is mounting that payment arrangements that reward outcomes are already helping to slow the cost of care.

In time, we expect the fee-for-service model under which many physicians have worked their entire careers to no longer dominate, and for accountable care organizations and patient-centered medical homes to proliferate. The economic incentives that have guided physicians as they have built their practices will change dramatically. Instead of being rewarded for the quantity of care they provide, doctors will operate under a payment structure that emphasizes preventive care and patient wellness.

This era of “person-focused medicine” will require doctors to form closer, stronger relationships with patients — not only to tailor wellness plans to each individual, but also to ensure that patients are taking the steps necessary to enhance their own health, such as taking medications or following dietary recommendations. No longer will it be enough to simply see a patient once a year for a checkup.

Indeed, physicians will need to form these stronger relationships not only for the health of their patients, but also for the health of their own practices. As the prominence of employer-provided insurance continues to decline, and high-deductible and defined-contribution plans continue to grow in popularity, patients will inevitably become more price-sensitive. Americans are becoming more motivated to seek greater value in health care. With the implementation of Obamacare, they will become more informed about their options. This represents a potential challenge for physicians working under the ACO model, for whom doctor shopping represents a direct threat to the bottom line.

The Growing Demand For Care

At the same time, most models estimate that, with the help of government subsidies, some 7 million previously uninsured Americans will acquire coverage in the first year after health care exchanges launch in October, with tens of millions more to follow over the next five years.  Groups like Enroll America, which Sen. Daschle is involved with, will help to usher the uninsured into the exchanges, providing them with information to help them pick the appropriate plan for their needs. With greater ability to afford regular health care, these new health care consumers represent an enormous opportunity for physicians to grow their practices.

Physicians would do well to respond to these changes by building deeper relationships with each individual patient and striving to deliver excellent customer service. But, at the same time, the entry of tens of millions of new consumers into the health care marketplace threatens to put a severe time strain on physicians.

Evidence suggests that the demand for physicians already outstrips supply. State-level studies compiled by the Association of American Medical Colleges (AAMC) found alarming doctor shortages across the country, a problem that is already worsening due to a growing and aging American population. Add in the expansion of the health care market brought about by Obamacare, and the AAMC estimates that the United States will likely face a shortfall of 63,000 doctors by the year 2015, and 130,000 doctors by the year 2025.

The challenge, then, is clear. Physicians will have to find a way to expand their practices to handle more patients, while at the same time forging closer relationships with them in order to improve the health outcomes upon which reimbursements increasingly will be based. Many health care experts argue that physicians can increase their patient load capacity through team-based organizational models; others have looked to the enhanced scope of practice approaches that have increased the roles of nurses, nurse practitioners, physician assistants and pharmacists.

Technology as a physician extender. These changes can help, but we believe that advances in smartphone technology, cloud computing, data analytics, and other innovations have put us in a place where technology can play a necessary and critical role in meeting these challenges. Unlike expensive new scanners and tests, the information technology required to meet patient demand is inexpensive and easy to incorporate into a physician’s practice. Over time, it should save money, not cost money.

For instance, technology can eliminate inefficiencies that plague physicians’ business operations (especially small practices). Online scheduling can help avoid revenue losses by filling appointments more efficiently. Physicians who regularly see 10 to 20 percent of their appointments turn into no-shows could make use of previously wasted time by putting appointment books online. Other advances in information technology can free up time currently spent on paperwork, patient follow-up, and other administrative tasks so that physicians can focus on the actual work of providing health care. And, as we have written, health information technology will be particularly important as physicians evolve their practices to account for new delivery and payment models.

From information technology that makes the operation of the physician’s business more efficient; to telemedicine that can allow physicians to assess a rash or read an MRI without scheduling a visit; to consumer electronics that allow patients to collect their own data and physicians to tailor care to each individual — these advances can serve as extremely effective “physician extenders” that assist physicians in expanding their capacity to match growing demand. They can help physicians build the kind of strong patient relationships that many thought would be impossible when the era of house calls came to an end.

Patients too are increasingly expecting these conveniences. Recent studies found that the majority of Americans plan to use social media and the Internet to find and review care providers, to check their symptoms, or to track their own health data. Mobile health and medical applications for smartphones are predicted to reach 142 million downloads by the year 2016. Large majorities of Americans report that they would like far more transparency, online scheduling, and email communication with care providers, as well as access to an electronic medical record to review information and email reminders when they are due for a visit. They also want the opportunity to receive diagnostic test results via email.

In addition, patients report that they will act on these preferences. A PriceWaterhouseCooper’s Health Research Institute study asked patients what would guide their choice between two physicians with equivalent reputations. The top answer was, unsurprisingly, cost, at 20 percent. But 19 percent answered that they would choose physicians whose offices were more technologically advanced. In particular, 59 percent of “Generation Y” patients say they would switch doctors for one with better online access.

Finally, as mentioned above, the movement away from fee-for-service will create a further need for physicians to use technology to efficiently forge a close relationship with patients. In many of these coming models of care, if a patient under a physician’s care decides to leave his or her medical home or accountable care organization to seek other care, the physician will be responsible for those expenses. Similarly, if a patient with a chronic condition does not follow practice guidelines to stay healthy, this could have financial (as well as clinical) consequences that the physician would have to face. In such a world, new advances in patient communications and health monitoring are critical for providers.

Change And The Need To Adapt

In sum, physicians need to expand their capacity in order to take advantage of the coming market transformation. They need to encourage patients to take ownership of their health care to secure outcomes under new reimbursement models. And in this era of doctor shopping, they need to provide the service patients are looking for.

Change is coming to the business of health care. In order to survive – and thrive – under Obamacare, physicians must adapt. And as they seek to do so, technology can be a critical asset.

Technology cannot eliminate all the uncertainty that comes with a major change in federal health care policy. Physicians must demonstrate resilience, innovation, collaboration, and leadership in the face of new developments.  And they must remain engaged in the public policy sphere as the implementation of Obamacare proceeds.

But technology can play a critical role as physicians seek to adapt their practices to the new landscape. This entails delivering customer service that inspires patient loyalty, offering new options for partnering with patients to achieve better outcomes, and expanding physicians’ capacity so they can take advantage of the coming influx of new patients.

While physicians may be hesitant to embrace the emerging economic reality of health care in America, we urge them to embrace the technologies that will help them succeed in the new reality.

This article was originally featured on the Health Affairs http://healthaffairs.org/blog/2013/08/14/technology-and-the-changing-business-of-health-care/

European Summer Travels 2013

Copenhagen's Mermaid

Copenhagen’s Mermaid

Copenhagen, Denmark

The statue of the Little Mermaid who gazes longingly out to sea from her rock to the harbor.  Copenhagen is one of the most historic cities in the Baltic region; loved exploring the 850 years of recorded history.

 

 

 

 

 

 

Helsinki, Finland

Helsinki, Finland

Helsinki, Finland

Missed the all-year round Igloo hotel, but did sit for a few minutes in the Rock Church, hewn from solid rock with a celling of copper. Rode bike out to Sibelius monument which honors the best-known Finnish composer Jean Sibelius (not related to out secretary of HHS in Washington I don’t think … but maybe).  It has 600 steel pipes. Cycled through the small islands and past private homes and along the coast. Nokia’s main headquarters are over here.

 

 

 

 

 

Amber Room

Amber Room

St. Petersburg, Russia

I get confused on this history … it’s not hard; it’s just hard to remember.  Catherine Palace is the estate presented by Peter the Great to his wife Catherine in 1710, and served as the Imperial family’s summer home until the time of the last tsar.  Loved the romantic park with mysterious arbors and pavilions.  The opulent Great Hall was huge and magnificent – over the top.

The Amber Room was just opened to public 10 years ago. German Emperor Frederick William I originally presented the 16-foot high mosaic panels of 100,000 perfectly fitted pieces of amber to Peter the Great.  They were dismantled by German troops in 1941 and sent to Germany.  What we see today is an exact reproduction by Russian craftsmen. (By the way, amber with a bug in it is worth more. It is soft. Would have loved to buy a piece of amber to give to someone.)

 

Pavlovsk Palace, St. Petersburg, Russia

Pavlovsk Palace, St. Petersburg, Russia

Pavlovsk Palace is the formal royal summer residence of Emperor Paul I the only son of Catherine the Great.

 

Yusupov Palace is where one of the most controversial personalities in Russian history was mysteriously assassinated.  The mystery haunts me, and it would you. Rasputin, a peasant who apparently had supernatural powers, counseled the Tsar’s family and  naturally became quite powerful because of his influence over very important decisions. Thus, Rasputin was murdered on December 16,  1916, to eliminate the power of his potentially manipulative position. The story is full of twists and turns and is re-enacted in detail.

 

Church on Spoiled Blood is built on the site where Tsar Alexander II was assassinated.

 

At Pushkin Gallery I bought small Matroishka Dolls, Fabergé egg pendants and Russian boxes decorated by semi-precious stones from local craftsmen and some modern masters.  I love the cupped puzzles that I will hand deliver to my grandson, “baby Harrison.”

The Hermitage

The Hermitage

The Hermitage (not Andrew Jackson’s Tennessee plantation!):  The Winter Palace makes up one of the buildings of the Hermitage.  Considered to be the largest art museum in Russia and maybe in the world, it was founded by Catherine the Great in 1764.  It  contains 2.7 million works of art., a masterpiece of architecture and elegant interiors.  The museum features incredible art collections of Italian, French and other European masters as well as one of the largest impressionist collections in the world.

 

The Peter and Paul Cathedral built around 1720 and designed by Peter the Great – has become the burial place of subsequent tsars.

 

Peterhof Palace

Peterhof Palace

Peterhof Palace.  Hydrofoiled to arrive to the former summer residence of the Russian imperial family located on the seashore of the Gulf of Finland, 18 miles from St. Petersburg.  It is called the “capital of fountains” because of the 4 huge cascades and 150 charming fountains. There is a huge amount of water flowing through Grand Cascade, which goes downhill, spraying into the air, while water artistically splashes. splashing artistically, and a famous chess Cascade waterfall..  (Interestingly enough, the entirety of the falls is powered by gravity instead of a pump.)

 

Ate lunch at the Orangerie—Russian cuisine.

 

Houses in Estonia

View of Estonian architecture from bike ride with my sister and her husband

Tallin, Estonia

Rode bikes with Mary through Kadriorg Park, site of Peter the Great’s Summer Palace, and then went by the President’s Palace.  Apparently he is a Princetonian but I did not see the orange and black flag flying that day (wonder if he was at reunions?  Finally to romantic Old Town to see the beautifully preserved ancient walls and Medieval Towers. Rode by Fat Margaret Tower and St Olav’s church and then paid respect to the old drug store, the Town Council’s Apothecary, which dates back to the mid-1400s.

 

 

 

 

Dinner with 16 fellow Tennesseeans in Stockholm

Dinner with 16 fellow Tennesseeans in Stockholm

Stockholm, Sweden

Founded as a fortress where Lake Malaren meets the Baltic.  Only a day here so once again on the bikes to tour with Lee.  14 islands, never realized so much water. St P is  a third water, a third city, and a third parks.   We rode the city and the parks. The waterfront has pillared arcades and of course we insisting on cycling past city hall where the annual banquet for the Nobel Prize is held.

Bike Ride Through Kadriorg Park, Estonia

Rode bikes with Mary and Lee through Kadriorg Park, Estonia, site of Peter the Great’s Summer Palace, and then went by the President’s Palace.  Apparently he is a Princetonian but I did not see the orange and black flag flying that day (wonder if he was at reunions?  Finally to romantic Old Town to see the beautifully preserved ancient walls and Medieval Towers. Rode by Fat Margaret Tower and St Olav’s church and then paid respect to the old drug store, the Town Council’s Apothecary, which dates back to the mid-1400s.

Health care system should focus on easing patients’ lives

(The Tennesseean, July 21, 2013)

By Senator Bill Frist, M.D., John Shuster, M.D., and Andrew Lasher, M.D.

Over the course of the past century, advances in public health and medical care have led to improvements in life expectancy that our ancestors would not have been able to imagine. Average life expectancy for Americans born in 2013 is approaching 80 years. While we now live longer and typically spend most of these years in good health, many live with advanced and complicated illnesses. Health problems that once caused death are now controllable as chronic conditions. With these chronic conditions comes the risk of chronic illness and chronic symptoms.

Our health care system is not well-suited to caring for the large and growing number of patients with multiple, complex chronic illnesses. The strengths of our system — the technology and expertise that have led to these amazing advances in survival — target specific diseases one at a time. For those of us who have a single curable or controllable disease but are otherwise healthy, this system works very well. But what about those with chronic health problems, especially when one person has multiple chronic diseases? Our current health care system is often too fragmented to be of substantial benefit for these patients.

The solution is a system of specialized, coordinated care focused on the needs of patients with complex and chronic illnesses, aimed at helping patients live as well and as long as they can, even when cure is not a reasonable expectation. This is palliative care.

The word “palliative” comes from a Latin word for a kind of cloak, so that palliation is properly understood as shielding and protecting patients from the suffering of illness. Palliative care is aimed at maximizing quality of life; minimizing suffering; and providing care, comfort, companionship and peace. Palliative care can be provided to patients at the end of life or to those who have years left to live and are receiving treatments aimed at cure and control of disease.

Patients with heart disease, lung disease, diabetes, cancer and other illnesses can live for years with controllable health problems. Palliative care uses a team of physicians, nurse practitioners and other professionals who collaborate with a patient’s other health care providers to deliver and organize care. This care is guided by the preferences and values of the patient and family and aims to help patients live as well as possible and avoid health crises that may lead to hospitalization. Care aims to minimize symptoms like pain and nausea; reduce worry, anxiety and depression; and maximize important relationships and finding peace of mind.

Palliative is provided at home and clinics, just in the hospital. Care is shaped to what patients need and want. When that care is moved to the patient’s home, complications and crises can be prevented. Patients feel better and spend more time out of the hospital, enjoying good quality of life. Health care costs go down when patients have fewer health crises that require trips to the emergency room or admissions to the hospital.

Making this care more widely available is an important step in improving our health-care system. In Tennessee, Aspire Health and Alive Hospice, the largest hospice in Middle Tennessee and one of the first hospices in the U.S., are forming a joint venture: Aspire Health Medical Partners of Middle Tennessee. We hope to bring the benefits of palliative care to more people in our community. This partnership will create a nationally scalable model for advanced illness care that can meaningfully improve the quality of care for patients facing a serious illness while simultaneously significantly reducing total medical costs.

Middle Tennessee is our home. We are proud to build this pioneering partnership here.

Dr. Bill Frist is a former U.S. Senate majority leader and currently the chairman of Aspire Health, a new palliative care company. Dr. John Shuster is a board-certified palliative care physician and the chief medical officer of Alive Hospice. Dr. Andrew Lasher is a board-certified palliative physician and chief medical officer of Aspire Health.

This article was originally posted in The Tennesseean

http://www.tennessean.com/article/20130721/OPINION03/307210082/

Nashville Health Care Council Fellows

“What we witnessed is bipartisan dialogue, exposure to world-known individuals, new methods of learning, strategies and tactics I have put to use, and a consistent and engaging forum for dialogue. I consider this class one of the single most important investments I have made in myself.” -Laura Beth Brown, Vice President, Vanderbilt Health Services, Vanderbilt University Medical Center, Fellows Class of 2013

Nashville is a one-of-a-kind city.  It is a melting pot of music, culture, people, and healthcare, the often-neglected facet of Nashville, despite being Nashville’s biggest industry.  In Middle Tennessee alone, there are 250 healthcare companies, 16 public companies, $70 billion in global revenue, and 400,000 global jobs, making the “Athens of the South” also the Silicon Valley of Healthcare.  While other cities throughout the country can meet those numbers, none other can beat the unprecedented collaboration, one-of-a-kind innovation and implementation, and combined expertise of current healthcare leaders.

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Recently, I developed and began teaching a course in conjunction with the Nashville Health Care Council.  In the ever-changing industry of healthcare, what worked yesterday or today does not translate into what will work tomorrow, which many of these students have already come to realize with their existing experiences.  The only way we can combat the upcoming tough challenges of the healthcare industry is for the leaders of today to come together and train the leaders of tomorrow to face challenges in the context of privately-held start ups all the way to publicly-traded companies through innovative collaboration.  Together, we can develop strong solutions to the problems of today and tomorrow.

Nashville Health Care Council Fellows Dinner on June 28, 2013. by Donn Jones.

To adequately teach this course on collaboration, I had to collaborate myself, so my colleagues from the healthcare industry of Nashville came together with me to create and teach the innovative curriculum.  The healthcare legacy needs to be carried on, and I hope that the future leaders from this Fellow course will launch themselves with the skills needed to think outside the box and collaborate to solve healthcare’s toughest problems, all while bettering themselves, their companies, and, ultimately, their communities.

 

LeConte Adventures

Tennessee features some of the most exquisite landscape on the planet, and I recently made the hike up to the LeConte Lodge in the Great Smoky Mountains National Park.

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Waking up at Zoder’s in Gatlinburg, saying “Hi” to Cesar the parrot, who has been here 31 years and says “Hello!” back to me each year. Also enjoying hot coffee before the hike up the mountain.

 

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Hiking down Alum Cave trail  from LeConte Cabins. I loved the sunset challenged by “smoke” of clouds and mist. Great tradition that is a part of my annual journey.

I encourage everyone to be active and explore the beauty surrounding them; pictures can’t do it justice.

Future of Healthcare is Personalized Medicine

(Diplomatic Courier, July 08, 2013)

By Sen. Bill Frist, M.D.

It is a common refrain that America has the best health care in the world, but our people are far from the healthiest. We spend twice as much as any other nation on health services, yet rank dismally, behind more than twenty other countries in basic health metrics like infant mortality and life expectancy. We have more MRI machines, heart transplants, new drug patents, Nobel Prize winners than any country in the world, and yet people in Greece, Israel, and Jordan live longer. How can this be?

The New York Times will tell you that the lack of a true healthcare system—preferably a nationalized and universal system—causes these failures. If only we had a true, equitable and universal system, such as Britain’s or France’s, we could skyrocket up the rankings. This is simply not true.

Data have shown that when all factors are taken into account health services only account for roughly 10 percent of determining how long we live. The two major factors are personal behavior, accounting for 40 percent, and genetics, accounting for 30 percent (social circumstances and environmental exposure round out the rest at 15 percent and 5 percent, respectively). So how do we harness the true drivers of mortality? How do we live healthier, create a more targeted and personalized approach to medicine, all while simultaneously cutting costs and eliminating waste?

The answer lies in what I call “New Medicine.” I believe that we are currently at an inflection point in medicine. We are poised to capitalize on decades of innovation, tying together disparate fields including genetics, social networks, supercomputing, the internet, stem cells, cutting edge imaging and sensors, and pharmaceuticals. These forces, unleashed in a dynamic, coordinated fashion can usher in this era of “New Medicine” that treats each patient as an individual, not the average; eliminates waste and adverse side effects; and maximizes the outcome of diagnosis and treatment for you specifically, not just for most people or the population in general.

We have been building towards this inflection point for decades with seemingly unrelated advances such as the advent of cell phones in the 1970s, the discovery of the double helix model of DNA in 1953, or the first MRI on a human being in 1977.

I have written in several forums about some of these advances, most notably pharmacogenomics and the rise of consumerism in healthcare, but today I focus on one breakthrough of incredible potential.

Stem cells hold the power to be a major pillar of the “New Medicine.” Scientists have speculated for years about the awesome potential of stem cells. Conditions as wide ranging as diabetes, spinal cord injuries, burns, limb amputations, heart disease, and neurological disorders can all likely be treated by stem cells. But what makes embryonic stem cells so special?

Embryonic stem cells are special for two reasons; first they produce exact copies forever and second they can grow into specialized tissue, which fully formed (or “adult embryonic stem cells”) human cells cannot, or at least were not thought able to. Embryonic stem cells are harvested from a five day old embryo, taking the inner cell mass of the blastocyst, generating pluripotent embryonic stem cells. These cells can be differentiated into heart cells, brain cells—basically any cell in the human body.

But there are two problems with embryonic stem cells. First is the ethical issue. It requires the destruction of embryos, the destruction of something that, left to nature, would become human life. Second, it is “non-self.” Even though these cells can become specialized into any type of cell, they do not come from you and your body knows this. But this approach has yielded remarkable scientific breakthroughs. We have cloned frogs and sheep. I had the great pleasure of visiting Dolly in Scotland, the first cloned sheep, which many may not know was actually named after Dolly Parton, the famous Tennessean entertainer. However, for reasons we don’t fully understand, humans cannot be cloned using this same method.

Thus, the real breakthrough came using a radically different approach. In 2012, the Nobel Prize for Medicine and Physiology went to Dr. Shinya Yamanaka (along with Sir John B. Gurdon). Yamanaka induced skin cells to become “Pluripotent Stem Cells” (iPS). These “iPS cells” have all the special properties of the magical stem cells. In the simplest terms, Yamanaka was able to take normal, adult skin cells and transform them, using four master genes, into pluripotent stem cells, just as capable of transforming into any cell type, but without the use, and consequent destruction of an embryo. Not only does this solve an incredibly complex moral issue, it also bypasses the issue of embryonic stem cells being foreign or “non-self” to the eventual patient or user. Doctors can simply use the patient’s own skin cells to create the iPS cells needed to treat him.

The first real application of this breakthrough is in the form of regenerative medicine. As a transplant surgeon, I have performed hundreds of operations to extend the life of patients by giving them a new heart or lung. This complex procedure meant that I would get on a plane, fly to the organ donor, remove the donor heart and fly back, transplanting it into my patient, all in a matter of hours. The patient receives years, even decades, of life with family and friends. I have many patients who I transplanted more than 25 years ago. But the heart transplant patient has traded a fatal disease for a chronic disease, which requires daily management. The heart a surgeon transplants is “non-self” and thus the body continually attempts to reject it. On top of having just undergone one of the most traumatic operations a human body can endure, the patient must then take multiple immunosuppressant medicines to keep his own body from killing his new heart. Consequently, pneumonia, or even a common cold, becomes deadly.

But this operation may well become a thing of the past, like the iron lung. In the not too distant future, we will take a patient who needs a heart transplant, perform a skin biopsy, create patient-specific iPS cells, grow them into healthy heart cells and then transplant, not a separate heart, but merely the genetically matched healthy heart cells. The body, recognizing its own genetic material, would find no cause for rejection and this operation can be done with a needle, not a bonesaw. There is also no shortage of organ donors or patients dying while waiting for just the right match.

This example represents just one of hundreds of applications. In fact, the first clinical trials for macular degeneration (blindness) will occur this year.

The second application of Yamanaka’s breakthrough is the huge potential for drug discovery. Take Alzheimer’s Disease for an example. Up to now, all drugs have failed. But what if we could test a new drug specifically on your brain cells to see if it works. Using this technology we can. We simply take adult skin cells, revert them to iPS cells in a test tube and then again into brain cells and then test their response to a potential drug in a dish. Now we can literally conduct “clinical trials in a dish.” It’s a new world.

The Gladstone Institute, where Dr. Yamanaka works, has already made cells for Alzheimer’s, Parkinson’s, Huntington’s, and cardiac disorders. With the ability to test drugs on actual cells of a specific patient, we can take the guesswork out of efficacy and toxicity of drugs. This should, and will, lead to a major rejuvenation of the pharmaceutical industry and more targeted, specific, and effective care for patients.

“New Medicine” is coming. Don’t be left behind.

Bill Frist is a transplant surgeon and former Senate Majority Leader (R-Tennessee).

This article was originally published in the special annual G8 Summit 2013 edition and The Official ICC G20 Advisory Group Publication. Published with permission. http://www.diplomaticourier.com/news/opinion/1523-future-of-healthcare-is-personalized-medicine

What a Difference a Decade Makes

(The Hill, May 28, 2013)

By Rep. Barbara Lee and Bill Frist

A Democratic Congresswoman and a former Republican Senator aren’t afforded many opportunities to work together. Especially at a time of fiscal crisis when every dollar is scrutinized and fought over, partisanship pushes us into opposite corners. But we agree on a program that truly has bipartisan support, saves millions of lives a year, and contributes directly to stability, security and economic growth worldwide.

Ten years ago this May, when the AIDS pandemic was at its worst, ravaging many African countries and a sure death sentence for millions, our country responded in an unprecedented way. We both, along with the late Republican Congressman Henry Hyde and the late Democratic Congressman Tom Lantos, worked with the Congressional Black Caucus and a bipartisan group of legislators to address this enormous problem. Soon after, in 2003, then-President George W. Bush instated PEPFAR, the President’s Emergency Plan for AIDS Relief, pledging $15 billion over five years to combat the spread of HIV, prevent further infections and improve access to care for millions of people across the globe.  Each year since then, Congress, with bipartisan support, has stood behind the program, providing critical funding to enable PEPFAR to truly help change the trajectory of the AIDS epidemic.

Now, a decade later, PEPFAR’s success isn’t just measured in dollars spent, but in lives saved and communities improved. The Institute of Medicine called the program “transformational” in global health.

PEPFAR has directly supported life-saving antiretroviral treatment for nearly 5.1 million men, women and children around the world, and is helping prevent hundreds of thousands of mother-to-child transmissions, an essential step toward achieving an AIDS-free generation. Engaging women is crucial to the broader goal; about half of the people living with HIV worldwide are women, and their empowerment is critical to beating this disease. PEPFAR supported HIV testing and counseling for more than 11 million pregnant women in 2012 alone.

Because of PEPFAR, we’re not just working toward an AIDS-free generation, we’re achieving an AIDS-free generation.

All around the world, PEPFAR is caring both for the health of the individual and the health of communities. The medications and programs supported by PEPFAR are so effective that people living with HIV/AIDS are doing just that — living. Infected individuals can care for their families and hold jobs. Communities enjoy economic stability. The United States earns a positive reputation.

But we are at a tipping point to truly realize this vision. If we back away now, the gains we’ve made will evaporate; the success we’ve had will disappear. Support of PEPFAR now is as important as it was 10 years ago.

HIV is a virus, not an ideology. Democrats and Republicans should be proud of PEPFAR’s legacy and continue to support it moving forward, providing the program with the robust funding it still needs to help achieve an AIDS-free generation.

Lee serves on the House Committee on the Budget and the House Appropriations subcommittee on State, Foreign Operations, and Related Programs, and is founding co-chair of the Congressional HIV/AIDS Caucus and represents the United States on the United Nations’ Global Commission on HIV and the Law. Frist is adjunct professor of surgery at Vanderbilt and Meharry medical schools and former majority leader of the U.S. Senate.

This article was originally featured in The Hill http://thehill.com/opinion/op-ed/302249-what-a-difference-a-decade-makes-

A Crucial Moment for Global Nutrition

(The Hill, May 22, 2013)

On June 8, the United Kingdom, under the leadership of Prime Minister David Cameron, will host “Nutrition for Growth,” a high-level meeting where donor governments, including our own, will pledge funding and other commitments to address undernutrition and its devastating impact on the long-term health and productivity of millions of people in developing countries.

Sitting side by side with donors and foundations will be representatives of developing country governments, the private sector and civil society organizations, demonstrating the truly complex and multi-stakeholder nature of nutrition.

Malnutrition is one of the world’s most serious, yet least-addressed, development challenges. It contributes to almost 2.5 million young child deaths annually. Malnutrition is a serious drain on economic productivity, costing countries as much as 11 percent of GDP.

Close to 200 million children throughout the world are chronically malnourished and suffer from serious, often irreversible cognitive damage. Physically, undernourished children are stunted—smaller in stature than their well-nourished peers, more susceptible to illness throughout life, including noncommunicable diseases such as heart disease, cancer and obesity.

The case for greater leadership and investments in global nutrition is clear. The Copenhagen Consensus, an expert panel of economists that includes several Nobel laureates, concluded that fighting malnutrition in young children should be the top priority investment for policymakers. In the group’s report, they stated that every $1 invested in nutrition generates as much as $138 in better health and increased productivity. Similar studies have found that undernutrition causes between $20 billion and $30 billion in additional health costs every year to treat the long-term consequences of early childhood malnutrition.

While the problem is complex, the solutions don’t need to be. Cost-effective, evidence-based solutions exist. What we need are the resources and the political commitment to scale up proven nutrition solutions.  Political commitment in the form of presidential leadership and bipartisan congressional support works. We have seen it in the Global Fund, the President’s Malaria Initiative, the Millennium Challenge Corporation and the President’s Emergency Plan for AIDS Relief (PEPFAR).

We can do it again — this time to scale up and align nutrition investments. To follow the proven PEPFAR model, we should target resources to benefit the most vulnerable; align resources across all agencies and programs; focus on countries where we have committed partners and country-led strategies; and coordinate efforts internationally.

UNICEF reports that 1 in 4 children under the age of five is stunted and 80 percent of those children live in just 14 countries. The Lancet’s series on maternal and child health and nutrition highlights the 1,000 days from the beginning of pregnancy to a child’s second birthday as the critical window of opportunity for human health and development.

Like PEPFAR, we can target our interventions to benefit those most vulnerable to undernutrition, namely pregnant women and young children. We have commitments from more than 30 countries, which as part of the Scaling Up Nutrition (SUN) movement — a partnership of donors, developing countries, nongovernmental organizations and the private sector — have identified undernutrition as a severe impediment to economic development. A number of those countries have developed national nutrition plans that offer donors an opportunity to build upon and strengthen the country-led aspect of the investments.

We can begin by working with those committed country partners through bilateral and multilateral channels and offer our government’s technical expertise and best practices to galvanize a concrete investment strategy that includes innovative public and private partnerships and financing mechanisms.

There is an emerging international coordination effort for nutrition: the Nutrition for Growth event in London, last year’s G8 commitment to the New Alliance for Food Security and Nutrition, the UK-led Hunger Summit of 2012 and the growing Scaling Up Nutrition movement. These efforts will help the United States to share with other donors the cost of alleviating this global problem.

This is a critical moment for the U.S. to lead on global nutrition. The June 8 summit in London is the perfect opportunity for the Obama administration to announce a bold global nutrition strategy that outlines a multifaceted and multi-year approach to better coordinate and integrate nutrition resources across sectors and agencies, with clearly defined goals and targets, and with the dedicated resources necessary to achieve the strategy’s stated goals. Bipartisan leaders in Congress must step forward and commit to working with the president to make global nutrition a top priority of U.S. development assistance.

The moment for turning the corner on global nutrition is here, and it is time for our elected leaders to demonstrate anew how American leadership is the driving force for building a healthier, safer and more prosperous world.

William H. Frist, M.D. is a nationally acclaimed heart transplant surgeon, former U.S. Senate majority leader, the chairman of Hope Through Healing Hands and Tennessee SCORE, professor of surgery and author of six books. Learn more about his work at BillFrist.com.

This article was originally featured in The Hill http://thehill.com/opinion/op-ed/301179-a-crucial-moment-for-global-nutrition

Phasing Out Fee-For-Service

(The New England Journal of Medicine, May 22, 2013)

By Bill Frist and Steven Schroeder

In March 2012, the Society of General Internal Medicine convened the National Commission on Physician Payment Reform to recommend forms of payment that would maximize good clinical outcomes, enhance patient and physician satisfaction and autonomy, and provide cost-effective care. The formation of the commission was spurred by the recognition that the level of spending on health care in the United States is unsustainable, that the return on investment is poor, and that the way physicians are paid drives high medical expenditures.

The commission began by examining factors driving the high level of expenditures in the U.S. health care system. It found that reliance on technology and expensive care, higher payments for medical services performed in hospital-owned facilities than in outpatient facilities, and a high proportion of specialist physicians as compared with generalists were all important cost drivers. But fee-for-service reimbursement stood out as the most important cause of high health care expenditures.

The commission then set out 12 recommendations for changing current methods of physician payment. The aggressive approaches that are recommended below provide a blueprint for containing costs, improving patient care, and reducing expenditures on unnecessary care. (The commission’s report is available at http://physicianpaymentcommission.org/report/ and in the Supplementary Appendix, available with the full text of this article at NEJM.org.)

Blueprint for a New Physician Payment System

Recommendation 1: Over time, payers should largely eliminate stand-alone fee-for-service payment to medical practices because of its inherent inefficiencies and problematic financial incentives.

The fee-for-service mechanism of paying physicians is the major driver of higher health care costs in the United States.1 It contains incentives for increasing the volume and cost of services (whether appropriate or not), encourages duplication, discourages care coordination, and promotes inefficiency in the delivery of medical services.

Recommendation 2: The transition to an approach based on quality and value should start with testing new models of care over a 5-year period and incorporating them into increasing numbers of practices, with the goal of broad adoption by the end of the decade.

The long-range solution is a system that provides appropriate and high-quality care, emphasizes disease prevention and the management of chronic conditions rather than treatment of illness, and values examination and diagnosis as much as medical procedures. This implies a shift from a payment system based on a fee-for-service model to one based on value through mechanisms such as bundled payment, capitation, and increased financial risk sharing. But changing from the current model of care to one that is value-based cannot be accomplished overnight. It will require a transition period, with the likely end point being a blended system with some payment based on the fee-for-service model and other payment based on capitation or salary.

Recommendation 3: Because the fee-for-service model will remain important into the future, even as the nation shifts to fixed-payment models, it will be necessary to continue recalibrating fee-for-service payments.

Whatever system reforms (accountable care organizations, bundled payments, patient-centered medical homes, or capitation) are ultimately adopted, fee-for-service payment will remain an integral part of physician payment for a long time.2 Although paying a fixed payment through bundling or capitation is reasonable, appropriate, and desirable for acute episodes of care requiring hospitalization, many issues remain as the concept is expanded outside of hospitals. Some services are not appropriate for bundling. And the best ways to allocate bundled payments to individual physicians remain to be clarified.

Recommendation 4: For both Medicare and private insurers, fees should be increased for evaluation-and-management codes, which are currently undervalued. Fees for procedural diagnosis codes, which are generally overvalued and thus create incentives for overuse, should be frozen for 3 years. During this period, efforts should continue to improve the accuracy of relative values, which may result in some increases as well as some decreases in payments for specific services.

The time that physicians spend on services that fall under codes for evaluation and management is reimbursed at lower rates than time that is spent providing services under procedural codes. The undervalued evaluation-and-management services at issue are often those that provide preventive health and wellness care, address new or undiagnosed problems, and manage chronic illnesses.

The current skewed physician-payment system creates disincentives to spending time with patients with complex chronic conditions. It leads physicians to offer care for highly reimbursed procedures rather than lower-reimbursed care. It neglects illness prevention and disease management. Lastly, it induces medical students to choose procedural specialties over evaluative ones. Although the relative undercompensation of primary care physicians has commanded much attention, the real issue is not one of relative payment for primary care physicians versus specialists but rather of payment for evaluation-and-management services as compared with procedural services. These evaluation-and-management services include those that are provided by neurologists, psychiatrists, pediatricians, obstetrician–gynecologists, and internal medicine subspecialists.

Recommendation 5: Increased payment for facility-based services that can be performed in a lower-cost setting should be eliminated. In addition, the payment mechanism for physicians should be transparent and provide physicians with roughly equal reimbursement for equivalent services, regardless of specialty or setting.

Over the past years, there has been a trend toward reimbursing medical services that are performed in facilities owned by hospitals at a higher rate than that for the same services provided in office settings. This disparity has a negative effect on the way health care services are delivered. Cardiology presents a telling example. Medicare pays $450 for an echocardiogram performed in a hospital and only $180 for the same procedure performed in a physician’s office.3

Furthermore, spurred in part by the inducements of enhanced income from procedures, large hospital systems are buying up independent practices, threatening the viability of independent physicians and raising the cost of health care. In 2010, the New York Times reported that practices around the country were selling to health systems or hospitals; the CEO of the American College of Cardiology was quoted as saying, “The share of cardiologists working in private practice had dropped by half in a year.”4

Moreover, private payers negotiate payment for services with individual health-care-delivery groups, often resulting in different payment levels for the same physician services, depending on the market power of the physician group. Payments by private payers for medical services should be transparent to the public. These payment differentials are difficult to justify in concept or in practice.

Recommendation 6: Fee-for-service contracts should always include a component of quality or outcome-based performance reimbursement at a level sufficient to motivate a substantial change in behavior.

The incentive inherent in fee-for-service payment arrangements to increase volume can be mitigated by incorporating quality metrics into the negotiated reimbursement rates. This is already being done in programs conducted by the federal government and private insurers. On a budget-neutral basis, the modifier will increase or decrease payment rates to physicians on the measures of quality and cost.2 Although to date the overall evidence on the effectiveness of pay-for-performance programs based on quality measures is mixed, some programs are showing positive results.

Recommendation 7: For practices with fewer than five providers, changes in fee-for-service reimbursement should encourage methods for the practices to form virtual relationships and thereby share resources to increase the quality of care.

Large, integrated networks of providers dominate the provision of health care services in some areas of the country, but small, independent practitioners provide care for 9 out of 10 Americans, including millions living in rural and underserved areas.5 Fee-for-service payment should reimburse small practices for care that is not delivered in person (e.g., by telephone or e-mail) and for coordination among providers, as well as allow for sharing of ancillary providers, such as nutritionists, social workers, and psychiatric providers, who are critical to the integrated “whole person” model envisioned in the medical home.

Telemedicine and other forms of remote communication have improved outcomes for many types of patients, including those in remote intensive care units,6 the frail elderly,7 and those being treated for depression in clinics not served by a psychiatrist.8 These interventions have shown reduced costs in some populations and should be reimbursed appropriately.

Recommendation 8: As the nation moves from a fee-for-service system toward one that pays physicians through fixed payments, initial payment reforms should focus on areas in which there is substantial potential for cost savings and better quality of care.

The sickest 5% of patients consume half the nation’s health care resources. Many of these patients have multiple chronic conditions, including behavioral health disorders. Improving their care offers substantial potential for cost savings and improved quality. A logical place to start is by changing how physicians are paid to deliver care to these high-cost patients.

Another logical place to begin implementing payment reforms is with in-hospital procedures and their follow-up. Treatments for many conditions, such as heart attack and joint replacement, lend themselves to fixed payments.

Recommendation 9: Measures should be put in place to safeguard access to high-quality care, assess the adequacy of risk-adjustment indicators, and promote strong physician commitment to patients.

Any prospective payment system should be accompanied by adequate protections for patients and recognition of the centrality of patient care. Quality measures are necessary to ensure that evidence-based care is not denied as a cost-saving mechanism. A body of evidence now shows that prevention, care coordination, and the prudent practice of medicine not only will save money but also will lead to better outcomes. Risk adjustment is important for any type of fixed payment to discourage physicians and other providers from cherry-picking the healthiest patients and avoiding the sickest ones.

Recommendation 10: Medicare’s sustainable growth rate (SGR) adjustment should be eliminated.

The SGR has not worked in practice and shows no prospect of ever working. The practice of setting expenditure targets for 1 year and ignoring the consequences of exceeding them the next year makes no sense. Moreover, setting a spending cap without addressing the underlying issues of the volume and price of services and health outcomes is a short-term answer to a problem that requires a long-term solution. And since the SGR is based on the aggregate payment for physicians’ services by Medicare, there is no incentive for individual physicians to try to hold down costs, and those who do so are, in effect, penalized.

Recommendation 11: Cost-saving measures to offset the elimination of the SGR should come not only from reduced physician payment but also from the Medicare program as a whole. Medicare should also look for savings from reductions in inappropriate utilization of Medicare services.

The commission believes that the $138 billion that the Congressional Budget Office estimates will be needed to offset the elimination of the SGR can be found entirely by reducing overutilization of medical services within Medicare. We believe that enacting the recommendations in this report can go a long way toward recouping those dollars.

Recommendation 12: The Relative Value Scale Update Committee (RUC) should continue to make changes to become more representative of the medical profession as a whole and to make its decision making more transparent. The Centers for Medicare and Medicaid Services (CMS) has a statutory responsibility to ensure that the relative values it adopts are accurate. Therefore, it should develop additional open, evidence-based, and expert processes beyond the recommendations of the RUC to validate the data and methods it uses to establish and update relative values.

The RUC, which is managed by the American Medical Association and composed of members named by national medical-specialty societies, makes recommendations to the CMS regarding updates to the relative value scale on which fee-for-service physician payment is based for Medicare as well as private payers. Both its composition and its operations are flawed.

The RUC has come under scrutiny for its composition, which is skewed toward the procedural and highly technological specialties9 and its operating procedures: meetings are largely closed to the public; RUC members sign confidentiality agreements; individual voting records are not made public; and transcripts of meetings are not published. Moreover, critics contend that since nearly 90% of the RUC’s recommendations have historically been adopted by the CMS,10 it should be considered as a federal advisory committee and be subject to the sunshine requirements and oversight mandated by the Federal Advisory Committee Act.

As of 2012, improvements in the RUC include the addition of new primary care and geriatrics seats and the requirement that vote totals for all recommendations be published. The commission urges continued improvement of the RUC and encourages the CMS to look more widely at alternative sources of relative value and other payment recommendations.

Conclusions

Controlling rising expenditures for health care will not occur without changing the way that physicians are paid. This will require the aggressive pursuit of new physician-payment models with no delusions that the fee-for-service model will be swiftly or entirely eliminated. As we transition to various forms of blended physician payment, fixing current payment inequities under fee-for-service models will be of the utmost importance. Those fixes include reducing gaps in payments between different sites of care, rewarding caring for complex and underserved patients, and ensuring that evaluative and management services are valued as highly as technological care.

Bill Frist, a physician, is a former Republican senator from Tennessee and Senate majority leader, and Steven Schroeder is a professor of health and health care in the department of medicine at the University of California, San Francisco. The two men co-chair the National Commission on Physician Payment Reform, which has issued a report providing recommendations aimed at controlling health spending by changing the way doctors are paid.
This article was originally featured in The New England Journal of Medicine http://www.nejm.org/doi/full/10.1056/NEJMsb1302322

Cost Sustainability

(Modern Healthcare, May 18, 2013)

By Bill Frist and Dr. Manoj Jain

We have done it. We have decreased the increase in the cost of healthcare. Let us explain. For three decades (1980–2009), the cost of healthcare has been increasing each year at an average rate of 7.4%—double the rate of inflation. However, over the past three years, the increase in healthcare expenditures has remained at a low 3.1%.

Is this decline the desperately needed bend in the healthcare cost curve or just the impact of the depressed economy?

Four leading studies point us in different directions. Last month’s Kaiser Family Foundation study deduced that 77% of the decline was attributable to the economic downturn and is likely temporary. A report by the Robert Wood Johnson Foundation echoed these conclusions.

In contrast, two articles in the May issue of Health Affairs point to structural changes such as “less rapid development of imaging technology and new pharmaceuticals, increased patient cost sharing and greater provider efficiency” as major causes of the decline, suggesting that only 40% to 55% of the decline was because of the economic downturn.

The final answer is probably somewhere in between, with about half of the decrease realized by encouraging changes in the way healthcare is delivered and the other half due simply to the downturn in our economy. Regardless, it is important to recognize—and celebrate—that the cost curve has bent without collapsing our healthcare system or being prompted by draconian measures in rationing of healthcare. Moreover, the decline has not led to deterioration in our quality measures. In fact, they have improved.

Now, the $2.7 trillion question is, “How can we sustain this slower growth over the next decades?”

Undeniably, during the past several years, the singular focus of conversation among policy makers has shifted from simply more care and better quality of care to better value in healthcare, where value is defined as quality over cost. The onset of value-based purchasing by Medicare and higher copays and deductibles for patients in employer-based plans has helped in disseminating this message to doctors and patients.

Yet if history is any indicator, the cost of healthcare will rise once again as our economy strengthens. So, last month the Bipartisan Policy Center made 50 bold recommendations on how to sustain the lower growth of healthcare costs. These recommendations are unique because they focus on improving the entire system of care over a prolonged period of time and break through the partisan rhetoric surrounding healthcare reform.

We want to highlight a few of the recommendations that will impact providers—hospitals and doctors. The BPC encourages advancing accountable care organizations to a 2.0 version where the entire spectrum of patients’ needs would be covered for a fixed payment, and in doing so replace the irrational and outdated sustainable growth-rate formula for physician reimbursement.

Also, the BPC policy paper suggests changing our present voluntary bundle payments program to the standard method of payments for certain DRGs. The impact of such a change in the payment system can be profound. When in the 1980’s Medicare changed payments to hospitals by DRG, length of stay and hospital payments declined.

If such measures are not successful in restricting the cost of healthcare, then a fallback spending limit or a “cap” would take effect based on annual per beneficiary spending growth to a target of GDP.

To sustain these reductions in cost, the availability of current cost data and transparency of such data are essential. At present when patients get their bills, they do not know the difference between healthcare charges, expenditures and costs. To borrow an analogy from car sales: the sticker price, the new owner’s price and the dealer’s invoice price, respectively.

As for providers, physicians are often unaware whether an antibiotic costs $150 or $15 when writing the prescription or a doctor’s order in the hospital chart.

These costs have real impact for Americans. One RAND Corp. study found that if healthcare costs had risen at the slower rate equal to the Consumer Price Index, an average American family would have had an additional $5,400 more to spend each year on education, entertainment, food and clothing over the past decade. But instead, the average family has spent that money on healthcare. With our healthcare system at this crucial crossroads, we need to take this opportunity and stop the collateral damage.

A slower growth of healthcare cost would mean less burden on the individual family, freeing that family to invest in and live a higher quality of life. And for communities it would free billions of dollars for education, businesses, job creation and future innovation.

The good news is that it can be done. And the blueprint for eliminating waste, lowering the cost and maximizing the value is actively being considered by voices that rise above partisan bickering.

Manoj Jain is an infectious disease specialist in Memphis, Tenn.
Bill Frist is a heart transplant surgeon and former U.S. Senate majority leader.

This article was originally published in Modern Healthcare.

How to Build a Better Health-Care System

(Washington Post, April 17, 2013)

By Tom Daschle, Bill Frist, Pete Domenici, and Alice Rivlin

Tom Daschle, a Democrat and former senator from South Dakota, was Senate majority leader from 2001 to 2003. Bill Frist, a Republican and former senator from Tennessee, was Senate majority leader from 2003 to 2007. Pete Domenici, a Republican and former senator from New Mexico, was chairman or ranking minority member of the Senate Budget Committee from 1981 to 2003. Alice Rivlin is a former director of the Congressional Budget Office. The four co-chair the Bipartisan Policy Center’s Health Care Cost Containment Initiative.

The four of us came together to change the conversation around how to improve health care and constrain cost growth. What we learned is that, until better care is prioritized over more care, our nation will continue to face a problem with health-care costs. The good news is that, through thoughtful policy, health-care practitioners can be encouraged through rewards to focus far more on what is best for their patients and less on the number of tests and procedures they can order. The even better news is that such a health-care vision can not only produce better care but also cost less.

With the Bipartisan Policy Center, we will release a report Thursday with more than 50 recommendations to achieve the critical goal of improving the quality and affordability of care for all Americans while containing high and rising health-care spending. This report is the culmination of nearly a year of work, including stakeholder outreach, thorough research and substantive analytics to quantify the impact of our proposed policies.

Too often we in Washington talk about health care as though it is little more than a line item on a budget table. Those of us who have experienced the best of health care know that is not how care should be delivered or policy crafted in this most personal of issues. Our country can achieve a higher-value health-care system — meaning both higher quality and greater efficiency.

Health-care cost drivers are complex and interwoven, but the most problematic ones we identified are the inefficiencies, misaligned incentives and fragmented care delivery in the current fee-for-service reimbursement system. To address these, we seek to promote coordinated and accountable systems of health-care delivery and payment, building on what has proved successful in the private and public sectors. Organized systems of care emphasize the value of care delivered over the volume of care. These systems are often better able to meet patients’ needs and desires and are able to effectively reimburse providers and practitioners for delivering high-quality care.

In all our proposals, we sought to avoid simple cost-shifting as a means to generate federal budgetary savings, instead promoting transparency and protecting patient choice. We also focused on reforms that will incite transformation across the health-care system, not limited to Medicare. We believe, however, that the power of Medicare can be leveraged to lead the way in transforming U.S. health care.

In brief, our recommendations:

●Preserve the promise of traditional Medicare while adding more choices and protections for beneficiaries, including accountable systems of care and a stronger, more competitive Medicare Advantage program.

●Strengthen and modernize the traditional Medicare benefit, including adding a catastrophic cap, rationalizing cost-sharing and premiums and expanding access to assistance programs for those with low incomes.

●Reform the tax treatment of health insurance to limit the taxfavored treatment of overly expensive insurance products.

●Empower patients by promoting transparency that is meaningful to consumers, families and businesses, and streamline quality reporting.

●Advance the nation’s understanding of potential cost savings from prevention programs, through support for research and innovation on effective strategies to address costly chronic conditions.

●Offer incentives to states to promote policies that will support a more organized, value-driven health-care delivery and payment system, such as supporting medical liability reform and strengthening their primary-care workforce.

All of these policies are designed to improve the quality and value of our nation’s health care. That is where every health-reform effort should start. The savings that we achieved — $560 billion over 10 years in debt and deficit reduction — is the outgrowth of our work, not the goal.

No single set of recommendations can fix the health-care system or the nation’s debt and deficit crisis overnight, but we hope this report can start a constructive, pragmatic dialogue among policymakers and political leaders. By presenting this report to federal, state and private-sector leaders, we hope to promote a collaborative dialogue and a shared understanding of strategies to put our nation’s health system, as well as its economic outlook, on a sounder, healthier and more sustainable path.

This article was originally published in the Washington Post http://www.washingtonpost.com/opinions/how-to-build-a-better-health-care-system/2013/04/17/a44dd478-a6d1-11e2-8302-3c7e0ea97057_story.html

States’ Rare Chance to Expand Medicaid

(Politico, April 11, 2013)

By Bill Frist

A proposal unveiled by Tennessee Gov. Bill Haslam late last month leverages federal funds to purchase private coverage for new Medicaid eligibles in the state’s health insurance exchange. In recent weeks, Arkansas became the first state to embrace a similar plan. This market-based approach, known as “premium assistance,” has piqued the interest of GOP-led states across the country, including Ohio, Florida, Pennsylvania and Louisiana. While the Obama administration has been receptive to alternative Medicaid expansion plans, a shortlist of frequently asked questions released recently did not go far enough to entice states to expand.

Since the Supreme Court’s ruling last summer, states can opt out of the Affordable Care Act’s Medicaid expansion, which extends coverage to anyone earning below nearly $16,000 per year. If every state expanded, an additional 21 million Americans could be covered through the Medicaid program. However, as of today, only 27 governors support the Medicaid expansion; 19 are opposed; and another five remain undecided. Many of those opposed are from big GOP-led states like Texas, where the opt out alone leaves millions of Americans without access to affordable coverage.

Here’s why expanding coverage for low-income people through the purchase of private insurance — premium assistance — is a good thing and why the feds need to continue to show flexibility regarding states’ private options.

Coverage numbers will be the measure by which the Affordable Care Act’s success is judged. If states do not expand Medicaid, millions of Americans will be left with no options for affordable health insurance coverage, and federal health reform could prove a hollow victory for the Obama administration. As the Medicaid program stands today, not all low-income individuals qualify for coverage. For example, 42 states offer limited or no coverage options for poor childless adults. A decision not to expand Medicaid leaves glaring inequities in coverage that federal health reform was intended to eliminate. If the administration is serious about broadening coverage and saving the most fundamental promise of health reform, then it needs to embrace new private market options.

Flexibility will get holdout states on board with Medicaid expansion sooner. There is no deadline for states to decide on Medicaid expansion, but the richest match rate of 100 percent will be available only for the first three years. If every state expanded Medicaid, the federal government would finance almost 95 percent of expansion costs over the next 10 years — that means leveraging at least $12 in federal matching funds for every $1 in state funds spent on Medicaid. In addition, the federal Department of Health and Human Services has made it clear that states can opt out after three years, the point at which a state would need to add any matching dollars. It is obviously a better deal to expand sooner rather than later — but in order to get ideologically motivated governors to adopt an expansion, states will need a way to distance themselves from Obamacare and put their own stamp on the program.

Expansion of private coverage is a good thing. I’ve written about the value of health insurance exchanges before and why we should embrace an expansion of these new competitive marketplaces. Private coverage affords higher rates of reimbursement for providers and richer networks for beneficiaries, and competition among private plans will help drive down costs. If Medicaid pays the premiums of private health plans in the exchanges, low-income people will also have the opportunity to stay on one health plan even as their income fluctuates. This means that for the 7 million people projected to move between Medicaid eligibility to the exchange or vice versa, they will be able to maintain continuity of coverage and care.

But states also must take responsibility for the expansion decision, because having health insurance matters. Governors and state legislators must acknowledge the impact a coverage expansion will have in people’s lives. It is irrefutable that health insurance improves individuals’ health and well-being. The insured are more willing to access care and ultimately, have better health outcomes. The uninsured skip preventive care and then show up at an emergency room with severe, costly, late-stage symptoms that are harder and more expensive to treat. As a physician, I’ve seen it time and again.

Governors have a very real opportunity — and a rare one at that — to advocate for some of the program reforms they want to see in Medicaid while simultaneously expanding coverage to millions of Americans. Similarly, if the Obama administration wants to entice more states into broadening coverage, it needs to accept that premium assistance will continue to be a growing segment of the Medicaid program.

Bill Frist is a physician and the former Senate majority leader.

This article was originally featured in Politico http://www.politico.com/story/2013/04/states-rare-chance-to-expand-medicaid-89959.html

We Must Continue Our Legacy of Saving Lives

(Roll Call, March 7, 2013)

Now is no time to shy away from our health investments

By Bill Frist

A decade ago, as I was beginning my time as Senate majority leader, bipartisan consensus in Washington helped launch a new era of progress in global health just when it was sorely needed. Twenty years had passed since I first saw AIDS patients in Boston, though at the time we didn’t even have a name for this savage disease. Advances in treatment and technology were helping control HIV in the United States, but AIDS was decimating communities worldwide. There were tens of millions of infections, yet only 400,000 people in low- and middle-income countries had access to lifesaving antiretroviral therapy, meaning only a tiny fraction were able to escape death.

World leaders united to tackle AIDS and other scourges through an innovative financing tool — the Global Fund to Fight AIDS, Tuberculosis and Malaria. President George W. Bush and Congress made a founding pledge of $300 million to the international initiative. Bush, with bipartisan support from both chambers of Congress, also established the President’s Emergency Plan for AIDS Relief, the largest program ever to combat a single disease. President Barack Obama has similarly embraced this program and America’s role in eradicating this disease.

U.S. leadership at the Global Fund, and bilateral health programs such as PEPFAR and the President’s Malaria Initiative, signaled a renewed commitment to a core facet of our country’s greatness: compassion for those most in need. Understanding that improving global health is good for national security, economically prudent and — most importantly — the right thing to do, the U.S. taxpayers made an unprecedented investment in the world’s future.

That investment is paying off.

As we mark the 10th anniversary of PEPFAR this year, the number of people on lifesaving treatment has increased more than twentyfold. HIV infection rates are down. The number of malaria cases has plummeted by more than 50 percent. Tuberculosis mortality rates are falling steadily. The Global Fund alone saves an estimated 100,000 lives each and every month, working in more than 150 countries. These health gains were once unimaginable.

A new chapter in global health begins this month as visionary leader Dr. Mark Dybul takes the helm as executive director of the Global Fund. With so much gridlock in Washington, Dybul’s appointment is a reminder of what we can accomplish by reaching across party lines.

Dybul, who began as a physician treating AIDS patients in the early years of the pandemic, helped transform the fight against the disease as the architect and leader of PEPFAR. Now at the Global Fund, he will lead the charge to defeat AIDS, malaria and tuberculosis. Armed with scientific expertise and dedicated to a mission that goes beyond political ideology, there may be no one better suited for the job.

Today there is real hope in this fight — but it’s far from over. We have the science to help people with HIV live healthy lives, but millions still lack access to the treatment they need. We can detect and treat TB, but drug-resistant strains represent a growing threat, and disease respects no borders. And malaria still takes countless lives each year, though it can be stopped with basic, incredibly cheap prevention.

Now is no time to shy away from our health investments. Scientific innovation continues to produce miracles at an accelerating pace. International donors are stepping up to the plate. Many traditional aid recipients are putting more resources into their own domestic health. The U.S. investment — less than 1 percent of our federal budget — saves and transforms hundreds of thousands of lives every year. It’s hard to imagine a better return on investment.

U.S. leadership has helped deliver a major blow to these three diseases, and backing down now would jeopardize that momentum. We’ve come too far to risk letting these diseases spread, mutate or reclaim the lives of people whom medicines have made healthy. We must finish this fight.

There are also real problems here at home, not the least of which is a challenging economic environment. And there is frequent division in Washington. But while sweeping agreement on Capitol Hill may be rare, the same bipartisan, compassionate commitment to global health remains strong. Obama called PEPFAR one of his predecessor’s “greatest legacies.” As Dybul and the Global Fund chart the path forward, we see new U.S. leaders from both parties taking up the mantle of global health, united in putting an end to these diseases.

Determined leadership today will help secure a stronger America and a brighter, healthier future for millions in the years to come. We have a long way to go, but together we can finally put AIDS, tuberculosis and malaria where they belong — in the history books.

Bill Frist, a physician, is a former Republican senator and majority leader from Tennessee.

This article was originally featured in Roll Call http://www.rollcall.com/news/frist_we_must_continue_our_legacy_of_saving_lives-222946-1.html

Changing the Way Physicians are Paid: Report of the National Commission on Physician Payment Reform

(Health Affairs Blog, March 4, 2013)

By Bill Frist and Steven Schroeder

The loud cries warning that rising health care costs are going to destroy the nation’s economy have been shouted so often that the will to move firmly in any one direction has almost halted. We’ve all heard them: health care costs are unsustainable, excessive spending is fueling our nation’s debt, and despite high costs, health outcomes are behind much of the world and aren’t improving.

The way doctors are paid is one of the most significant drivers of escalating health care costs. The National Commission on Physician Payment Reform, which we chair, was formed by the Society of General Internal Medicine to provide the public and private sector with recommendations for transforming the way we pay doctors in order to rein in spending and improve quality.

On Monday, after a year of intensive study, the 14-member Commission issued a blueprint for exactly how to move the nation toward a physician payment system that will yield better results for payers and patients.

Addressing Physician Payment

Numerous proposals have been put on the table to stop the well-documented rise in health care expenditures. Recent plans have included raising the eligibility age for Medicare, turning to high deductible plans, reducing physician reimbursement, and limiting services available to those with coverage. Such proposals have escalated as calls to reduce the nation’s overall debt have dominated lawmakers’ agendas and the feared sequestration has gone into effect with cuts that directly impact the medical community.

But many of these ideas are short-sighted, making cuts that will yield savings now, but not keep costs from continuing their upward spiral or improve patient care. In fact, many of them could harm patients. Any effort to overhaul the current system must start by addressing the core structural problem: our physician payment system and its misaligned incentives.

The Commission calls for drastic changes to the current fee-for-service payment and urges a rapid transition to new payment models, shifting the US to a blended payment system that rewards value over volume.

Accelerating Adoption Of New Payment Models

Although the effectiveness of mechanisms such as bundled payments, financial risk sharing, pay for performance, and other experiments in reducing costs and improving quality are not yet proven, the Commission believes that the nation must move swiftly to adopt these promising models.

The Commissioners judged that five years would be an appropriate length of time to test these new models and incorporate them into increasing numbers of practices, with the goal of broad adoption by the end of the decade. A five-year transition period would give physicians and health care organizations adequate time to make needed changes to their models of care, such as install electronic medical records or change billing systems.

It would also enable CMS time to further evaluate the experiments currently underway to test accountable care organizations, patient-centered medical homes, and other alternative delivery and payment mechanisms. Yet, the Commission believes that the nation cannot wait until definitive results come in to activate these new payment and delivery models.

During this transition period, we should start implementing new payments models for the care of people with multiple chronic conditions, including behavioral health disorders. Use of fixed payments should also begin now for in-hospital procedures, such as heart attacks and joint replacements, and their follow-up. These are areas where significant potential exists now for cost savings and better quality.

Fixing Fee-For-Service

The Commission is fully aware that ACOs and bundled payments are not a panacea; many of these models still pay individual physicians on a fee-for-service basis. What we don’t want is old wine in new bottles — we need to ensure that the current skewed fee-for-service incentives aren’t incorporated into these new models.

That’s why the Commission makes a number of recommendations for immediate changes to the current fee-for-service system that will yield cost savings and improve patient care, including the following:

Include a component of quality or outcome-based performance reimbursement in all fee-for-service contracts.  UnitedHealthcare reports that the 250,000 physicians participating in its Premium Designation program — whose compensation depends in part on their meeting quality measures — have significantly lower complication rates for stent placement procedures and knee arthroscopic surgery, and have 14 percent lower costs, than specialists not in the program.  WellPoint has obtained similar results in its pilot programs.

Increase reimbursement for evaluation and management (E&M) services. The current fee-for-service system places a higher value on high-technology care than preventive measures.

For both Medicare and private insurers, annual updates should be increased for evaluation and management codes, which are currently undervalued. Updates for procedural diagnosis codes, which are generally overvalued and thus create incentives for overuse, should be frozen for a period of three years. During this time period, efforts should continue to improve the accuracy of relative values, which may result in some increases as well as some decreases in payments for specific services.

The undervalued evaluation and management services at issue are often those that provide preventive health and wellness care, address new or undiagnosed problems, and manage chronic illnesses. The current skewed physician payment system causes a number of problems, such as creating a disincentive to spend time with patients with complex chronic conditions; leading physicians to offer care for highly reimbursed procedures rather than lower-reimbursed cognitive care; and neglecting illness prevention and disease management. High reimbursement for procedures also subtly nudges specialists such as gastroenterologists and pulmonologists away from E&M services and toward doing procedures.

Moreover, physicians doing diagnostic or therapeutic procedures earn considerably more than physicians who mainly evaluate and manage patients — even those with multiple chronic conditions.  In 2011, a radiologist, on average, earned $315,000 a year, while a family doctor on average earned $158,000. This has led medical students — many of whom leave school heavily in debt — away from the E&M specialties and toward the higher paying procedural and imaging specialties.

While the discussion about reimbursement has generally focused on services performed by primary care physicians, the real issue is not one of relative payment of specialists versus primary care physicians but, rather, of payment for E&M services as contrasted with procedural services.  These include E&M services provided by, among others, cardiologists, endocrinologists, hematologists, infectious disease specialists, neurologists, psychiatrists, and rheumatologists.

Eliminate higher payment for facility-based services that can be performed in a lower-cost setting.  Recently, there has been a trend to reimburse medical services performed in outpatient facilities at a lower rate than those same services when provided in hospitals. For example, Medicare pays $450 for an echocardiogram done in a hospital and only $180 for the same procedure in a physician’s office. It makes no sense to pay extra for an in-hospital procedure that can be done more cheaply in an ambulatory facility.

Make payment mechanisms for physicians transparent so physicians are reimbursed roughly equally for equivalent services, regardless of market power. In recent years, the pace of hospital-system consolidation has accelerated. Because of their increased market share, large health care systems can negotiate higher reimbursement for services provided by their physicians than can physicians working independently or in smaller practices.  Large hospital systems are buying up independent practices, threatening the viability of independent physicians and raising the cost of health care.

This has led to a situation where private payers often pay different rates for the same physician services, depending on the market power of the physician group. Payments by private payers for medical services should be transparent to the public.

Abolish Medicare’s Sustainable Growth Rate (SGR). Simply stated, the SGR has not worked in practice and shows no prospect of ever working. The practice of setting expenditure targets one year and ignoring the consequences of exceeding them the next year makes no sense.  Moreover, setting a spending cap without addressing the underlying issues of the volume and price of services and health outcomes is a short-term answer. Since the SGR is based on the aggregate payment for physicians’ services by Medicare, there is no incentive for individual physicians to try to hold down costs, and those who do are, in effect, penalized.  It is the Tragedy of the Commons.

There is wide agreement that the SGR should be eliminated — a decision made easier by the fact that the Congressional Budget Office recently reduced the cost of doing so to $138 billion.  However, there is still little agreement on how to pay for it. We contend that the funds can be found entirely by reducing overutilization of medical services within Medicare.

A Time To Act

The chorus of voices that shouted loudly and repeatedly about the need to rein in health care costs should be commended. But those same voices should now unite around a solution. From where we sit it starts with moving away from stand-alone fee-for-service payment. The Commission’s recommendations put us on that path.

Bill Frist, a physician, is a former Republican senator from Tennessee and Senate majority leader, and Steven Schroeder is a professor of health and health care in the department of medicine at the University of California, San Francisco. The two men co-chair the National Commission on Physician Payment Reform, which has issued a report providing recommendations aimed at controlling health spending by changing the way doctors are paid.

This article was originally featured in the Health Affairs blog http://healthaffairs.org/blog/2013/03/04/changing-the-way-physicians-are-paid-report-of-the-national-commission-on-physician-payment-reform/

To Contain Health Care Costs, Pay Doctors Differently

(Politico, March 4, 2013)

by Bill Frist and Steven Schroeder

Lawmakers have spent decades dancing around how to stop health care costs from eating up greater and greater portions of our overall budget. Even now, the proposals on the table look at cuts in services, asking seniors covered under Medicare to pick up a higher proportion of out-of-pocket costs or assessing whether to eliminate the sustainable growth rate formula aimed at controlling Medicare spending on physicians. These proposals, at best, address the problem of health spending at the margins.

The real culprit here is fee-for-service payment to doctors.

We cannot control runaway medical spending without changing how physicians in this country are paid — currently the single most significant driver of health care costs. We pay physicians according to the number of services they provide. The skewed financial incentives inherent in a fee-for-service model promote fragmented care and encourage doctors to provide more — and more costly — care, regardless as to whether those services improve the health of patients.

Recent reports from the Congressional Budget Office and the Centers for Medicare and Medicaid Services show that the rate of health care spending growth is slowing. But that doesn’t mean the problem has been solved or that slowed growth is permanent.

As co-chairmen of the National Commission on Physician Payment Reform, we urge lawmakers, health care providers and insurers to abandon the fee-for-service payment system within five years.

Five years should provide enough time for CMS and private health insurers to further explore models of care such as accountable care organizations and patient-centered medical homes that reimburse doctors through fixed payments and shared savings, and adopt bundled payments for patients with multiple chronic conditions.

The current system places an emphasis on high-technology care and interventions, such as imaging and surgery. Services provided by surgeons, radiologists and other procedural specialists are reimbursed at a much higher rate than critical wellness visits with a primary care physician or office visits to discuss diabetes care. This reimbursement model discourages doctors from spending time with patients, particularly those with complex chronic illness, and has fueled the widening pay gap between specialties and the nation’s primary care shortage.

This same pay structure is influencing the number and type of services that physicians recommend and even where those services are done. Under Medicare, medical services performed in outpatient facilities are reimbursed at a lower rate than the same services provided in hospitals. For example, Medicare pays $450 for an echocardiogram done in a hospital and $180 for the same procedure in a physician’s office. That makes no sense.

As physicians who have practiced medicine under the current pay system, we know only too well the temptations to order more tests, to be sure that we have tried everything. We also know that high-tech tests aren’t necessarily what the patient needs or wants, especially if the tests won’t improve health outcomes. Patients want the best course of treatment for their conditions — a course driven by their doctor’s experience and expertise, not a price list of costly tests and procedures.

The inequities in fee-for-service are so great and health care costs so high, that we cannot wait until new models of care have been adopted to improve the system. We also cannot continue to follow Medicare’s Sustainable Growth Rate formula. It hasn’t worked as intended for almost two decades. It should be abandoned now.

The current rate of cost growth may have slowed, but at nearly $3 trillion a year — 18 percent of gross domestic product — spending on health care is still exorbitant. Our population is aging, chronic conditions are more prevalent and the leading edge of the baby boom generation is now entering the Medicare system.

Lawmakers, care providers and insurers must act now to change physician pay incentives to ultimately improve how care is delivered and ensure that the cost of that care is affordable for generations to come. That means moving away from fee-for-service now.

Bill Frist, a physician, is a former Republican senator from Tennessee and Senate majority leader, and Steven Schroeder is a professor of health and health care in the department of medicine at the University of California, San Francisco. The two men co-chair the National Commission on Physician Payment Reform, which has issued a report providing recommendations aimed at controlling health spending by changing the way doctors are paid.

This article was originally featured in Politico http://www.politico.com/story/2013/03/to-contain-health-care-costs-eliminate-fee-for-service-88339.html

Podcast: Bill Frist Discusses the Fellowship Group with Modern Healthcare

Transplant surgeon and former Senate Majority Leader Bill Frist (R-Tenn.) sees a healthcare industry in flux, driven by the need crack the “value equation” that ties cost control to outcomes. Frist signed on as co-director of a new fellowship program established by the Nashville Healthcare Council to help council members’ executives meet that challenge. Modern Healthcare reporter Beth Kutscher talked with Frist about how the fellowship program will work and the forces at work in the industry that he says created a need for it.

 

Click Here To Listen

How do you want to die?

(The Week, Sept 11, 2012)

It’s a fraught question, but unless we move beyond caricatured “death panels” and deal with grim realities thoughtfully and responsibly, we’re all in trouble.

How do you envision death with dignity? I like to think of being at home in the comforting and supportive environment of family and friends. But the odds are that neither you nor I will leave this world as we might wish — unless policymakers change course.

End-of-life care is perhaps one of the most complex, emotional, and delicate issues in all of health care. Those final weeks and months can be an incredibly challenging and, too frequently, confusing period for us. At a time we hope for peace, tranquility, and dignity, a patient is often pulled in opposing directions by doctors, intensive care unit treatment options, family and friends, and by the demands of one’s own — at times excruciating — pain, and stubborn defiance.

My perspective comes as a surgeon who by the nature of my specialties of heart disease and cancer has walked with hundreds of patients and their families though these final days of life. It is never easy.

Now is the time for a national conversation on how we should allow death to unfold. Why now? Because in this technology-driven age of high expectations, we are losing patient autonomy and dignity in dying — and it is costing each of us a lot. This is a discussion important to us as patients, families, care givers, and policymakers whose responsibility it is to set a framework where autonomy and dignity in both healing and death are maximized.

The discussion must rise above the rhetoric of “death panels” and partisanship; it must be civil, inclusive, and thoughtful. It must include respect for every individual patient’s wishes, consideration of often complicated family dynamics, and the roles of doctors, nurses, and healthcare providers. And yes, in this day and time of miraculous but expensive technology, the conversation must include the recognition that our society cannot afford the skyrocketing cost of inappropriate end-of-life care.

Just last week, a grieving son asked me how it is even possible that the last two months of his 93-year old mother’s life could cost $200,000 in medical bills when his mother, suffering from fatal cancer, wanted no further extraordinary treatment. Surely there is a better way. But what are the solutions?

Cost of healthcare is a challenging issue because solutions often suggest fewer services or “less care.” But increasingly, we learn that is not the case; they can mean more appropriate care. Cost discussions become especially sensitive when it centers on care and treatment at the end of life. But in reality cost is an issue —– especially when tied to futile spending which detracts from the patient’s wishes and the dignity of death and dying.

Part of the cost problem is the low barrier to expensive, but truly miraculous and potentially life-saving, technology. I have lived it. My medical specialty included lung transplants, artificial hearts, and mechanical extracorporeal circulation. Such advances have tremendously improved American medicine. Over the last 50 years, average lifespan has increased two months every year! We live almost 10 years longer today than we did in 1960. We routinely transplant hearts into patients who would otherwise die within a month, and they live an additional 20 years. Fathers doomed to death live to watch their daughters marry and have children. But technology comes with a hefty cost, if misused.

Here are the facts: 30 percent of Medicare dollars are spent in the last months of life. That amounts to more than $150 billion annually. On top of that, a quarter of Medicare recipients spend more than the total value of all their assets on out-of-pocket health care expenses during the last five years of their lives. Every day in an intensive care unit can cost $10,000. Nearly 1 in 5 Americans spend their last days in an ICU.

Technology and intensive care treatment have limitations when misapplied. People spend fortunes on the last months of life. The high expectations and demands of grieving family members fuel this process. And because someone else is always paying, it is inevitable that unnecessary tests and procedures and high-intensity services creep into the equation. The system is set up and incentivized to bend to the whim of an unusual family member’s demand to “keep mom alive at all costs,” even if she is 93 and hopelessly ill.

So how do we fix all this? We begin a national, high-profile, civil dialogue, which should begin in the living rooms of patients and their families and extend to nurses’ and doctors’ offices, hospitals, religious institutions, and policy chambers. “How do I want to die?” That’s the framing question. It’s a tough place to start, but grounds the discussion in the reality that unless we act, our final days will be spent very differently than we would like.

Ventilators, mechanical heart assist devices, high-tech intensive care units, and powerful medicines provide the means of postponing the inevitable, usually uncomfortably and at high cost, while stripping away independence and dignity from those final days. Do we want to die at home or strapped to machines in a hospital bed? How much quality of life, how much loss of normal function, are we prepared to live with? Does my husband or daughter know my wishes?

Here are three proposals we should include in the conversation.

1.

Each of us must act to assume responsibility for expressing our preferences and intentions up front. Act today. Begin with establishing a written “advanced directive” to make your intentions clear. One type of advanced directive is a living will, which applies if you become incapacitated and lack competency to decide medical questions for yourself. Another important advance directive is the “durable healthcare power of attorney,” which designates a person to make medical decisions for you if you have not signed a living will or other directive.

Four out of five of us have not done this. These important legal documents provide an essential roadmap for your preferences and relieve your family and your doctors from having to guess what you would really have wanted and help resolves conflicts among family members. Share your values and intentions directly with your doctor, your family, and leader in your life.

2.

Medical education for our caregivers must be reformed to more specially address end-of-life issues. Many doctors and nurses are inadequately trained to lead families though these challenging times. How do you determine when further care is futile and then compassionately communicate the moment when technology adds no value, and in fact detracts from the dignity of life? How do you handle the well-intended-but-unreasonable family member who demands “more care” when the science says it’s futile? A physician, nurse, or hospital will worry about a lawsuit if the armamentarium of high technology is not exhausted even though evidence-based medicine says it is a waste of resources.

My physician dad and earlier generations of doctors were not confronted with a health service environment so complex and replete with alternatives as ours. In their day, medical science was inexpensive and limited in scope. They had less technology at their fingertips. Today’s physician requires more training in end-of-life communication and evidence-based decision-making.

3.

Expand both palliative and hospice care. Hospice provides compassionate and appropriately specialized care for those who will soon die. The setting is typically at home. Palliative care is a new specialty grounded on a multifaceted team-approach to comprehensively manage severe, often long-lasting chronic disease and persistent pain and suffering. Both center on autonomy and dignity and appropriate medical and social care for a particular patient’s medical condition. Both are based on science and evidence-based medicine. Both have been shown to improve patient satisfaction, reduce pain and discomfort, and improve quality of life.

Expansion will require rethinking reimbursement mechanisms to allow scalability. How do these two models fit within more integrated health systems? How should caregivers be compensated for providing more appropriate care but not more procedures and more technology?

Isaac Asimov wrote, “Life is pleasant. Death is peaceful. It is the transition that is troublesome.” It is time to focus on the transition. No one has the answers yet. But we can find them together. The way to begin is to initiate a rational national dialogue, as uncomfortable as the conversation may seem to be.

Dr. William H. Frist is a nationally acclaimed heart transplant surgeon, former U.S. Senate Majority Leader, the chairman of Hope Through Healing Hands and Tennessee SCORE, professor of surgery, and author of six books. Learn more about his work at BillFrist.com.

This article was originally featured in The Week http://theweek.com/article/index/233111/how-do-you-want-to-die

Personalized Medicine

(The Hill, July 10, 2012)

It’s time to think of health in a disruptive way. Policy must set the enabling landscape, but the truly dramatic and the transformative will come from the exploding but still very young field of personalized medicine.

All healthcare is local, and all health is personal.

Personalized medicine is healthcare targeted to YOU, and just you. It means your individual health interventions — prevention, diagnosis and treatment — are custom-tailored specifically for you. Our individual needs — based on our personal DNA, the expression of powerful proteins and each of our unique biological responses — determine how our bodies respond to diet, to medicines, to exercise and to various modes of treatment.

A more individualized and personal approach translates to earlier prevention and diagnosis, and more targeted and appropriate treatment. By eliminating overspending in prescribing drugs that don’t work and under-spending on prevention and wellness, it opens the door to slowing the relentless growth of healthcare costs.

Personalized medicine is coming of age. Genetic testing, when coupled with massive clinical data sets made possible by privacy-protected electronic health records, can show predisposition to a growing list of conditions so that preventive action can be taken to maximize health and well-being and minimize expensive interventions in the future.

For example, if you know your genetic code demonstrates a risk for breast cancer, you can proactively engage in more prevention, be it more frequent self-exam and imaging or adjusting your diet. If you need to take a medicine to keep your blood thin after a stent placed to reverse a heart attack, you can be assured you will take one that not only works but also causes the fewest bad side effects. And this earlier detection of disease and targeted use of drugs leads not only to better life but also real cost savings.

The conditions for which we have genetic and proteomic tests for risk profiles is growing daily. They include heart disease, such as atrial fibrillation; cancers of the stomach, colon, lung and breast; vascular aneurysms and thrombosis; multiple sclerosis and Alzheimer’s disease; Crohn’s disease and type 2 diabetes. For the most part, we don’t know the exact cause of these diseases; it’s a combination of genetic and environmental factors. But the tests can give us predisposition to and risk for disease, and thus allow us to take early action.

One exciting field that will have a measurable clinical and cost-saving impact is pharmacogenomics, which focuses on how people with different genetic variants respond to certain medicines. It is transforming the pharmaceutical industry. For my field of organ transplantation, a genetic test at Vanderbilt shows whether an anti-rejection drug is likely to be effective —this can be a matter of life or death. Your genetic code can show whether a drug will work, or even whether it will have side effects. It can determine the appropriate dose to achieve the best and safest effect for you.

Obesity is destroying our children’s futures. We are today raising a generation of children who will not live as long as their parents. It is currently thought that two-thirds of the risk of obesity is associated with genetic markers on particular genes, while about a third is attributed to pure environmental effects. The genes might not cause obesity, but knowledge of increased risk markers just might give us the motivation to alter our nutrition and exercise habits, and modify our lifestyle and behavior.

Increasingly we will see individual genome sequences become a formal entry in our medical records, just like allergies and history of previous surgeries. As information technology in healthcare matures, we will see more connectivity among providers and labs, more support to eliminate costly and deadly medical errors, more automation to reduce the chances of making bad mistakes, and more data mining that will lead to science-based predictions of how to reverse disease and prevent it in the first place.

Government investments can really pay off — we shouldn’t forget that in the spending debates that are sure to follow in Congress. For instance, the government-funded Human Genome Project, begun in 1990, was completed two years ahead of schedule in 2003, and under budget! That project determined the sequence of nearly all of the more than 3 billion chemical building blocks that comprise the human genetic code.

Personalized medicine is more than DNA. Your individual genome is the original blueprint, or plans, but the final human body actually reflects a complex system of environmental and genetic influences, expressed through more than a million different proteins. Advanced computing and a systems-engineering approach to massive databases will open even more sophisticated and useful personalized medicine fields, and a new healthcare revolution will begin.

Frist is a former heart and lung transplant surgeon and is currently an adjunct professor of surgery at Vanderbilt University. He served as majority leader of the U.S. Senate from 2003 to 2007.

This article was originally featured in The Hill http://thehill.com/blogs/congress-blog/healthcare/237155-personalized-medicine-

 

What my doctor thinks of Obamacare?

(The Week, August 29, 2012)

Lawmakers in D.C. may truly be committed to improving America’s health-care system. But according to actual physicians, our leaders are going about it all wrong

Want real health reform that is in the interest of you and your family? Don’t make the same mistake that Washington did. In formulating ObamaCare, the politicians listened to lobbyists, policy wonks, academics, health theorists, regulators, and occasionally to each other. But they failed to listen to the people who actually care for patients: Doctors. Granted, the lobbyists for physician groups were at the table, but not the doctor him or herself. Ironic, isn’t it? Especially when it’s the doctor who has the daily responsibility of directly caring for the patient.

Go ahead, ask your physician at your next visit what she or he thinks of current Washington-directed reform and its impact on the doctor-patient relationship. What you hear will likely surprise you, because it will likely be markedly different from what you hear from Washington. The policy theorists are simply too far removed from the reality of front-line patient care. Health reform, whether via the implementation of ObamaCare or the GOP’s “repeal and replace” plan, should no longer ignore the input and counsel of experienced, front-line, practicing doctors.

Here is a sampling of what my own internist, who has taken care of thousands of patients over the past 20 years, shared with me:

Frist: We hear the electronic health record (EHR) will solve much of what ails our health sector.

Doctor:

The EHR is not the savior of the medical system. In fact, it is effectively destroying the relational aspect of the art of medicine. Instead of talking with a patient and hearing her “story,” we are being relegated to looking at a computer screen and pointing/clicking during the visit. I know there are long-term benefits to an EHR, but most internists who value the art of medicine will tell you it is killing the “story.” And it is expensive. Physicians with EHRs see 15 to 30 percent fewer patients (and work later into the night). And yet with ObamaCare, we will be asked to take care of an additional 30 million patients.

We are told that increased government regulation and monitoring will reduce waste.

Unnecessary regulations and increased paperwork are drowning us and reducing quality of care. We have allowed just “one more thing” to be added over and over again. The camel’s back is now breaking. I have never seen physicians as depressed and stressed in my 20 years of practice. At each visit, I am required to tell the government whether the patient I am seeing had a flu shot last winter! Please help me understand how that improves care. I know the many quality metrics (i.e.: check this box) mean well, but they are having the opposite effect. They are diminishing quality because they (the boxes) become the focus of each visit, rather than the human interaction.

But increased documentation in charts and billing surely improves value to the patient?

Hardly. We are now working with 17,000 diagnosis/billing codes — absolutely ridiculous. There are nine codes for abdominal pain (right upper, left upper, right lower, left lower — you get the idea). And the government has recently increased the number of codes from 17,000 to 155,000. The bottom line — 300 codes would probably cover everything. It could be printed in a four-page leaflet, not three large volumes. It is unnecessarily complicated and it does absolutely nothing to improve patient care.

Doesn’t more careful documentation with the required codes help eliminate fraud?

That’s ridiculous. It is just the opposite. The actual diagnosis/billing codes have nothing to do with fraud. The EHR creates the appearance of a perfectly prepared note. In truth, it simply makes it easier to copy and paste from note to note. The note is filled with unnecessary information, making the truly pertinent information hard to find (and therefore negatively impacts patient care). The nice-looking, “electronic documentation” in the EHR opens the door for the unethical doctor to game the system and get away with it. It just makes it easier for them to upcode and not get caught. Fraud is skyrocketing while the EHR provides the cover.

But Washington tells us that “evidenced-based medicine” is the surest way to better outcomes.

Quality care comes from a careful, professional analysis of a clinical situation that leads to a correct diagnosis and treatment for the particular patient at hand. Quality care will never be found by mindlessly marking boxes or following algorithms that are at the heart of what is being called “quality measures and evidence-based medicine.”

What stands between you and caring for the patient?

The paperwork is overwhelming — nursing home admission forms, medical device forms, diabetic supply forms, home health forms, insurance records requests for “additional information.” Everyone has their form that must be completed. All forms roll downhill and the internist is the final resting place. Regulations requiring more needless paperwork mean less time for patients.

The law in Washington is that your reimbursement is to be cut every year. But you seem to be working harder than ever.

Reimbursement for our services continues to decline, because overhead costs rise. I am very blessed. I am paid well. But I have not seen a raise in 13 years. While CEOs, managers, administrators, benefit managers, and insurance executives see regular raises and bonuses. Physicians in our clinic feel fortunate that our pay has not declined. Yet our workload is so much heavier than it once was. Not because of patient volume, but because of the higher expectations of patients, the higher complexity of medical care, and the excess “stuff” that we are being required to do.

I’m told the primary care shortage of 40,000 doctors over the next 10 years can be met by non-physicians.

The suggestion that non-physician practitioners can fill the primary care needs of the American people is simply false. Their training, knowledge base, and ability to form a complete differential diagnosis is limited. The press often proclaims that nurse practitioners can replace doctors. There is a role for the NP and we need to support that role. But to suggest that someone with two years of training can provide equivalent care to that of a physician who, after college, has spent four years in medical school, three to four years in residency (working days and nights), and who, each day, makes hundreds of decisions for which he or she is ultimately responsible is not only wrong, it disrespects the training and ability of the physician. Remember, quality care is not measured by patient satisfaction surveys, but instead, by the ability to properly diagnose and treat a patient.

So… we’re not moving in the right direction with health reform?

At the age of 49, I feel that the practice of the art of medicine is becoming impossible, even for those of us who live for the chance to care for others. Our goal should never be to cure disease. Instead, our goal should be to heal people. The direction of our present system is negatively impacting the ability of good doctors to try and heal people. We must remove the growing distractions and be allowed to spend time with each unique patient and their “story.” We need to ask of each regulation or mandate that “seems” to sound so good: How will it impact the doctor-patient relationship? It is now, and will always, be within this relationship that healing occurs and true quality care is found.

Those are the words of one, but they are the sentiment of many. Ask and see.

And what is interesting is that this sort of conversation from the front-line would never make it all the way up to my office when I was majority leader of the U.S. Senate. The existing, overly restrictive filters of Washington lobbyists and bureaucracy simply don’t allow such real-life information to flow all the way up to the legislator.

So for the next round of reform, let’s make sure we don’t ignore the insights of real-life doctors. Let’s make sure this time around they are at the table.

Dr. William H. Frist is a nationally acclaimed heart transplant surgeon, former U.S. Senate Majority Leader, the chairman of Hope Through Healing Hands and Tennessee SCORE, professor of surgery, and author of six books. Learn more about his work at BillFrist.com.

This article was originally featured in The Week http://theweek.com/article/index/232510/what-my-doctor-thinks-of-obamacare