Category Archives: Culture

Medicaid expansion rejection starts to bite

What happened to my hospital?

What happened to my hospital?

In its ruling upholding the Affordable Care Act, the Supreme Court did allow states to opt out of the expansion of the Medicaid program, which serves the poor. My feeling at the time –and still today– is that you’d have to be pretty ideologically rigid and stubborn or just plain uninformed to turn down the expansion. The feds pay 100 percent of the expansion’s cost in the first three years and at least 90 percent thereafter.

Try hard and you can find reasons to oppose the expansion — maybe the feds will go back on their word, maybe Medicaid will make people lazy– but these are hypothetical and farfetched. Meanwhile, the costs of not expanding Medicaid are very real, in the form of billions of dollars in foregone funding for the provision of healthcare to the poor and the undermining of communities that lose their hospitals.

Twenty-four states, including almost the whole South, took the stubborn path and have so far refused to expand Medicaid. They’re starting to experience the consequences.

A George Washington University study reveals that more than 1 million patients who use community health centers will lose out on coverage because their states refused to expand. One-third are in five Southern states: Alabama, Florida, Georgia, Louisiana and Mississippi.  That’s putting a strain on community health centers, many of which will lack the funding to provide needed care.

Meanwhile a Wall Street Journal article (Rural Hospitals Feel Pinch) highlights the strains confronting rural hospitals as the world changes around them. The article features a hospital in a rural North Carolina community that’s closing. In the 21st century, losing a hospital is a major blow for a town or rural region. It’s often the biggest employer, a major driver of other local businesses, and a key to quality of life. Once it’s gone it’s not coming back any time soon.

Failure to accept the Medicaid expansion isn’t the only reason rural hospitals are struggling, but it’s a big part of the equation. Southern politicians are trying to make policy changes to shore up rural hospitals, but their efforts are a drop in the bucket compared to the funds that flow from the feds.

Rural America is the most Republican part of the United States. At least on Medicaid expansion, many rural citizens are poorly represented by the people they vote for. There’s an election coming up in November and folks would be wise to re-examine their assumptions before casting their ballots.

photo credit: Range of Light via photopin cc

By healthcare consultant David E. Williams of the Health Business Group

It’s ok to care about your work, especially if your job’s at a children’s hospital

Who cares?

Who cares?

The Wall Street Journal has become more like Cosmo since Rupert Murdoch took it over, with all sorts of advice on life and work mixed in with the serious business and other news. Some of the articles are pretty decent and I enjoy reading them, even if they are a bit fluffy.

Sue Shellenberger’s piece (When It Comes to Work, Can You Care Too Much?) is about people who love their employer so much that they get carried away and take things too personally. They care about whether someone is wrongly promoted in another department and get upset when their employer strays from its mission.

We learn of the two types of people, the “organization lover” who cares too much but is a strong team player, and the “free agent” who is more calm but also seen as cynical.

The impetus for the article is a book by an employee who “fell in love” with BP because she heard the CEO talk about reducing greenhouse emissions. Eventually she became disillusioned and wrote a book about it. The article seemed like a harmless diversion about a pretty obvious topic. Clearly it doesn’t make sense to get too carried away about working for an oil company, you don’t want to be a busybody obsessed with everyone else’s business, and there’s a need to strike a balance.

They could have left it at that.

But then the very last example was about a nurse educator who moved from an internationally renowned pediatric hospital to a small hospital when her fiancee got transferred.

Employees there were using what she regarded as outdated methods of managing infants’ breathing tubes and other aspects of respiratory care, says Ms. Pender, who had worked as a neonatal intensive-care nurse for the Children’s Hospital of Philadelphia.

“I didn’t want to come across as a know-it-all,” she says. She quietly observed her colleagues. She met with a nurse educator and showed her research and videos on new techniques. She created a written survey for other nurses, asking their opinions. And she sought out allies, joining a hospital task force on improving care. Then a new manager arrived who supported her ideas.

Ms. Pender and her fiancé recently moved back to the Philadelphia area, and she rejoined Children’s Hospital. Her former colleagues have adopted many ideas she advocated. She says she’s happy to know “positive changes are moving forward.”

I honestly don’t think this last example is really about loving your employer too much. If you’re going to work in healthcare –especially taking care of infants with breathing tubes– you better care about patients and their families. It should have very little to do with whether you are the type who likes or loves your employer.

photo credit: Kalexanderson via photopin cc

By healthcare consultant David E. Williams of the Health Business Group

Patient failed his therapy or vice versa?

Who failed?

Who failed?

The other day I heard a physician use a phrase I really don’t like. “The patient failed his therapy,” he said. Although I don’t want to be too picky about wording, I find that formulation to be quite disempowering and depressing for the patient.

Imagine a sick patient who tries a promising drug with the hopes of improving or being cured. It’s bad enough when a drug doesn’t work, but if the patient is made to think he’s failed as well that doesn’t seem very constructive. It would be more accurate and less threatening to say that the therapy failed the patient.

Going a step further, it might also be accurate to say “the physician failed the patient,” but I don’t think doctors would want to think of it that way!

Misattribution of blame is not unique to the heallthcare industry. Another example is provided by airlines, who are eager to avoid being faulted when they screw up. In recent years I’ve started to hear airline employees say, “the flight has cancelled,” making it sound somehow like the plane itself decided not to fly. A more accurate statement would be, “the airline canceled the flight.” Now they may have had their reasons, like bad weather, but even the most modern planes don’t cancel their own flights.

But back to healthcare, I hope physicians and other healthcare professionals will be more conscious of how the language they use affects how patients feel about themselves. It doesn’t mean walking on egg shells; instead it means trying to be empathetic, and soliciting constructive feedback from other members of the care team and patients and families themselves.

I don’t mean to make too big a deal of this. In fact, most physicians don’t use this “failure” terminology these days and I’m glad they don’t.


photo credit: LifeSupercharger via photopin cc

By healthcare consultant David E. Williams of the Health Business Group


Give Boomer Esiason a break on birth comments

Retired football star and current radio host Boomer Esiason has opened the floodgates of righteous indignation by suggesting that the Mets second baseman should have encouraged his wife to have a scheduled C-section before opening day. That would have prevented him from missing the first two games of the season when he flew home to be with her.

Esiason got the blowback that he should have expected, and made a lengthy apology for his comments today.

I’m happy though, that this mis-step has turned into an opportunity to educate people about the dangers of early elective delivery. There’s actually been a major, successful effort underway to reduce the use of early elective deliveries. Such deliveries –either induced or scheduled C-sections before 39 weeks– represented 17 percent of births in 2010 (as high as 25 percent in some states). As of 2013 the rate has fallen dramatically, to less than five percent according to the New York Times.

It turns out babies born at 37 or 38 weeks have a lot more health problems then those born at 39 or 40  weeks, even though it doesn’t seem that such a short time difference should be so important. So I hope the reaction to Esiason helps to get this message across.

Esiason is getting the word out. Here’s what he said:

I’m very grateful to my many friends over at the March of Dimes who graciously reached out and re-educated me that if a pregnancy is healthy, it is medically beneficial to let the labor begin on its own rather than to schedule a C-section for convenience. In fact, babies born just a few weeks early have double the risk of death compared to babies born after 39 full weeks of pregnancy. As their promotional campaign says, ‘Healthy babies are worth the wait.’ And as a proud father, I couldn’t agree more.

I find it quite interesting how societal expectations about fatherhood have changed in the recent past. A generation ago, the notion of a father being in the delivery room was unheard of. Fifteen years ago I had a job interview with a large financial services company. The hiring manager (in his early 30s at the time) told me the job required an all out commitment, and that while he hoped to be present at the birth of his child, that wasn’t really the way things were prioritized there. I didn’t agree with that sentiment then, but it was the norm in many places.

So it’s interesting to me that Esiason took it for granted that the player would be present for the birth –he didn’t seem to question whether work should come first.

Esiason said the wrong thing, but I think we should cut him some slack. First of all, being a football quarterback is different from being a baseball second baseman. Baseball teams play 162 games per season, NFL teams only 16. A star quarterback plays every game, whereas even star baseball players get a day off from time to time. So maybe we can accuse Esiason of lack of empathy for thinking about how he would have behaved, not what a baseball player would do. But I understand his point about not wanting to miss a game.

Esiason is 52 and times have changed. He gets part of the new way of thinking –dad should be there for the birth. But he screwed up by suggesting unnecessary surgery. And while I don’t fault him for not knowing that earlier births aren’t good for babies, at least it gives people a chance to bring it up and make it known to a wider audience of would-be fathers who might otherwise not be paying attention.

By healthcare consultant David E. Williams of the Health Business Group


CVS and cigarettes: Asking the wrong follow-up question

After CVS, what's next for smoking?

After CVS, what’s next for smoking?

CVS’s decision to stop selling cigarettes is a smart one. Cigarette sales are incompatible with the company’s positioning as a health care provider. With the reduction of smoking rates, growing restrictions on where people can smoke, and increasing numbers of localities banning cigarette sales in drug stores it will probably make business sense over time as well.

I’ve been surprised that so much of the commentary on CVS’s decision has focused on what else the company should stop selling. Candy, gum and soda are bad for you, too, so maybe CVS should stop selling that. And the list goes on from there –maybe some of their toys are dangerous, for example.

Asking what else CVS should stop selling is asking the wrong question. Cigarettes cause an order of magnitude more harm than those other categories and are more addictive. That’s a good reason  to stop selling smokes without having to stop selling other things that aren’t 100 percent healthy.

I’d like to see a bigger emphasis on reducing the availability of cigarettes more broadly and making them more expensive.

Cigarette taxes vary wildly by state. Missouri is the lowest at $0.17 per pack and New York is the highest at $4.35. (New York City tacks on an additional $1.50.) The federal tax is $1.01 and some places add other taxes including state and local sales tax. The average retail price for cigarettes is about $6, so tax represents a big part of the price.

These big differences provide a major incentive for smuggling. Although no one knows exactly what percentage of cigarettes are smuggled, it’s a lot.

Indian reservations are another source of low-tax cigarettes. High tax states like New York have seen considerable friction as non-Indians have sought out on-reservation stores for bargain prices.

The effects can be insidious. A friend told me recently about a public housing project in his area where a man goes door to door selling cigarettes he obtains cheaply on a nearby reservation. If the price were higher the rate of smoking in this price sensitive population would be likely to decline.

I’m not proposing a specific mechanism to address these challenges, but I would like to see the low tax states raise their tax rates,  more enforcement effort devoted to stopping interstate smuggling, and more aggressive action to reduce the availability of reservation cigarettes. Although this will never happen, one approach could be fore the federal government to charge a tax of $6 minus whatever the states charge. That would provide an incentive for every state to raise the tax to a uniform, high amount.

photo credit: The Guncle via photopin cc

By David E. Williams of the Health Business Group.

Legacy videos by the terminally ill: What does the future hold?

What's over the horizon?

What’s over the horizon?

It’s been common practice for decades –and probably longer– for terminally ill parents to write letters to their children. The idea is for parents to be able to communicate to their offspring as the kids get older and are able to handle more mature messages. Some parents leave letters to be opened at specific times, like a 16th birthday, college graduation or wedding. Not surprisingly these letters are being supplemented and superseded by legacy videos, according to a recent Wall Street Journal article (A Mother’s Last Gift to Her Children May Be a Legacy Video).

Multiple organizations –including Just So You Know and Thru My Eyes have been set up to enable patients to make these videos for free. I think it’s a great idea. I would record such a video myself in the same situation. Many surviving children and other family members find the videos to be a source of comfort, and the ill patient often finds the process therapeutic.

There are some challenges, though. As the article says,

“Legacy videos also can sometimes contain painful messages, overbearing advice or wishes that the children don’t feel they can carry out.”

That got me thinking about how the evolution of technology will inevitably take us beyond the legacy video. In the not-too-distant future technologies including virtual reality, artificial intelligence, and natural language processing may enable legacy projects that are a lot more powerful, with the potential to be more comforting and meaningful but also more invasive and even spooky. And going even further, what happens when someone’s entire brain can be downloaded and ported to a new medium?

Not to be too futuristic, but it’s reasonable to expect that these videos will evolve into something a lot more lifelike and interactive within a few years. The potential for good is real, but we’ll have to navigate through some sensitive issues to make sure that’s the case.

What do you think? Would you record a legacy video? Have you received one? Would you want to be the producer or recipient of something more interactive? Let me know in the comments section or @HealthBizBlog

photo credit: Pilottage via photopin cc

By David E. Williams of the Health Business Group.

Marijuana is not gay marriage


It’s tempting to draw parallels between the legalization of gay marriage and legalization of marijuana. A pollster is quoted in today’s Boston Globe (Marijuana advocates lay groundwork for legalization in Mass.) doing just that:

“Opinion is changing very quickly on marijuana,” said Steve Koczela, the president of the nonpartisan MassINC Polling Group. He said a number of 2013 national polls found, for the first time, that a majority of Americans favor legalization of the drug. The rapid change, he said, “mirrors, in some ways, the same-sex marriage shift that’s taken place over the last few years.”

And the parallels go beyond that. Decriminalization of marijuana as Massachusetts has done is akin to allowing civil unions. The next step: full legalization, is viewed as a natural evolution of tolerance.

But there are serious differences. Civil unions lead to gay marriage because the rest of the population has a chance to discover for themselves that gay couples are no threat to heterosexual families. Contrary to some irrational fears, children are not “recruited” into homosexuality just because acceptance of gays goes up and is enshrined in the law. Once gay  couples are accepted and not feared, it becomes an equal rights issue –civil unions confer only partial rights and there’s no rationale to withhold full rights.

Time will tell, but I expect that experience with marijuana legalization will be different. Marijuana use is a health threat. Legalization does make underage use more acceptable, increasing harm. It becomes harder for parents to keep their kids from using pot.

It’s not inevitable that marijuana laws will become more and more lax. Cigarette smoking is becoming increasingly restricted and less culturally acceptable. The latest frontier is over smoking in public parks. Trans fats are being legislated out of use. New York City’s drive to limit soft drink sizes is not as crazy nor unpopular as it sounds. And beverages that mix alcohol and caffeine have been pushed from the market.

The abuse of prescription drugs is finally starting to get the notice it deserves. Parents are waking up to the fact that their kids –and if not them, their kids’ friends– are awfully interested in what’s in the drug cabinet, especially if that includes painkillers like Vicodin or Oxycodone. Something similar will happen with marijuana: barriers to its use will fall when the stigma of buying it from a dealer is removed and when its purity and freshness can be guaranteed by the retailer. I don’t want to see that happen in Massachusetts or elsewhere.

Having said that I do support decriminalization so people’s lives aren’t ruined by a marijuana possession conviction and so law enforcement loses the incentive to pursue property seizures.

photo credit: Eric Constantineau – via photopin cc

By David E. Williams of the Health Business Group.