Healthcare Musings For May 21, 2021

 

May 21, 2021

Dear Interested Readers,

 

Getting Reoriented

 

I was surprised and delighted last Friday when Amazon delivered Elizabeth Warren’s new book, Persist, two days before its official publication date. I was eager to read what she had to say about healthcare. I had hoped that perhaps there would be a chapter about what she was expecting to happen for healthcare during Biden’s administration. Would he be able to pass a “Public Option?” How would Democrats lower the cost of drugs? Would she be working to have the eligibility date for Medicare dropped to sixty or even as low as fifty-five?

 

Since healthcare was such a hot topic during the 2020 Democratic Presidential Primary Debates, I had expected that she would have a lot to say. Healthcare had been one of the few passionately debated issues that showed a difference between the Democratic contenders before everybody but Bernie dropped out of the race shortly after Biden won South Carolina and Super Tuesday so decisively. 

 

As I looked down the table of contents I saw chapters with titles like  A Mother, A Teacher, A Planer, A FIghter, A Learner, and A Woman. That was no help and a bit disappointing so I flipped to the index and looked for “healthcare.” What I found were connections to stories related to deficiencies in what we provide, but without solutions. I did learn that the most common reason for people to seek help from others with a “GoFundMe” campaign was medical expenses. Did you know that more than 250,000 people a year raise more than $650 million dollars to help defray costs for medical care for which they’re not covered? That is a startling fact looking for a plan for improvement. She did follow the GoFundMe comment with an assessment of what it meant, but she limited the solution to a very broad outline.

 

We are the richest nation on earth and a quarter of a million of our kin are reduced to begging friends and strangers to help pay their medical bills. Morally and economically, this is flat-out wrong. 

I have studied our country’s health-care problem for a long time, and for years I said I thought we should do three things: improve the Affordable Care Act; lower drug costs; and move toward full health-care coverage for everyone.  

 

I found that the report about GoFundMe was cross-indexed between healthcare and the Affordable Care Act. It appears near the beginning of her longest healthcare statement which is in a section of the chapter called “A Planer.” The fact that the section is about healthcare is disguised by its title, “Planning Creates Transparency” which is on pages 109-112. The section is primarily a review of the ACA, what it has accomplished, and the problems that persist after its passage.

 

She comments about the fact that before the pandemic 41% of Americans, seventy-two million people, were trying to pay off medical bills and that 42% were struggling to pay for prescription drugs. In 2019, one out of four Americans failed to get the care they needed because they could not afford it. She reviewed the suggestions that she had made to expand care and make it more affordable during the campaign. She also reasserted the fact that if we only had the will to fairly tax the very wealthy we could give care to everyone without raising taxes on the middle class. She reminds us that Trump promised to replace the ACA with “something beautiful” but never offered a plan for consideration.

 

The more I read and pondered her words on these three plus pages I realized that Warren sees adequate healthcare as a component of a larger picture of pervasive inequity that may be morally wrong, but that the compelling reason to fix it is that to maintain it as it is unnecessarily expensive and a drag on the economy. My insufficient analogy is that it is like preferring to use an old camera with expensive film and processing that limits the number of pictures you can take over buying a smartphone and taking thousands of pictures for less than the cost of a roll of film. If you don’t like that analogy then it is like preferring a mid-sixties gas guzzler that pollutes the environment to a more efficient hybrid or all-electric car. In both instances, there is a better way to get more for less. The economics of the status quo is just foolish. The combination of stupid and expensive really galls Elizabeth. I think that she realizes that her contributions to healthcare policy will be backstage as she continues to advocate for progressive legislation to improve the status of women, children, and the poor. She finishes the section with a powerful assertion of persistence for the concept of universal access to care:

 

When I decided to get in the race [for the nomination], I was ready to slug it out over every health-care issue on the table. I was eager to talk about how to reduce the cost of insulin and EpiPens. I was prepared to explain how to make unions whole by requiring employers switching to Medicare for All to put the now eliminated cost of health benefits into higher salaries for union workers. I was happy to debate whether we should change our health-care system by taking a couple of big steps or a lot of small steps. And start to finish, I was ready to fight for the ultimate goal of getting universal coverage for all Americans. 

Show your plans.

 

As I thought about what has happened during the pandemic, I wondered if the theory that we have been using for the last twenty years about how to “cross the quality chasm” on the way to the Triple Aim was wrong. I have always believed that if we focused on quality, safety, patient-centeredness, and the need to improve the health of the nation, we– those of us in healthcare– would see the need to eliminate the waste in our processes to lower the cost of care. We would also come to believe that better care and safety reduced the cost of care for both the individual and the population. The expectation then was that with better, more innovative care we could improve the cost of care and be able to offer better care to everyone for less than our current healthcare expense.

 

In Lean we learn that we improve a process by studying it, forming a hypothesis about how to improve it, and then that testing the process. It is essentially the scientific method. The possible improvement is expressed in an “if we do x then y will happen.” At some juncture, the hypothesis is proven and the change is adopted or the failure is observed and analyzed and the cycle starts again with a new hypothesis that is based on what has been learned from failure.

 

Since we have not had the will to discard fee for service payment in favor of some form of universal capitation for the care of the population, we have tried to go forward with the improvement of our care system through bonuses and penalties based on patient satisfaction and quality and safety metrics. I fear, and the pandemic suggests, that we have not accomplished much. This pandemic has revealed that twenty years of focus on quality and safety did not prepare us for the domestic, not to mention the worldwide, challenge COVID presented  Some of the economic and individual devastations of the pandemic might have been avoided if we had truly operationalized the suggestions in Crossing the Quality Chasm which was really a strategic plan that never got adequate focus, acceptance, or traction within healthcare and within the political process that determines the rules and finance of care delivery.

 

I am impressed that Warren either doesn’t know the language and the objectives of the quality movement or does not believe it is a road to where she thinks we should go. One could look at the bulk of her work and say that it is directed at the creation of programs that reduce inequity and improve the social determinants of health. Perhaps what we should surmise is that she believes that better healthcare that fits the definition of the Triple Aim is more likely to be achieved by direct actions that improve the lives of people before they are sick and is readily available when they are sick and when we are all challenged with the emergence of a new and powerful pathogen. I suspect that she believes that healthcare will not fix itself. We have tried and failed. Plan two may be to fix inequity and make innovation unavoidable by controlling the finance of healthcare from outside the industry. That is what she imposed on banking and credit institutions following the other disaster of our times, The Great Recession when she created the Consumer Financial Protection Bureau to correct the banking and credit industry.

 

Warren’s book has certainly got me thinking. The pandemic has revealed that we have been fooling ourselves. As we emerge from these devastating times I hope that her “persistence” will be noticed and her voice heard because who knows what challenges are ahead. COIVID came in a flash. It left us dazed and confused. As the fog clears will we formulate a new hypothesis that suggests that if we eliminate inequity and improve the social determinants of health we will enjoy better health and better lives for everyone. I am pretty sure that Elizabeth Warren believes it is true and that belief drives her to persist.

 

Taking Off Your Mask In The Real World Is Not That Simple: Personal Experiences

 

Last week the CDC surprised us when they said that if we were vaccinated we could take off our masks in most places. I was happy to hear that I no longer needed to wear my mask, but then it quickly became obvious that the announcement had created great concern in many quarters. 

 

At the local non-profit that I work with we realized that we needed to rewrite our COVID policy. For the last 14 months, we have followed a strict policy based on CDC recommendations and our Governor’s directives. We have been doing all of our contacts online, on the phone, or outdoors with masks and attention to social distancing. Our policy meant that we had not been going into homes and apartments to provide services and we were not providing rides to doctor’s appointments or other places that people without resources need to go. Many people called asking for rides or in-home services and it was painful to say again and again that we wished that we could help but because of COVID we could not respond to their obvious need. 

 

Monday night was our regular board meeting and the chair of the board asked me if I would write a new policy. Following the CDC announcement confusion seemed to reign across the country and could be felt in small-town New Hampshire. Governors, mayors, business owners, and educational institutions suddenly realized that they had a thorny problem since the CDC said that those who had been vaccinated could discard their masks without fear in most environments, but how did we know who had been vaccinated and who was not? Was it wise to use an honor system for something as important as the transmission of a potentially deadly disease? Since the vaccine is approved for children twelve and older, what about younger children? How should business owners and other responsible institutions like churches allow those who are vaccinated to come into their business and facilities while making sure that the unvaccinated continue to wear masks without intruding on the personal privacy of both the vaccinated and unvaccinated? In the “Live Free or Die” state we take personal privacy as a holy right that is almost as sacred as our right to own as many guns as we want while refusing to pay taxes. 

 

I wrote my policy and circulated it before the meeting to two members of the board and asked for their comments. Even before writing, I had asked the board chair about whether or not we should ask our volunteers for proof of vaccination since we do ask them to submit to CORI checks. It is a big job managing more than 150 volunteers, but a few of our volunteers have automated the process and I reasoned that it would be easy enough for everyone to take a picture of their vaccination certificate and text it to the manager of our database who could then attach it to their file.

 

I realized it was intrusive, but I reasoned that as an organization we have a moral obligation to be careful not to allow an unvaccinated volunteer to come in contact with one of our “neighbors.” [We refer to the clients of the organization as “neighbors.”] It was clear from the moment I asked the first person what they thought that the idea of requiring verification of vaccination was a “non-starter.” President Regan was famous for saying “Trust, but verify,” but verification can be a violation of privacy.

 

It felt strange for me to realize that I was about the only one who was comfortable with verification. I think my preference for verification comes from the idea that our neighbors are somewhat like “patients,” and throughout my professional life, I have ascribed to the principle that in every situation what is best for the patient should be considered when determining policy. I reasoned that caregivers have a right to privacy as long as that right did not endanger anyone. With the issue of trust considered, but also realistically expecting that some of our neighbors would expect services but had the right to keep their immunization status private, I wrote the following policy;

 

KNP accepts from its volunteers their truthfulness without documentation when they assert that they have completed an approved course of immunization for COVID and that at least two weeks have passed since their immunization was completed.  When a neighbor requests either help with transportation or help within their home KNP will provide the service if the individual also asserts that they have met the standard for immunization that has been set by the CDC. When in an enclosed space such as a car or inside a client’s home both volunteers and clients will be advised at this time, but not required, to continue to wear masks and maintain separation if possible.

 

We had a lively discussion and that simple statement got modified. During the discussion, I realized how we all see the world in slightly different ways. I had not considered what the policy should be when neighbors are not present and the activity involved only volunteers. That question was immediately raised. Up till now we all wore masks and practiced social distancing while we stacked wood and delivered wood together or performed some other group activity like preparing trays of plants to distribute to encourage gardening and healthy diets.  Should we still wear masks when we are together since we are going to treat vaccination as a matter of privacy? The policy that emerged by the end of the meeting bore some relationship to my original draft but was different:

 

Since March 2020, it has been the policy of KNP that all of its volunteers wear masks when representing KNP and that its Volunteers do not enter the homes of Neighbors, provide transportation, or come within six feet of Neighbors when providing a service. All in-person contact with Neighbors has been outdoors and while masked.

 

Revised Policy:

 

• When KNP services require Neighbors and Volunteers to be in close proximity to each other, KNP requires that our Volunteer be fully vaccinated. Examples include: transporting a Neighbor, helping a Neighbor to move, and the like.

 

• If a KNP Neighbor requesting help does not state that they have been vaccinated, KNP will require the Neighbor to wear a mask when indoors or in close proximity with a KNP volunteer.

 

• If KNP Volunteers are working with other Volunteers in close proximity, and a Volunteer is not vaccinated, the Volunteer that is not vaccinated is requested to wear a mask.

 

• We will provide the Neighbor and Volunteer with vaccination information so that they can make an informed risk decision about the KNP activity.  Even if vaccinated, a Volunteer will honor a Neighbor’s request to mask. 

 

Well, that was not the end of the mask transition issues. The KNP board meeting was on Zoom Monday evening. Tuesday evening the Church Council had its monthly meeting on Zoom. Before the meeting, the church secretary sent me a request.

 

As of last evening, the mask ordinance has been lifted in the town of New London.

Please discuss at your meeting this evening and advise the office as to next steps – hymnals & bibles back in pew racks?  Social distancing?  Tape remaining on pews? 

We have an Eagle Scout ceremony this coming Sunday afternoon and I would like to inform the family as to our procedures so they can inform their guests ahead of time.

We have also received a request for use of the choir room by the Sunapee Singers on Monday afternoons beginning next week.  Thoughts?

 

Below her note was the somewhat ambiguous statement from the board of selectpersons:

 

 PUBLIC NOTICES

The New London Board of Selectmen voted to lift the town’s mask resolution.

The Selectmen support businesses that continue to require masks in their establishments and encourage all to continue to observe safety guidelines designed to slow the spread of the coronavirus including social distancing and mask-wearing for those not yet vaccinated.

Please consider getting vaccinated today. 

 

As background, my church resumed in-person worship services last June following the advice of the Governor. There are no hymnals or Bibles in the pew racks. Only every third pew can be occupied by one individual or family. There is no passing of the offering plate and communion has been substantially modified. The sanctuary has been wiped down with disinfectants between the 9 and 11 AM services. Normally the sanctuary will seat five hundred people, but with COVID modifications it seats less than sixty. A majority of members, including me, have attended online. We are the only church in town that has had “in-person” services since March 2020. 

 

I won’t bore you with the details, but again the discussion was a serious one. It was obvious that most people are both unwilling to ask people for their vaccination status or to return to “normal” quickly. Our compromises were to continue masks, put the hymnals back in the pews, open up every other pew, and then reevaluate in a month. The building is used by many community groups from AA to the Boy Scouts. There are weddings and funerals that are waiting to happen.

 

I guess that the best way to describe the COVID experience is that at any one moment it feels like we are walking in the dark. I frequently refer to modern life as a VUCA experience: volatile, uncertain, complex, and ambiguous. I also have written many posts where the central theme was “adaptive change.” The COVID experience for each of us as individuals, as families, as communities, as a nation, and as the occupants of a small planet, has been a Mega VUCA experience, and a requirement to adapt or risk destruction. We have been individually and collectively traumatized. We will need a long time to process what we have learned. Perhaps as a society, we will have some sort of post-traumatic syndrome. We are going to need to be very patient with one another. Coming out of the pandemic may prove to be as great a challenge as living in it. I think the two examples I offer are probably being reproduced across the land and around the world. It is a time when we need wisdom and the ability to listen to one another. Healthcare professionals will have an opportunity to be a new kind of “essential worker.”

 

If Dandelions Were Dollar Bills…

 

…I would be very wealthy. The header for today’s Musings shows just some of the dandelions in my front yard which is a sea of yellow. Living on the lake we want the water to remain clear so that we don’t use pesticides or fertilizers. My wife is the president of the Little Lake Sunapee Protective Association and needs to follow all of the rules as an example to others. Over the years we have learned a lot about the efforts that are necessary to protect the environment. 

 

Recently she informed me that dandelions were an environmental benefit. They even have medicinal purposes although they can be poisonous. Hit the link and check it out. Dandelions are great for pollinators, but they are also quite good for you. If you follow the link you could learn more, but to save you time and effort, here is an introduction:

 

The dandelion plant is a rich source of beta-carotene, which our bodies convert to vitamin A. It is also loaded full of vitamin C, fiber, potassium, iron, zinc, magnesium, calcium, and phosphorus. It contains vitamin D, B complex vitamins, organic sodium, and even has more protein than spinach. Yes, you might say that dandelion is a true wonder food worth the hefty price. And it’s actually very tasty too.

“Dandelion leaves act as a diuretic, increasing the amount of urine your body makes,” according to Penn State’s Hershey Medical Center. “The leaves are used to stimulate the appetite and help digestion. Dandelion flower has antioxidant properties. Dandelion may also help improve the immune system.”

 

It’s the leaves and roots that carry most of the medicinal benefits. As knowledgeable as most of my readers are, you probably already knew these things, but it has been news for me. You probably won’t run out and start harvesting your own dandelions since I am told that health food stores have various dandelion products like dandelion tea, but if you do want some homegrown dandelion tea, here is how to make it:

 

You can also make dandelion root tea yourself by steeping a tablespoon of the roots in about five ounces of boiling water for 30 minutes.

If you want to make more of a coffee-like beverage, you’d chop up the root and dry it out by roasting it in the oven for about two hours at 300 Fahrenheit. Then steep it for 10 minutes in hot water.

The tea is also a mild laxative

 

As I get older I realize more and more how limited my “fund of knowledge is.” Dandelions are but one of many wonders that have alluded my attention up until now. If you don’t want to pull up the roots of the dandelion which can be hard work, you can snip the leave for a fresh salad. You may already be making dandelion salads out of the leaves because you know that the leaves are:

 

…packed with vitamins and nutrients that your body needs like vitamins K, A, and C, magnesium, potassium, and B vitamins. Some of the benefits of dandelion leaves include:

• Reducing high cholesterol.

• Promoting eye health.

• Decreasing water weight.

• Reducing bloating.

• Promoting weight loss.

• Protecting against liver disease from oxidative stress.

• Improving the immune system.

 

Who knew? Certainly not me. The flowers are also reported to have medicinal benefits for GI problems and depression. It seems that you don’t eat them raw but you put them in cookies or jellies. There is one word of caution. You might be allergic to dandelions if you have problems with ragweed, daisies, marigolds, and chrysanthemums. 

 

As mention earlier dandelions are a boon to bees and other pollinators and despite the efforts of so many who want their lawn to look like a golf course they are also good for other plants and even your turf because their taproots bring nutrients from deep in the soil up closer to the surface. 

 

Pondering my dandelions got me thinking about what it is that creates value. What is the difference between a weed, a wildflower, or a flower that you would buy from a florist or buy at a garden shop to plant in your garden? In fact, how we see things is very subjective. One person’s weed is another person’s wildflower or valued source of herbal medicine. There is a scripture, Mark 12: 10-11, that suggests that a stone that was once rejected by the masons can be the cornerstone of the structure. I heard a commentator recently ask a rhetorical question, “Who was more valuable to us all during the pandemic? Was it an “essential worker” or a stockbroker or management consultant? Why do we reward some people who are never at risk as they provide us with a non-essential service and fail to reward those whose contributions are critical to our survival? 

 

I have enjoyed the beauty of my dandelions. They were a gift. We didn’t plant them. Until my perspective changed I didn’t want them. Before I lived near a lake I would always try to eradicate them from my lawn. Slowing down to look around in retirement and the forced confinement and isolation of the pandemic have made me more observant of many wonders that I never took the time to appreciate. 

 

I hope that you will have a little time this weekend to go out and see something that has always been there in a new light.

Be Well,

Gene