Archive for 'Healthcare & Communication' category

When Rules Get in the Way of Good Time
Posted: Tuesday, April 8, 2014

by Scott Good

The healthcare environment is changing rapidly and compelling good people at great community service and healthcare organizations to collaborate. For instance, the Institute for Healthcare Improvement (IHI) is working with several programs across the U.S. to develop and implement Triple Aim goals to improve community health, enhance patient experiences, and lower the costs of care. 

Though programs differ substantially, a common thread is that they all include diverse sets of people trying to work together.  The people providing the variety of services (i.e., care model members) are generally eager to work together, try new things, and take limited risks in order to achieve Triple Aim goals. Many are eager to forge new strategies and develop new relationships. However, interagency collaboration often requires additional legal agreements and guidance.

Programs need to be designed so that patient privacy is fully protected, collaborating organizations can easily work together, and financial matters are clearly understood among all parties - payers, providers, patients, and others. To do so, requires sets of legal documents and related documents.

When designing programs that address healthcare reform requirements or opportunities, development of the legal architecture underlying programs can seem to take an agonizingly long time to complete. Carefully woven legal agreements are the backbone of successful, sustainable program. However, when designing new programs to respond to healthcare reform, how do we synchronize innovation and legal processes?

In order to avoid the pitfalls of program delays due to legal review, consultation, and document development associated with healthcare reform-based activities, consider the following ...

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Patients & the New World of Healthcare, Part 1: PCOR
Posted: Thursday, August 15, 2013

by Beth Austin

Today's turbulent healthcare environment has brought a great deal of scrutiny on insurers, provider/delivery systems, and the general business of healthcare. In a system poised for major change, America's healthcare consumers will have important new choices and an evolving need for education. In this first of a series of blogs, I'd like to start a conversation about the impacts the Affordable Care Act (ACA) and current industry trends will have on the role of the patient. This post focuses on patient-centered outcome research (PCOR), but other topics - such as Accountable Care Organizations (ACOs) and the Health Insurance Marketplace - will follow.

The ACA legislation established the Patient-Centered Outcomes Research Trust Fund, which is the primary funding source for the Patient Centered Outcomes Research Institute (PCORI). The mission and vision of PCORI are centered on helping people make more informed healthcare decisions that will improve desired healthcare outcomes. It's not hard to support these objectives in principle, since if successful, not only do paitents thrive, but providers, insurers, and payors also have the potential to reap indirect benefits. The organization funds research projects that are centered on key patient-centered questions::

"Given my personal characteristics, conditions and preferences, what should I expect will happen to me?"

"What are my options and what are the potential benefits and harms of those options?"

"What can I do to improve the outcomes that are most important to me?

"How can clinicians and the care delivery systems they work in help me make the best ...

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The Healthcare “Reformation”
Posted: Friday, December 7, 2012

Posted by: Scott Good

The Protestant Reformation is one of the more interesting events in European history over the past thousand years - regardless of one's faith-based leanings.  I was recently put in a position where I needed to know enough about the event to lead a public forum on the topic. My talk went fine, and the information - particularly after brushing up on my history a little - was fascinating.  Having a somewhat unique perspective on large issues such as this (i.e., the bifurcation of a major institution), I recognize some of the parallels between bellwether events (such as the one which was the subject of my forum) and the structural changes in healthcare. Although I do not intend to draw any comparisons between Martin Luther of 1517 and the Affordable Care Act, I think that some observations may be appropriate.

Martin Luther was a German monk who had some life changing events and then - through some unintended consequences - was put into a position of making some very difficult decisions. In his case, it involved the cataclysmic decision of splitting off from the Catholic Church. Except for the "German monk" and "Catholic Church" parts, some participants in a recent healthcare-related focus group that I moderated had stories that paralleled Luther's tale. For them, the life changing events related to a life threatening illness with their son; the unintended consequences were related to a series of responses by the health plan and care providers.  The difficult decision was the need to sell family business (small ...

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Meaningful Use of Patient Portals
Posted: Monday, August 20, 2012

Posted by Heidi Wurpel

The Health Information Technology for Economic and Clinical Health Act (HITECH) based reimbursement for certified Electronic Health Record (EHR)/Electronic Medical Record (EMR) technology on "Meaningful Use".  Both Medicare and Medicaid make incentive payments under HITECH.  However, "meaningful use" standards become increasingly stringent each year.

Hospitals and medical practices who have received reimbursements simply for having an EHR/EMR that includes a patient portal (even if it was turned off) will not only need to turn on their patient portals to continue receiving reimbursement but will also need to start showing that a percentage of their employee population is actively using the patient portal. 

The success of meeting this requirement is likely to hinge on the strength of the medical provider's patient communications.  On surveys, patients almost always express desire for telemedicine, e-mail communications with their provider, electronic prescription refill requests, and 24-hour self-scheduling abilities.  However, getting patients to break old habits and utilize these new patient portal technologies will take more than just flipping a switch.  How do you do this?

  • Medical practices and hospitals should start identifying patient e-mail addresses - and each patient's interest level in utilizing technology - now. A database will ease the challenge of targeting patients for communications.
  • Start talking to your patients about the specifics of your portal. Whether this is a formal survey conducted by an evaluator such as Crescendo, or simply ad hoc conversations in the waiting room, knowing the aspects of your portal that patients find most exciting will allow you to ...
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    Doing it the Hard Way
    Posted: Tuesday, June 5, 2012

    Posted by Beth Austin

    Today's healthcare consumers are increasingly asked to take a more participatory role in their care. For many this is a daunting task - even if the patient desires being in the driver's seat. There are a myriad of issues undermining patient-physician communication - such as time constraints, lack of comfort with the subject matter, lack of shared language, or even fear - that can make the task of being an empowered patient akin to trying to assemble a puzzle with several pieces missing.

    In the recent New York Times article "Afraid to Speak Up at the Doctor's Office", Pauline Chen, MD, suggests that patients often feel "trapped" in communication patterns with their physicians. This phenomenon is not unique to patient and physician. As a graduate student, I taught a freshman-level communication class in which we called these ongoing communication challenges URPs - or Undesirable Repetitive Patterns. Addressing and correcting the common patient/physician URPs are important factors to improving communication.

    In my professional experience, I consistently encounter a specific example of the classic "he said/she said" scenario with regard to patient/physician relations. On the patient side, I have never conducted a patient focus group when at least one did not say something to the effect of:

    "It feels like my doctor doesn't listen to me. All s/he wants to do is write me a prescription for something."

    Conversely, in focus groups with physicians, it is rare that I do not hear one say:

    "Patients really don't seem to ...

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    Patient Education and Consumer Empowerment – The Missing Family Factor
    Posted: Wednesday, May 2, 2012

    Lack of communication is not a problem in my family.  When the bi-weekly meal of approximately 25 of my closest relatives comes around, we already know the minutiae of each others' health and relationships before we take our seats at my grandparents' dinner table.  We are a matriarchal family, headed by an 88-year-old woman who mastered her leadership from her mother. 

    When she recently landed in the hospital with pneumonia, the phone calls, texting, and facebooking began and remain in constant stream.  We want to know every conversation she has, hour she slept, what her 88-year-old husband ate for dinner each night, etc.  We were prepared to cook and clean and inform.  We weren't prepared for what some call "temporary hospital dementia," but more appropriately called "delirium." 

    "Delirium - sudden and severe confusion - is a common complication of hospitalization among people ages 65 and over.  As many as 20% of those admitted to hospitals, 60% of those who have certain surgeries, and 70% or more of those treated in ICUs develop delirium," reports the Harvard Women's Health Watch in its May 2011 issue.[1] While it goes against all of my over-communication training, I have hesitated to share with my family that, according to a study in The Journal of American Geriatric Society, "once this sudden brain dysfunction occurs, it multiplies the chances of dying.  Not only do patients have a 25 percent to 70 percent higher chance of dying during their hospital stay, but they are also at a 62 percent higher risk of ...

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    Doctors Die Differently
    Posted: Wednesday, April 25, 2012

    Posted by Jim Kupel

    In recent weeks three things each suggested to me that we need to do a much better job of learning how to die with dignity and peace.  

    The first was a get together with about 20 high school and college friends.  Virtually everyone there was dealing with complications of aging relatives.  That wasn't surprising because on-average over 6,500 Americans are dying every day according to the CDC.  What was surprising is that everyone's process was different.   It begged the question: why isn't there a "best practice approach" to the end-of-life journey? Of if there is one, why isn't it more widely shared?  

    The second interesting item was from a recent IHI Triple Aim conference.   In addition to lots of inspiring and practical information, the presenters supported their observations with good data.  In a somewhat detailed discussion about the difference between measuring DFLE (Disability-free Life Expectancy) and LF (life expectancy), Kevin Nolan noted that the gap between the two had actually widened from 5.4 years to 7.0 years in a United Kingdom study.  In other words, Brits are living longer but this equates to more years with "long-standing illness, disability or infirmity."  Great.  Can it be much different in the U.S.?  

    Finally, I read with interest a great piece on Why Doctors Die Differently in the Wall Street Journal by Ken Murray.  In it Dr. Murray suggests "Doctor's don't want to die any more than anyone else does.  But they have usually talked ...

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    A Herniated Disc, by Any Other Name…
    Posted: Tuesday, February 14, 2012

    Posted by Beth Austin

    A while back, my brother-in-law was experiencing low back pain and my sister told me that the doctor had diagnosed it as a "herniated disc." The conversation eventually evolved into a discussion about the difference between a "herniated" disc and a "ruptured" disc. My position was that ruptured was worse; my sister's that they were the same thing. Since inquiring minds want to know these things, I decided to look it up, and a fairly quick internet search yielded explanations from an assortment of people professing to be physicians. The summary of the findings is as follows:

    a. there is no medical difference between a herniated and ruptured disc

    b. the difference is a matter of degree in the herniation

    c. a "herniated disc" also describes a "bulging disc" (therefore making a ruptured disc a type of herniated disc)

    d. there is no scientific definition of "bulging," "herniated," "ruptured," or "prolapsed" discs  

    And, my favorite,

    e. The term "herniated disc" is so misused that a patient is better served to just obtain the actual measurements of the protrusion

    As the saying goes, "Ask five doctors and get six different answers." This seems to be a case in point.    

    But the bigger underlying issue here is communication. For patients that want to be constructively involved in their care, at a minimum, they need to know the diagnosis, understand the treatment options, be aware of the pros and cons of the various therapeutic options, and have access to quality/performance metrics for the ...

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    Turning Awareness Into Action
    Posted: Monday, October 10, 2011

    Posted by Beth Austin

    As I'm sure you already know October is breast cancer awareness month.  Given that breast cancer is a topic that's near and dear to my heart, I spent some time thinking about what this month means and how it can make a difference in people's lives.

    For many years, breast cancer was a disease that nobody talked about.  Thankfully, the efforts made by many innovative organizations and dedicated individuals have changed that.   Social marketing campaigns, outreach, education, and survivors telling their stories have allowed for significant progress in raising awareness about the disease.

    With the gains in awareness, you probably already know important statistics such as one in eight women will get breast cancer in her lifetime and that between 85-90% of breast cancers can be detected by mammogram, leading to earlier diagnoses and better outcomes.  You probably also know that mammogram screenings are recommended for women 40 or older (and even younger if the woman is at higher risk). So, what's the next step?  The next step is taking the knowledge that we've gained turning this awareness into action.   Here are some suggested actions to consider:

    1.  Get a mammogram. I know there's been a lot of confusion about screening guidelines and who should get mammograms and how often, but the bottom line is if you're female and your 40, you should get a mammogram. You'll also want to talk with your doctor about a screening schedule that is appropriate for you.
    2. Spread the ...

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    Choosing a Doctor and Other Death-defying Feats
    Posted: Wednesday, August 10, 2011

    Posted by Beth Austin

     

    I’ve spent a lot of time in my professional life knee-deep in articles on healthcare quality and medical information, as well as working with local doctors, hospitals, and health-focused, not-for-profit agencies.  As part of this work, I often share information and resources with others that might help them choose a doctor.  I’ve also spent a lot of time wondering whether anything I knew or said ever made a difference to anyone, or whether people always end up picking the specialist their PCP recommends or just geolocating the practice closest to their house.  Does anyone even pay attention to their health or healthcare unless there’s a problem?

    Recently I received an unexpected medical diagnosis (although I suppose most of them are unexpected).  It was of the frightening and potentially life-changing variety where you blow through your health plan deductible and out-of-pocket max faster than you can say “hospital johnny.”  Suddenly I felt as if I were being put to the test – an almost surreal, multiple choice exam where the wrong answer could have significant consequences.  I would soon be faced with important decisions – and would learn first-hand whether anything I knew actually mattered.   I’ll share with you a few tips based on my experience, but first, a couple of caveats.

     

    Big Caveat Number One:  It’s personal.  A big lesson learned for me is that there is no single “right answer.”  Choices about treatment approaches or where one receives care can be affected significantly by one’s personal life ...

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    A (Confused) Patient's Perspective on a Physician's Social Media Mistake
    Posted: Monday, May 2, 2011

    Posted by Beth Austin

    Recently, Dr. Alexandra Thran, a Rhode Island surgeon, was fined and fired by Westerly Hospital for a Facebook post she made that included identifiable information about a patient.  The post has since been deleted, but all news accounts state the post did not include the patient's name, but the nature of the patient's injuries allowed "an unidentified third party" to recognize who the patient was.

    This event has caused a great deal of scuttlebutt in the health care social media (#hcsm) world, with posts from Drs. John Mandrola, Kevin PhoBryan Vartabedian and Wes Fisher providing their thoughts about the incident.  They all provide excellent insight through their various points.  In my post today, I'll try to provide a patient's perspective.

    First though, the reports have stated that Westerly Hospital did not have a social media policy.  Seriously?  How many more public debacles do we need to endure before provider organizations realize that having a social media policy is a necessary part of doing business? 

    Not having actually seen the post, it's a bit difficult to give a hard and fast opinion, but I can generally imagine what the post might have contained.  As alluded to by both Drs. Vartabedian and Mandrola, my first and most significant concern about this story was not the post itself, but the hoopla about the medium.  In many cases, provider organizations seem to have an almost irrational fear of social media (they can't even put together a social media policy ...

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    Don't Miss a "Beat"
    Posted: Friday, April 22, 2011

    Posted by Scott Good

    Samuel L. Jackson's movie, The Cleaner, did fairly well at the box office.  However, the highest number of website hits for the movie occurred on April 19, 2011 - more than two years after its release.  This was also only one day after an air traffic controller was suspended for watching this movie while at work.

    The air traffic controller who put so many people's lives in danger didn't understand "EKG communications."  An EKG machine is used by physicians to measure cardiac activity - usually showing a low or straight line that spikes up when the heart beats. The controller watching the movie apparently thought that he could adequately respond to "heartbeats" of communications (short, but vitally important radio transmissions from aircraft) while watching The Cleaner during the quieter moments.  He had become calloused, or ignorant, to the potentially catastrophic effects of missing the aircraft-to-tower communications - the EKG "heartbeats."

    There are other examples that we can easily point out - texting while driving, many patient/physician discussions, employer/employee communications, etc.  In each of these instances, one simple error in communications could potentially cost, or save, a life.

    Are you attentive to your communications?  Do you actively listen during an otherwise mundane conversation and screen for any important nuggets of information (or, "heartbeats") that could present great opportunity or thwart potential problems?

    Some important steps to make sure that you stay sharp include the following: Be an active listener - take notes, highlight written items, ask questions or otherwise feedback what you are ...

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    Fighting Weight is Like Fighting Sneezes
    Posted: Tuesday, April 5, 2011

    Posted by Heidi Wurpel 

    Being raised in a family with a long history of thyroid problems, genetic predispositions to easy weight gain, slow metabolisms, and a very Eastern European view on food and family gatherings (plenty of both as often as possible), I understand that fighting weight is much harder than it seems.  Hearing "eat less; exercise more" is not the best motivator or a comprehensive answer to America's weight problem. 

    My life experiences have given me a passion to help people with their weight.  However, the truth is that obesity is a symptom of a larger problem not the disease itself.  Though I am often excited to see articles on the "obesity epidemic" it always strikes me as a little funny, like saying we need to cure the "sneezing epidemic" instead of fighting the colds or allergies that cause the sneezing.  Weight is deep; it deals with real physical and psychological issues.

    Here is an example of the psychological side: when you tell me that the food I am eating is "bad" I feel a rapid series of attacks unconsciously; essentially my mind quickly processes that you are attacking my intelligence (if it was "bad" shouldn't/ wouldn't I know that?), my upbringing (if it was "bad" why did my parents feed me it?), and my financial decisions (if it is "bad" I just wasted my money), etc. 

    This is why defensiveness and rejection of the advice become the natural responses.  To protect our psyches and definitions of self, we must begin to ...

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    Live the Sheen Nightmare
    Posted: Tuesday, March 29, 2011

    Posted by Beth Austin

    For weeks now, we've been assaulted by the media maelstrom covering the up-to-the minute details of Charlie Sheen's latest antics.   We've seen blog posts, twitter accounts, TV shows, and websites such as "Live the Sheen Dream" providing forums for satirizing his bizarre behavior.  In the spirit of full disclosure, I should confess up front that I've been known to consume my share of Hollywood tabloids and that maybe no one enjoys a good round of schadenfreude more than I do.  However, the Sheen spectacle has many suggesting this is more than a case of Hollywood egoism run amok and more likely an indication that he is in need of psychiatric help.

    Even a popular medical news site got into the act by using its weekly survey as a platform to ask readers for their thoughts on the topic.  (Et tu, MedPage Today?) The results of the survey suggest that readers are neutral about whether the media coverage is good or bad.  Even more interesting was the diversity and nature of comments the poll prompted.   The comments showed that there is a contingency that feel that Sheen is no victim and that he is the instigator of the media coverage, but also another camp who feel that it is pure exploitation, since Sheen is likely not in any condition to making an informed and rational choice.  It doesn't matter how wealthy or famous or spoiled Sheen might be, mental illness is just that - an illness.  Would the Internet ...

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    Guideline-compliant Care - Where are the "Right Answers"?
    Posted: Tuesday, January 11, 2011

    Posted by Beth Austin

    If you were following my tweets last week you might think I was anti-evidence based medicine.  This isn’t categorically true, but a few articles caught my eye that I thought worth sharing.  And when I considered these articles in conjunction with an interesting webcast, it raised some questions for me about the consumer’s role in getting quality care.


    The first article of interest is by Dr. John Mandrolla, a cardiologist/EPS, responding to the recent media hype regarding the “overuse” of ICDs (a.ka. pacemakers),devices implanted in some patients with irregular heart rhythms.  Dr. Mandrolla tells the story of “Mr. Smith”, a patient in whom Dr. Mandrolla had implanted an ICDas a preventative measure, even though testing indicated that he was marginally outside the scope of the current guideline.  While Mr. Smith is at Denny’s one morning, feeling perfectly healthy, he experiences what would have been a fatal cardiac event had the ICD not been in place to administer the lifesaving shock.

    The second article is from Dr. Jessie Gruman, chronicling her own experience fighting cancer.  In an effort to treat her stomach cancer (likely a result of receiving excessive radiation from her previous bout with cancer – the guideline at the time) she interviews three surgeons.  Two say that they will essentially need to remove her stomach in order to be compliant with the guideline of leaving a 6cm margin around the cancerous area.  The third surgeon, however, is more concerned with trying to leave as much of ...

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    Engaging Consumers and Employees in their Health - Lessons (Re)Learned
    Posted: Tuesday, December 7, 2010

    Posted by Beth Austin

    A primary focus of Crescendo's work is to create programs and communications that encourage people to become more engaged in their health and healthcare.  I had the opportunity a couple of weeks ago to interact directly with the employees of a large organization to educate them on a new health program we were launching.  I always value the face-to-face time that I have with the target audiences of our communications and programming as it is both an opportunity to learn new things and to reinforce knowledge from previous experience.  This most recent visit with the organization's employees was no exception, and it prompted to me to share the lessons and messages I hear most often.   

    1.       People want to be engaged.   From an employer perspective, wellness efforts are often met with a problem: those most likely to participate are those who least need to.  While there will always be some percentage of the population that is non-participatory and apathetic, my experience suggests that they are not the majority.  My conversations with employees at this recent visit reinforced what I have heard at other employee sites, focus groups, and other one-on-one conversations over the years.  People do want to be engaged - they just need the right education, motivation, resources, or simply that "one last push" to do so.   The more your program or environment is open, supportive, and easy-to-use, the more likely it is that people will get involved.  

    2.       The tipping point may be closer than you think.   I recognize ...

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    12 Minutes: A Day in the Life of a PCP
    Posted: Tuesday, November 2, 2010

    Posted by Beth Austin

    I once again had the pleasure of hearing Erik Steele, D.O., speak at the Maine Health Management Coalition's recent payment reform symposium.  His presentation: Health Care Costs....A Provider Perspective offered the audience "a taste" of his life as a primary care physician.  He walked us through the phone calls he might receive in a day (ranging from a potentially suicidal teen to a patient vacationing in Las Vegas looking for a refill on a methadone prescription), a challenging patient case (an incidental finding of a lung nodule on an abdominal CT Scan), and a typical office visit (with a diabetic patient with high cholesterol).   A key message of his presentation was that he does not get compensated appropriately - if at all - for many of the complex and critical tasks he will complete on this ordinary day.  However, the point that most resonated with me was something he included in his opening remarks:

    "I have 12 minutes to do whatever it is I have to do with patients.  If you remember nothing else today, remember this."

    Hmmm.  On many days, it takes me 12 minutes to figure out what to have for lunch, which is hardly a life and death decision. (I mean, the mayonnaise would have to have seriously passed.)  To play that out further and think of all the decisions I make in a day, I can't even fathom making them all in 12-minute increments, and yet, Dr. Steele needs to make choices that can have a ...

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    Stop, Stand, and Listen
    Posted: Wednesday, October 27, 2010

    Posted by Heidi Wurpel

    For the past few weeks I have been standing by a new car, smiling, and waiting for people to approach me to chat about the vehicle in an effort to be sure as many employees as possible are involved in a wellness program for which the car is a Grand Prize.  The findings from this exercise have been plentiful but one in particular that I call “Stop, Stand, and Listen” can be applicable (car optional) for many marketing and human resource managers - and even executives.   

    As a society we have defined what “work” is: it is sitting at a computer, having meetings in official conference rooms, laboring in an obvious way, or talking on a land-line phone.  Somehow we have said work is not impromptu meetings and personal discussions between two people in the hall or parking lot.  However, when we step back and ask what the purpose of all of those Word documents, voicemails, e-mails, and meetings is, we may see that all of our “work” is working against us and actually making us less able to communicate the message we are seeking to share effectively. 

    I had more meaningful conversations about health and wellness with people who admit having had genuine questions and concerns for months, by simply standing there – with no distractions or signs of my being “working” - than through all of the written reports, crafted e-mail messages, tradeshow style set-ups, or targeted phone calls I have previously used to communicate this exact same message to this exact same ...

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    Health Reform Continues To Roll Out – Even In Cartoons
    Posted: Tuesday, October 5, 2010

    Posted by Jim K.

    Just this past week several important provisions of the Health Reform legislation started having an impact, including the CMS Background Check Expansion we noted last month.  Another major change getting underway is the new 'Center for Medicare and Medicaid Innovation', which you may recall is substantially funded in the years going forward.  CMS Administrator, Don Berwick, announced that the former CEO of Geisinger Health Plan and family physician, Richard Gilfillan, M.D., will be the new Acting Director of the Center for Medicare and Medicaid Innovation.  Currently Dr. Gilfillan directs CMS’ performance-based payment policy staff.

    Even for those of us doing lots of work in the field, it is a challenge to understand the impact this important legislation will continue to have on our lives.  For the rest of us, it may be nearly incomprehensible.  Luckily there’s a cartoon version!  My son passed along a link on the Kaiser Family Foundation called “Health Reform Hits Main Street[1].”  In it narrator Cokie Roberts (a news commentator for ABC News and NPR) explains how the new health reform law really works - with the help of animated "YouToons."  It does its best to explain the problems with the current health care system, the changes that are happening now, and the big changes coming in 2014 – all in nine minutes!

     
    [1] http://healthreform.kff.org/the-animation.aspx

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    Physician Smackdown: Dr. Grumpy vs. BaltimoreDoc
    Posted: Tuesday, September 21, 2010

    Posted by Beth Austin

    I wasn’t there when it happened, but the way the story goes is that our client was grousing about two prominent individuals in his field, as he quite often did, since these individuals were also the bane of his professional existence.  Then someone asked him: if these two individuals were ever in a Celebrity Smackdown competition, who did he think would win?  Without missing a beat, our client allegedly said “who cares?”  

    This rather odd setup leads me to the topic of my post today, which is to explore the desirable role for patients in managing their health(care).  Currently, this role is ill-defined at best and the disagreement among physicians as to what this role should be exacerbates the patient challenge.  While many physicians in practice today are doing great work in helping patients define their role, there are others who are not quite as supportive.  

    In the left corner, we have Dr. Grumpy. I recently read a blog post by Dr. Grumpy in which he laments about recently being named a "Best Doctor" by a local publication ( http://drgrumpyinthehouse.blogspot.com/).  The points he makes about the downside of this recognition are mildly amusing, but I get stuck on the part where he says something to the effect of he would also get new patients who had been to other neurologists who "weren't able to fix them" but think that he may be able to help since he made the best docs issue.

    Wait a second.  Did I ...

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