At the Quality Colloquium which took place at Harvard last month, patient safety was all tied up in reducing the costs of healthcare. Millions of dollars can be saved by not very sexy practices of washing hands, making sure the right medications go to the right person at the right dosage at the right time, making sure that the surgery is performed on the patient. Oh, there was more…but you get the idea.

I asked a simple question: With all the potential savings, when will our premiums be reduced…if we are healthy and productive and good people and the waste in healthcare is minimized..will our premiums go down? The answer: No. Small businesses have no negotiating power.

So, my answer is that our individual and collective power is the power we have to make much needed changes not only in healthcare, but in the demonstration of our rules of civility and strength in each other by taking on healthcare and thinking through whether this is about money or about life and death…which has no monetary value.

That current lack of civility, going after President Obama, taking positions while using patients as pawns in the game of healthycare monopoly is not how our history is. We have shown each other that we can show up and do what is right.

I remain hopeful. And, as you are, vulnerable to those who will decide whether or not I am worth medical treatment. Those who think they are not vulnerable are like those here in Nevada who play slot machines and think they can win with enough spare change.

Evidence-based public debate is longed for here….

I know that writing a blog is usually done on a more regular basis than once a month. However, this is not easy for me. I am caught in the web of concerns that are vast and influence that is limited. So, when I write each month, I try to share whatever has risen to the top of the pile. Lately…and actually for a very long time, the healthcare debate has kept me up as if I am watching the World Series in the 14th inning. Yes, the players are exhausted, most of us have lost track of who should win, the losers and winners all look alike…and most of all, no one is paying attention to the millions who could not afford to buy a ticket to the game.

What is really haunting me is what is not being talked about. For example, my brother, who works with many insurance companies, long ago told me that ones insurance is only as good as 30 days, between premium payments. And, the paid premium buys the 30 days and the unpaid premium lurks in the dark so that if the payment is one day late, the insurance company can cancel the policy and we would have to start over. Further, 30 days is the real length of the binding contract where you can count to some degree on the terms of the insurance you understand.
What this really means is that you and I are living premium to premium with some degree of security, which can be interpreted in many ways.
Years ago, I sent in a healthcare premium on the Monday prior to Thanksgiving. The check got caught up in the flood of holiday mail. It posted not when it was postmarked, but when the insurance company had time to post it. They posted it on the second of the month. It was due on the first of the month. Our policy was cancelled. Period. Cancelled. Also, we couldn’t reapply for six months. No discussion. No options. Nothing. To say we were upset is a gross understatement. I called the company, pleaded on the basis of three years of on time payments and low utilization…nothing. “They” could do nothing.
Another time, we were with Great Republic Life Insurance. The policy for two of us was $227/month. We, at that time, were in our early 40’s. Every month we paid on time. I then get notification of a fee increase effective in 30 days. The premium was being increased to $587/mo. I called the agent and asked her to find new insurance… that would, of course, require another medical history and time to check. Fortunately, we had not even used the policy. We had had it for three years. Within the month, Great Republic cancelled the whole master policy, leaving 40,000 people without insurance. It made “60 minutes” …so many of the 40,000 people had cancer, heart conditions, were diabetic…were trapped in the prison of pre-existing conditions.

This discussion about healthcare reform is absurd. No one is willing to say that the current system buys everyone with insurance 30 days and those who are un-insured never get into the ball park.

While the problem seems unsolvable, the reality has yet to be clearly stated so every person in the country who is fighting to the status quo gets what exactly they have. The problem is hardly the doctors. Their fees are relatively low. The problem is not the hospital…after all; they have to cover their costs no matter where the money comes from. The problem is not the attorneys because who else is going to advocate for patients who are victims of either faulty care or insurance companies who claim they do not have to pay. The problem is not the patient? Hmm. Right now that has not come up directly. But, clearly the best way to manage the healthcare system is to not use it.

What if we were playing a shell game and the pea was not under any shell? It may not matter which one we pick, because the game is set up for us to lose. I would rather change the rules so that at least patients and families had the upper hand. Oops! This could be considered heresy! That patients and families would actually have some stake and control at the table of this debate would be a major change. So major that maybe all the players would start working together. In truth, when it comes to illness, life threatening diseases, accidents that render us at first helpless and then trapped in the needs that follow…when it comes to all of these terrible events we all dread…then the shell game should be stacked so that there is a pea under every shell…so that patients and families cannot lose..…but have ample support among the best available.

While this month is the 17th anniversary of the C.A.R.E. Channel and Healing HealthCare Systems, it is also the 17th anniversary of the last best effort to reform a healthcare system that was then declared broken. Although the critics have analyzed Hillary Clinton’s errors in process and have tried to lay singular blame for why nothing happened, the reality is that all debates about economic process in relationship to healthcare are major distractions from the issue of providing healthcare to every man, woman, child, elder, rich and poor, old and young, employed or otherwise.

Personally, I am familiar with the ways distractions disrail debate. Anything to end the discussion in ways that prevent in depth conversation and accountability. That seems to be what is going on right now. I am hopeful, however, that the situation has become dire enough to push through the rhetorical wall. A system that does not provide care, kills. This healthcare system, as it stands, is lethal.

Nonetheless, in the 17 years since Dallas and I dreamed up a way serve patients at the bedside, healthcare has certainly reformed, transformed, moved closer to looking at the patient as a human experience rather than a diagnosis. Far from perfect or consistent, the fact that our work is now serving patients and families in close to 500 hospitals is evidence of this profound change. When we started, it was clear that there was no money, no budget, no understanding of why nature and music were as needed as clean water, clean air. While Florence Nightingale had long ago identified the human needs, her words and policies has been buried beneath progressive science, antibiotics, and what is called “modern medicine.” Nonetheless, we persevered knowing that, as we were told, the challenges for patients are at three in the morning, when the lights are out, the staff is less, when the world is sleeping, and when the patient is most alone.

So, here we are 2009. 17 years later and feeling as driven and passionate and committed as we did in 1992. I have no words to express how grateful I am to have a mission incomplete. I love the work and the work will never be done. I love the people I work with, the hospitals who take on this challenge, and the other missionaries who walk as nurses, physicians, therapists, chaplains, volunteers…who know that serving patients is so much more than treating them.

If there is any truth that can be claimed regarding healthcare and the costs it may be that we can neither afford to have it or not have it. That we cannot afford to pay the current tab on the wages or profits being made by most Americans (not counting the most wealthy whose healthcare will never be dependent on cost).

Yes, we are going through most difficult times for so many, but not all. The insurance and health care issue, however, long predates this recession. It is at least 17 years old and getting older. It is actually as old as the first patient and family that were denied care, were turned away from a hospital or emergency room, and as old as the first infant who died because the mother could not afford prenatal care.

I remain hopeful and grateful and driven and passionate.

The original lyrics come from Pete Seeger’s song…Where have all the flowers gone…etc. At that time, it was about war. However, the same question can be asked regarding health, poverty, and education. When will we all learn that hand washing, preventive care and cleanliness, education are as requisite for good health as poverty and health illiteracy is a threat? During this recent threat from the H1N1 virus, it was not surprising that other countries had more serious outbreaks than those in the US…and that those whose lives are at a subsitence level are as much at risk today as those who lived prior to antibiotics and other medical miracles.

Florence Nightingale asked the same question: When we will ever learn that pauperism (poverty), lack of good hygiene and clean water, toxic air, and lack of good diet is why patients die who would otherwise live?

Barack Obama’s hint to wash our hands and cover our mouths remains so boringly low tech. The push is for vaccines so that we no longer have to wash our hands. My sarcasm may not be appreciated. However, there is more truth in my observation than even I am comfortable with.

Give me anything but don’t tell me to change what I am doing, how I am doing it, or when! This has become the mantra of patients, the profit margin of pharmaceutical companies, and the job description of clinicians: Diagnose and prescribe, but don’t look beyond the symptom. OR, if one looks, still do everything that can be done other than tell the patient what kind of decisions would ensure their best shot at improving their health, if not protecting it.

I am personally invested in healthcare reform. Our company rates for 8 healthy people increased 33% this year. This includes an increase in our deductible by 20%, to $2500.

Monday, the New York Times stated “Signers of the letter (of commitment) said that large amounts could be saved by aggressive efforts to prevent obesity, coordinate care, manage chronic illnesses and curtail unnecessary tests and procedures; by standardizing insurance claim forms; and by increasing the use of information technology, like electronic medical records.” This is a start, but will not help you and I in paying for our insurance or guaranteeing that when and if we really need it, our insurance will cover what we need when we need it. The question, however, is whether we will do our part in staying healthy.

I am not going to enter the debate of whether the players now willing to participate are wolves in sheep’s clothing. Rather, I am going to offer that the healthcare system, as an institution, has created a codependent relationship with all of us, making us feel like we cannot take care of ourselves. There is clearly too much profit in sickness and hardly any in wellness. Too many make too much on the sick, those of us who fear being sick, and those of us who have come to believe that cures are there to forgive our indulgences.

I am not blaming any of us for this. However, as Dr. Leland Kaiser said years ago, if we do not begin to re-frame our healthcare systems to invest in health rather than illness, offering another sickness-based system in any form will be rearranging the chairs on the deck of the Titanic.

When will we ever learn that have had health care rationing ever since doctor’s treated for money, that most vaccines will fail if we fail to use them; that the miracle of the antibiotic died at the age of 40 with the advent of HIV; that the current spread of the H1N1 virus points to the need for us to own our collective health as being all of our business. We live globally if one child in Mexico can get a virus and within days it spreads to many countries.

Florence Nightingale would have told us all to wash our hands, clean our sick homes and offices, and that the best way to deal with illness is prevention. Clearly, how this one young child in Mexico is, so how the world is.

Coming from the Aging in America conference in Las Vegas last month, I am again struck by the good news and other news about how life progresses. The word ‘aging’ is one with mixed meaning: to age may mean become richer, more seasoned, and certainly better over time (such as in wine, in wood, in personhood…). However, in the current western way of looking at it, longevity has a point of diminishing return: we climb the mountain only to have to go down the mountain… We are an ageist culture, valuing youth over age, valuing new over old, valuing innovation over experience. We are also out of balance with ourselves and, as many of have seen, are doomed to repeat a sordid past if we do not balance innovation with knowledge.

I would say to anyone who looks back over history, that we are the first to live this long, to celebrate good health longer and, to create a whole economy around this new stage of life that was never lived before.

At the Aging in American conference last month, I heard Debbie Reynolds speak, saw her dance and sing, heard her stories of youth and marriage(s), declare that aging with only about one word: perseverance. She was beautiful and articulate. She almost fainted…she had had pneumonia only a month earlier. But, she did not. She just said, “Things like that happen.” We all laughed at ourselves, with Debbie, in her descriptions of how life plays out as an older person.

The new issue for me is age related hearing impairment…it is pandemic, it is isolating, it is a major quality-of-life impairment. Yet, even at this amazing conference, there was a certain level of denial about how pervasive the issue is. This is the second conference dealing with aging where I have presented on this specific issue. I feel like I have to build a case for dealing with it each time. The continuing level of shame and embarrassment around wearing a hearing aid and the unwillingness to invest in the technology that can remedy (to a high degree) the challenges remains the great barrier. Remember, we dealt with the presbyopia…loss of nearsighted-ness…with line-free transitional glasses, hiding the obvious. Even if we spend a few thousand dollars on in-ear hearing aids, complete with remote control, this hiding has not really made the grade in how nursing homes, long-term care organizations manage a population whom collectively and individually cannot respond appropriately because they cannot hear. Certainly a topic for another blog…one that will arise over and over.

On my end, I am not waiting until I am old to do anything, nor do I think I will want to do everything when I am old. When I am old, I will wear not only purple…but also, hopefully, will wear my experience and wisdom in ways I could not possibly wear them now. Yes, I will always avoid the persistent graying of my hair; I am starting a separate hearing-aid acct for Dallas and I so we can get the best; I will always wear makeup; I will always want to engage in the present and put the past in perspective. But, most importantly, I will seek to be treated for who I am in the moment, rather than the numerical measure of my age.