HealthCommentary

Exploring Human Potential

Emancipating Pragmatism: Emerson, Ellison, Hillary, Donald, The New Museum, The ADAP Association and African American Health.

Posted on | September 24, 2016 | No Comments

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Mike Magee

In the shadow of Monday’s Presidential debate, expected to attract close to 100 million viewers, this has been a week of remarkable highs and lows for African Americans.

Today President Obama will preside over the official opening of the National Museum of African American History and Culture on the National Mall in Washington, DC. This morning, our President said, “This museum doesn’t gauze up some bygone era or avoid uncomfortable truths. Rather, it embraces the patriotic recognition that America is a constant work in progress; that each successive generation can look upon our imperfections and decide that it is within our collective power to align this nation with the high ideals of our founding.”

This week also, in a JAMA article by Victor Fuchs titled “Black Gains in Life Expectancy”, we received positive news on the narrowing disparities in health outcomes. In the past decade, life expectancy in black Americans is now rapidly approaching that of whites in this country. The former has gained 6.0 years (69.6 to 75.6), while the latter has gained 2.5 years (76.5 to 79.0). Where did those extra years come from? .37 years from less cardiovascular deaths; .31 years from decreases in HIV mortality; .28 years from declines in traumatic injuries; and .14 years from fewer perinatal deaths. These 5 success areas alone delivered 60% of the progress.

And yet, as this week’s events in Tulsa and Charlotte so tragically indicate, there is so much work left to be done. The Museum is part of that healing. It’s narrative power will help challenge well-entrenched perceptions, and counteract bias and prejudice, drawing them into the open where they can be managed. More concretely, we will also continue to rely on groups like the ADAP Association, who for nearly a decade have labored to assure education, testing and treatment are accessible to vulnerable populations with HIV/AIDS.

The ADAP Association is fresh on my mind since I delivered the opening keynote address at their 9th Annual Convention at the Georgetown Westin Hotel yesterday. I was honored and pleased to receive the invitation from Executive Director, Brandon Macsata, who had been responsible for my original invite nine years ago at their 1st convention. That invite, in turn, was the result of Brandon hearing me address John Kemp’s Disability group a year earlier.

Brandon suggested I might reflect on the role of “advanced professionalism” and “enlightened leadership” at this critical moment in our history, with the first Presidential debate literally upon us. To prepare, I relied heavily on a book my son, Michael, had published with the University of Alabama Press in 2004, titled, “Emancipating Pragmatism: emerson, jazz, and experimental writing”. The book derived from his PhD dissertation at the University of Pennsylvania, and extensively delved into the writings of both Ralph Waldo Ellison, author of “The Invisible Man”, and his namesake, Ralph Waldo Emerson. More on that in a moment.

In my ADAP Association speech, I began with the concept of Positive Leadership that I had developed in the early 1980’s grounded in two diametrically opposed approaches to change.

One type of leader resists change, using fear as currency to achieve short-term goals. This type of leader retrenches and divides, segregating populations as he builds walls and silos.

The other type of leader embraces change, using visioning as currency to achieve long term goals. This type of leader reaches out across the divide, congregating and integrating diverse populations as she builds islands of common stewardship.

Each style, I said yesterday, has strengths and weaknesses. The negative leader can appear, in the heat of the moment, to be strong and decisive. His weakness is that, while he may be able, with fear, to freeze a population in place for a short period of time, the world continues to evolve around him. And eventually he is revealed for what he is – a fraud.

The positive leader also has strengths and weaknesses. Her message is open and hopeful, her vision inclusive and real. The critical weakness is that, while she may be able with some accuracy to predict what will occur, it is unlikely that she will be able to predict exactly when it will occur. Her followers, therefore, must constantly be encouraged and revitalized to avoid discouragement and abandonment of the vision.

To their credit, the positive leaders of the ADAP Association, over the past 9 years have done an amazing job of revitalization and keeping hope alive. (Consider that one of the afternoon sessions was titled “Building a Focus on Healthy Aging for Older Adults Living With HIV/AIDS”.) And to the credit of African American leaders – in government and churches, schools and communities, in business and at home – they have been doing the same, over many decades. Their efforts and history are what is so vividly displayed in this new Museum.

So what did my son Michael say in his book that was so compelling that I turned to it yesterday, and return to it today to share with you?

Page 3: Quoting Emerson, “To interpret Christ, it needs a Christ…to make good the cause of freedom against slavery you must be…Declaration of Independence walking.”

Page 7: Why Words Matter, “Ultimately, Emerson came to believe that ‘America’ itself was a kind of text being read, its meaning a matter of collective decision. It followed that one’s linguistic theory, one’s view of how words generate meanings, had potentially large-scale social ramifications. In suggesting that words were ‘million-faced’, Emerson came to realize, he was suggesting that social possibility was remakeable.”

Page 18: On Change and Diversity, “Emerson writes…’the philosophy we want is one of fluxions and mobility’”.

Page 19: The American Culture, “‘Out of the democratic principles set down on paper in the Constitution and the Bill of Rights’, Ellison says, Americans ‘were improvising themselves into a nation, scraping together a conscious culture out of various dialects, idioms, lingos, and methodologies of America’s diverse peoples and regions’”.

Page 24: American Evolution, from Ralph Waldo Ellison, “We forget, conveniently sometimes, that the language we speak is not English, although it is based on English. We forget that our language is such a flexible instrument because it has had so many dissonances thrown into it ….from Africa, from Mexico, from Spain, from God knows, everywhere.”

Page 25 and 28: Creating Our History, “The jazz musician—who, Ellison says, always plays both ‘within and against the group’ — constantly reflects and redefines the ensemble in which he plays. Likewise the ensemble reflects and redefines the larger community to which it belongs….that ‘anticipatory arena where actuality and possibility, past and present, are allowed to collaborate on a history of the future.’”

This has been a momentous week. We have made progress. But there is much left to be done. This should neither surprise nor discourage. On the final page of Michael’s book, he writes, “An emancipated pragmatism happens whenever and wherever a creative mind or community of creative minds engages in democratic symbolic action.”

Our future is being written now. VOTE.

Islands of Common Stewardship – TLC/Dartmouth/ReThink Health UCRV/Schweitzer Fellowship/RCP

Posted on | September 12, 2016 | 2 Comments

img_5761VIDEO

Mike Magee

A little over a year ago, I made a quick trip to Washington – one day, back and forth, from Hartford, CT. I was there to seek advice from an old friend, Fitzhugh Mullins, as we completed planning for the second decade of the Rocking Chair Project. This early childhood intervention program targets young, economically disadvantaged, expectant mothers, supporting them with a health professional-led home visit which includes the gift of a upholstered glider rocking chair and ottoman as a “gift of nurturing” for both mother and child. The visits, repeated over 1000 times in the past 10 years, include reinforcement of healthy messages, nurturing, and emphasize long term continuity with the health care system.

We had been relying on individual 2nd year Family Medicine residents around the country to identify the target moms, and to follow through with these “high-touch” visits. The challenge now was how best to scale up to the general population of economically disadvantaged families.

Our lead adviser, Yale Professor Emeritus, Ed Zigler (Father of Head Start), told us a long time ago that the intervention was so low cost and powerful, tapping into two critical social networks (Medicine and Family), that it should be offered to entire populations, not just a lucky few individual patients.

Fitz summed up the challenge immediately. He said we were seeking a vertically integrated network with existing distribution channels. In other words, a well organized, efficient, and financially sustainable system that had the ability to identify the target population prenatally, and already was accustomed to making home visits in the immediate postnatal period.

Our next stop was Hanover, NH, to garner the advise from another old friend from the Chick Koop days, Joe O’Donnell, Senior Advising Dean and Director of Community Programs at the Dartmouth Geisel School of Medicine. Joe is a brilliant and empathetic clinician, and within weeks we were introduced to Steve Voight, Executive Director of ReThink Health – Upper Connecticut River Valley. ReThink Health focuses on healthy collaboration and meaningful disruption. In their words, “We spur big-picture thinking that allows leaders to step outside their own frames of reference. This lets them better see how the various parts of the system interact in unexpected ways and determine how and where they can exert influence. We do this by deeply understanding their challenges, listening to diverse voices, and working together to harness the information, insights, and actions needed to overcome entrenched beliefs and disrupt the status quo.”

Steve’s regional organization has focused on two counties in New Hampshire and two counties in Vermont. Through their active and inclusive planning process, they have identified many of the challenges and opportunities, and the key personalities and health service organizations. One of those organizations was the TLC Family Resource Center in Claremont, NH. Joe and Steve introduced us to Executive Director, Maggie Monroe-Cassel, and Clinical Supervisor, Melony Williams. Several meetings later, we committed to working with each other.

We defined four separate goals for the collaboration:

1. To expand the recruitment of eligible expectant moms (with a special focus on teens) into existing TLC comprehensive health programs. The primary strategy is to offer the high quality RCP glider chair and ottoman, assembled in a home visit, to eligible moms, who agree to a comprehensive pre-natal TLC intake interview and to one follow-up home visit.

2. To create a high impact experience, through the RCP visit, which will enhance the relationship between the moms and families and the TLC health professionals, and aid therefore in long-term retention.

3. To include highly motivated, and well-trained, carefully selected medical students from Dartmouth Geisel School of Medicine, and positively impact the formative training of humanistic medical students with a focus on empathy and community service.

4. To reinforce inclusiveness of mothers and family as part of the team and positively impact the future trajectory of family members and child.

The collaboration, launched on Mother’s Day, May 8, 2016, received an immediate boost when two Dartmouth Medical Students, Emily Johnson and Kristen Delwiche, who Joe had been mentoring, applied for and were granted a Schweitzer Fellowship focused on supporting our new home visit collaborative.

Kristen Delwiche

Kristen Delwiche

Emily Johnson

Emily Johnson

Where are we now? We are 5 months into the program. TLC recruitment of new moms into their programs has increased. They have already completed four Rocking Chair Project home visits, and have four new arrivals scheduled for births in the immediate future. The TLC professionals and medical students have blended well professionally. All say the experience has been rewarding. They have gained fresh insights into the home-based needs of economically disadvantaged families, and see important benefits of participation in team based approaches to care.

On every level, we are capturing insights to share and communicate with others in the future. For example, TLCs Melony Williams is presenting our program this October at the Healthy Families America (HFA) 2016 National Conference For America’s Families.  Our two Schweitzer Fellows post monthly updates and will be preparing a summary paper in the future. ReTHINK HEALTH: UCRV is preparing a blog post of our progress together, which in turn will be shared with the national ReTHINK HEALTH program. And Dartmouth is planning a Grand Rounds on our collaboration.

For a health care system which has been historically silo’d, segmented and professionally segregated, the disruptive work of collaboration doesn’t just happen. We need projects and challenges that bring us together and simultaneously unite us with patients and families in their settings and on their terms. Judging at least from this one project so far, our gliding rocking chair is much more than a piece of furniture. It is a vehicle capable of bringing us together; strong enough to support the weight of widely differing professional points of view; and comforting enough to calm and encourage beleaguered families while reinforcing empathetic professionalism which is so often in short supply.

Will this model – uniting the Rocking Chair Project with regional home visitation family services, regional health promoters, health professional schools and students – be scalable? Only time will tell. But this much is already clear, when communities collaborate in caring ventures, those who give gain at least as much as those who receive.

9/11 Is Still Fresh.

Posted on | September 9, 2016 | No Comments

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Mike Magee

Fifteen years ago, I had the honor to recount the stories of 10 boat captains and 10 passengers who participated in the maritime evacuation of Manhattan Island on 9/11 (the largest maritime rescue operation since Dunkirk in WWII). The experience continues to remind me that America is a great country, and part of our “goodness” is not giving in to fear and prejudice. Fear is never a currency that should be supported or rewarded.

Here are some reviews of ALL AVAILABLE BOATS. If you don’t have a copy, I encourage you to purchase one HERE.

The America it portrays deserves a place in your home.

_______________________________________________________

4.0 out of 5 stars
9/11 Still is Fresh
By Ouisie on July 18, 2016
Having just seen the 9/11 monument, this book was interesting.

5.0 out of 5 stars
Good people doing what they can for each other on 9/11
By Manhattan on April 27, 2015
I consider this material the best of all that has been produced about 9/11. It’s about people coming together to help each other in an extreme situation. They hadn’t prepared for it yet they couldn’t have done better if they’d planned for it for years. Leaders rose to the situation. In the weeks after 9/11 the material in this book was on display with audio of interviews of these people and still photos of them. I visited the show several times. It was displayed in two different locations in lower Manhattan.

5.0 out of 5 stars
A much overlooked yet critical segment of 9/11 rescue.
By Maria Pagano on August 6, 2013
I had no idea of all the effort that went into the water rescue- 450,000 people were picked up all along the shoreline of lower Manhattan and taken out of harms way by these fearless mariners. The photographs and stories were startlingly new, fresh, even for me, another volunteer on that awful day.
BklynMom

5.0 out of 5 stars
New insight into a familiar tragedy
By Camilla W. Von Bergen on January 19, 2012
This book is heartening, and provides a lot of insight into one aspect of the 9/11 tragedy with which most of us have no experience. Although most of us saw television or still photos taken from offshore, I do not think many of us focused on the boats, and mariners, heading towards the devastation. I have always had a great admiration for those who, “…go down to the sea in ships.” My admiration is if anything greater now.

5.0 out of 5 stars
All Available Boats!
By John Curran on October 29, 2011
This @mims Twitter post: ‘Moving documentary of 9/11 evacuation by boat shows #resilience of cities[…]reminded me of how humbled and impressed I was after reading how successfuly the evacuation was conducted by literally ‘All Hands’ who came together and made a difference during this crisis!

5.0 out of 5 stars
All Available Boats
By Mary on August 31, 2011
Short read with lots of pictures. Good book on September 11th and very touching story on what happened that day in New York City. A real eye opener that is sad but shows the hero’s on that terrible day. I would recommend it if you want some inside stories on what happened on that day that will always be remembered by all of us. Mary

5.0 out of 5 stars
WOW!
By A customer on June 24, 2003
I HATE READING BUT I SAW AN ARTICLE IN MY BOATING MAGIZINE ABOUT THIS BOOK SO I HAD TO GET. I READ THE WHOLE THING IN 2 DAYS. THIS IS FULL OF INFO THE NEWS STATIONS NEVER TOLD YOU ON THIS DAY WE WILL NEVER FORGET. THIS IS A MUST FOR ANYONE. NEVER FORGET 9/11

 

Precision Medicine vs. Public Health $$$ – NIH Funding Priorities Not A New Debate.

Posted on | August 29, 2016 | No Comments

PaulStarr_1-18-2011Paul Starr, Princeton

Paul Starr’s observations (The Social Transformation of American Medicine, p.370) in 1982:

“In 1964 a Presidential Commission on Heart Disease, Cancer, and Stroke (the DeBakey Commission) which had been appointed at the behest of the Lasker lobby, recommended a massive commitment of federal funds to establish ‘a national network of regional centers, local diagnostic and treatment stations, and medical complexes designed to unite the worlds of scientific research, medical education and medical care.’ The report paid no attention to any environmental, nutritional, or other public health and preventive concerns. Like the report of the Hospital Commission of the 1940s, the DeBakey Commission report was a classic of the kind of myopia that the medical establishment of the mid 20th century confused with visionary ideas. No one, as Elizabeth Drew later pointed out, ever asked whether other diseases such as those affecting children or diseases that could actually be cured might be more worthy of federal effort. The commissions conclusions in favor of a medical assault on heart disease, cancer and stroke were foreordained by the commissions name and its composition (the Lasker lobby as one of its representatives said had a quorum.) The aim was to make medical services more available, but there was little thought as to whether such an investment might actually make a difference in health.”

eliGinzbergEli Ginzberg, Columbia U. Health Economist

And from Eli Ginzberg in 1992:

“I learned several important lessons from my term on the Advisory Committee to the National Institutes of Mental Health(1959-1963): that most bureaucrats measure their success by the amount of money they are able to extract from Congress…; that there was a cozy relationship between the senior officials of NIMH and the academic medical leadership, much like the relationship of senior procurement officers in the Pentagon and the aerospace companies; (and) that fashion and enthusiasm dominate the world of medical ideas and policy as they do other fields.” (from The Eye of Illusion, p.82.)

Mylan EpiPen? What About Medicare Part D?

Posted on | August 25, 2016 | No Comments

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Mike Magee

Pediatric drug prices have led the news recently with the fantastic and purposeful price escalation of Mylan’s EpiPen. With all that going on, it would have been easy to miss the analysis of the complete Medicare Part D year over year costs (2014 vs. 2013) that were recently released. 70% of Medicare patients carry Part D policies. The others are enrolled in Medicare Advantage plans or “stand-alone prescription drug plans”.

Here’s a summary:

1. Total billing tic’d up a bit over 17%, with total health care claims up 3.3% by way of comparison. 12.6% of this was from prescription drugs. CMS delivered $121 billion in 2014 compared to $103 billion in 2013.

2. Nine of the top ten drug contenders (by numbers of claims, not total cost) were unchanged from 2013, and all ten were generics. #1 generated a spend of $748 million. #10 a mere $136 million.

3. If you look at cost, however, the top ten in 2014 were all brand name. In the lead, as you might guess was the Solvaldi Hep C star with a $3.1 billion spend. Then came Nexium (antacid), Crestor (cholesterol), Abilify (depression), Advair (bronchitis/asthma), Spiriva (COPD), Lantus SoloSTAR(insulin pen), Januvia(Type 2 Diabetes), Lantus (insulin pen), Revlimid (anemia). Each of these drew more than $1 billion.

4. There were over 1 million prescribing health professionals.

5. Medicare patients who chose brand name over generics on average pay co-pays that are 10 times higher than they need to. 

Lessons from Ebola in the Age of Zika

Posted on | August 23, 2016 | No Comments

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Mike Magee

In the run up to the Olympics, and now as they have drawn to a close, Zika has been top medical news when it comes to exotic infectious diseases. It’s story has been so compelling that the mosquito borne disease has pushed Ebola to the sidelines – an epidemic which infected  28,616 Africans and cost 11,310 their lives between 2013 and 2016.

The WHO Ebola Response team, to their credit, has recently published their insights in the NEJM. Here are some of their findings:

“The largest numbers of cases and deaths occurred in Guinea, Liberia, and Sierra Leone, but an additional 36 cases were also reported from Italy, Mali, Nigeria, Senegal, Spain, the United Kingdom, and the United States.”

“Since 1976, and before the recent epidemic, there were 23 known Ebola outbreaks in equatorial Africa.”

The first case occurred in a 2 year old boy from a forested area of southeastern Guinea who died within 2 days on December 28, 2013. The causative agent was Zaire ebolavirus “probably acquired from an animal”. In March and April, the problem exploded with more than 100 regional cases. Thereafter, it spread primarily throughout three countries – Guinea, Liberia, and Sierra Leone.

Of the three, Sierra Leone had the slowest spread. Their epidemic affected 8706 and lasted 22 weeks – case load doubling every 5 weeks. In Liberia 3163 were infected over 15 weeks with case load doubling every 2.8 weeks. Finally, Guinea’s 3358 cases occurred in only 9 weeks long but it’s case load doubled every 1.9 weeks, over-whelming resources.

The study stated, “For Ebola, as for some other infectious diseases, roughly 20% of cases can be considered to be ‘superspreaders,’ being sources of infection for about 80% of cases in the following generation… For example, during an outbreak in the fishing community of Aberdeen in Freetown during January and February 2015, EVD was confirmed in 24 people, with infection apparently acquired from a single source.”

Other observations:

“It is conceivable, but has not been proved, that the more explosive spread of infection across Liberia, and within the capital of Monrovia, stimulated the development of more rapid and effective interventions than in Guinea and Sierra Leone”

“Admitting patients to Ebola treatment centers and shortening the delay before hospitalization could have played a large part in slowing the increase and accelerating the decline in case incidence.”

“ The epidemic took 10 months to reach peak incidence (September 2014), but cases were reported for an additional 18 months (until April 2016), and there may be more to come.”

“In the long tail of the epidemic, foci of transmission persisted for many months during 2015, particularly in areas of Sierra Leone and Guinea where symptomatic patients were unwilling to seek medical care, where contacts of patients fled quarantine, and where deaths from EVD (epidemic viral disease) were followed by unsafe burials”

And finally, this lasting truth about infectious diseases and vulnerable populations:

“The critical question now is how to ensure that populations and their health services are ready for the next EVD outbreak, wherever it may occur. Health security across Africa and beyond depends on the resources made available both to strengthen national health services and to sustain investment in the next generation of technologies for Ebola control.”

“Medicaid-for-all” vs. “Medicare-for-all”.

Posted on | August 16, 2016 | No Comments

Screen Shot 2016-08-16 at 8.57.40 AMFamilies USA/Medicaid Expansion

Mike Magee

The verdict is pretty much in – increasing health coverage through whatever means possible, improves health outcomes.

This is especially true for the large numbers of formerly uninsured who are now covered through Medicaid expansion plans offered through the Affordable Care Act. Healthy citizens are not only less sick (which means less expensive), but also more employable and productive. All the more confusing that 19 states continue to defy logic by refusing to sign up for ACA sponsored plans in their states. A careful look at the numbers may help explain why.

Here are a few facts:

1. Each state dollar invested in Medicaid expansion draws $7 – $8 dollars in federal support.

2. Decreases in uncompensated care could save non-participating states around $22 billion and the federal government around $40 billion.

3. In all states that have used the ACA Medicaid offering, savings have exceeded costs.

4. 19 states have refused to expand Medicaid to adults with incomes at or below 138% of the federal poverty level. Were they all to participate, an additional 5 million currently uninsured would be covered.

Resistance to expansion of ACA Medicaid has been led primarily by Republican governors and Republican legislative bodies in 19 states. They fear being left with a big bill, even though the federal government covers 90% of the costs in perpetuity. They also worry that this is simply a strategy to convert the health care system from private to public, and from state to nationally controlled, much as they view the Medicare-for-all plans that have been floated during this political season.

Less often reported is physician resistance to seeing Medicaid patients. This has had less to do with politics, and more about financial self interest. Historically, Medicaid has been a remarkably poor payor in many states, with the occasional exception of obstetrical care. Rates today continue to be set by individual states. So even though you provide coverage, poor reimbursement may limit physician participation and therefore limit economically disadvantaged patients’ access to care.

What many physicians, especially specialists, have failed to realize is that Medicaid now comes very close to Medicare reimbursement levels in most states. In fact, in 33 states, Medicaid reimbursement is between 70% and 100+% of Medicare payment levels. That’s according to Kaiser’s “Medicaid-to-Medicare fee index measure”. Here are the top five best and worse states: 

Best:  North Dakota  141%, Alaska  129%, Montana  104%, Delaware  98%, Wyoming  96% (Wyoming is the only ACA non-participating state)

Worst: Rhode Island  38%, New Jersey  45%, California  52%, Michigan  54%, Florida  56%. (Florida is the only ACA non-participating state.)

But  comparing “Medicare-for-all” to  “Medicaid-for-all” is like comparing apples and oranges. Medicare is fundamentally a national fee schedule with local adjustments for cost-of-living etc. Medicare is accepted by most clinicians and functions with patient protections codified and enforced by a federal agency. It is true national health insurance, albeit administered in some cases though private insurers. Medicaid, in contrast, varies from state to state in its coverage schedule and payments, which are frequently adjusted to reflect individual state financial pressures and priorities, as interpreted by state political bodies.

The expansion of coverage for the poor in America through the ACA Medicaid offering has been a success in identifying the most vulnerable, bringing them out of the shadows, and enlisting them in programs of varying value. This is no doubt progress. But in health delivery, high degrees of variability in coverage schedules, or payment schedules, or consumer protections, is never good.

At the end of the day, as soon as is feasibly possible, we need to build upon Medicare’s national model. After all, if our national taxes are on the hook for 90% of the cost of Medicaid expansion anyway, why should we continue to carry the cost, in financial and human terms, of high state by state variability in performance?

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