Months after the concept paper was published, I’ve finally edited my initial response in anticipation of a revised proposal and public comment period that will soon occur. I’ll likely author formal comments and will submit them to NY and/or CMS. I expect that my comments will mirror those below – at least in structure.
Perhaps others will find this framework helpful in the development of their own comments – hence my posting of them today.
New York’s DSRIP program succeeded in many ways and failed in many ways. I experienced both of these, as the CEO of one of the 25 Performing Provider Systems (PPS) in the state. This essay is my personal view – and while I do still have an advisory relationship with Alliance for Better Health and Healthy Alliance IPA – I am no longer the CEO of either entity. These comments are therefore explicitly mine – and don’t necessarily represent the organization.
Let’s start with some context. What did DSRIP 1.0 get right?
The program’s goal was to improve the health of New York Medicaid Members. As a consequence – “preventable utilization” of medical services and therefore cost would be reduced. With this goal in mind, organizations statewide were formed with benevolence, collaboration, and engagement as guiding principles. This is good. I am certain that the lives of many people were improved and even saved by the efforts facilitated by DSRIP.
Yet we also missed many opportunities to do better. The causes of our missed opportunities were many – but I’ll outline a few as this will help guide our reading of the framework proposed for the next iteration – the Kotter Edition – named after the 70’s era TV show.
What was wrong with DSRIP? Too many and too few. That’s all.
Too many organizations. Managing 25 PPS – many of which overlapped each other in geography – was an administrative challenge both for DOH and our communities. It made DSRIP look and feel like a competition where PPS overlapped, and diminished the opportunities for whole communities to come together and solve fundamental challenges in how the needs of Medicaid members and the uninsured could be met.
Too many targets. The objectives of DSRIP 1.0 – a laundry list of HEDIS measures – made the program difficult to manage “on the ground” and too tightly tied to medical measures of success.
Too many choices. PPS were given choices about which projects they would work on – and by extension – which projects would be funded and measured. The projects were tactically expressed – and therefore too prescriptive – not just defining goals to be achieved – but presuming that DOH knew how goals would best be achieved. In many cases – this mismatch between what to do and how it would be done was the cause of great frustration. While DOH and CMS looked for accountability, they actually handcuffed the program by instantiating accountability as prescriptive demands that simply didn’t fit the reality on the streets. Any innovator knows that learning and agility are imperative guiding principles. This was largely absent from the program – it was waterfall from the start.
Too many dollars (going to the wrong places). This is likely the paragraph that will get me in the most trouble. Here goes: the front-loading of the DSRIP program caused dollars to go to PPS sponsors for setting up the program and for checking boxes (literally – “we had a meeting with so-and-so”) to satisfy reporting requirements and subsequent payments. These dollars were permitted to flow to sponsoring organizations (most of them medical care systems) in advance of any true performance expectations. Indeed – the first ½ of DSRIP funding (so – billions of dollars) flowed to medical care systems in advance of any expectation of improved health or reduced preventable spending. The justification for this was often that there were anticipated losses of fee-for-service revenue – and that the medical providers needed to be made whole in advance of these anticipated losses. As any economist will tell you – payment in advance of something to be done is not an incentive to cause that thing to be done. It’s a handout. Indeed – a disincentive! By half-time of DSRIP – performance started to be the objective – and PPS had to choose whether to be effective or not. In several cases (yes – I have personal knowledge of these) PPS leaders who wanted to do very well on performance (therefore undermining the fee-for-service revenue of their parent organizations) were let go. Yes. This happened. (No – not to me!) The medical systems didn’t really want to change. They fired PPS leaders who did – as a product of rather simple economic decisions. Performance would net them $x from DSRIP, but maintained and maximized fee-for-service revenue would net them $x+$y. Done. Did this happen everywhere? No. This was a minority of PPS. But it happened.
Too few outcome objectives. By focusing on medical definitions of success (generally expressed as HEDIS measures), the program medicalized social problems and failed to explicitly recognize the significant role that social determinants play in the health of our communities.
Too few governing organizations. By permitting (encouraging?) the majority of PPS to be governed by medical care providers, the foxes were guarding the chicken coops. Our organization was an outlier – in that the governing organizations permitted us – in conflict with their own interests – to act in a manner that aligned best with the health of the people we served. This speaks to the integrity of our Board – maintaining their fiduciary duty to do what was best for the organization (and by extension the whole community) rather than (or – ok – in addition to) their own institutions. This was the case in a small minority of PPS – and even in ours – the tension was always there. As our Board will recall – we even bought hats at one point – to explicitly remind them to “wear their PPS hat” when making governance decisions. It wasn’t easy. Had PPS been required to have broader governance – including community-based organizations, health plans, faith-based organizations, Health Information Exchanges, and other nonprofits, we would have had more balanced governance decision-making that would have supported the policy goals of the program more consistently statewide.
Too few dollars (going to the right places). A core tenet of the program was that no more than 5% of the money could go to so-called non-safety-net providers. The definition of safety-net providers explicitly excluded the true safety-net: most of the community-based organizations. This structural flaw caused a cascade of funding challenges that (to this day) plague PPS successor organizations who do their best to get the dollars upstream – so they can prevent downstream cost and suffering.
So with this too many/too few framework – let’s parse the Kotter Edition and see how we are doing. I’ve cut/pasted selected sentences from the DOH document to make it easy to follow here – but (of course) the full document has more detail/explanation. DOH prose has a blue background so you know what’s theirs and what’s my commentary. Since you have already read the concept paper, (warning: pdf) feel free to scroll through the blue sections.
$17 billion over five (5) years to fund a new 1115 Waiver Demonstration that addresses the inextricably linked health disparities and systemic health care delivery issues that have been both highlighted and intensified by the COVID-19 pandemic.
Not a bad start. They even separate “health” and “care” – (as they should) 👍
Indeed, to address the full breadth of factorscontributing to health disparities, NYS will not onlypursue reforms and investment in the health care delivery system, but also in training, housing, job creation, and many other areas
Again – so far, so good. The target includes upstream work. SDOH. Cool. Devil in the details .. How will this work?
Goal #1: Building a more resilient, flexible and integrated delivery system that reduces racial disparities, promotes health equity, and supports the delivery of social care.
1.1 Investments in Regional Planning through HEROs
HEROs, which will be mission-based organizations that build a coalition of MCOs, hospitals and health systems, community- based providers (including primary care providers), population health vehicles such as accountable care organizations (ACOs) and independent provider associations (IPAs), behavioral health networks, providers of long-term services and supports (LTSS) including those who serve individuals with I/DD, community-based organizations (CBOs) organized through social determinants of health networks (SDHNs, as described below), Qualified Entities (QEs) (which in New York are Health Information Exchanges (HIEs) and Regional Health Information Organizations (RHIOs)), consumer representatives, and other stakeholders.
HEROS may be led by a variety of existing and new corporate entities (e.g., LLC, not- for-profit) including but not limited to local departments of health or social services, behavioral health IPAs and other structures formed by regional participants. HEROs would assume a necessary regional planning focus in order to create collaborations, draw insights from different data sources and needs, and develop a range of VBP models or other targeted interventions suitable for the populations and needs of each region.
The primary deliverable for HEROs is a Regional Plan:
Uniform Social Care Assessment.
Measure Selection and Development.
Targeted VBP Interventions.
In each region, the NYS Department of Health (DOH) will contract with a HERO entity, which may be an existing entity or a new corporate entity formed by regional participants, including MCOs, primary care and other clinical and community-based providers, QEs, SDHNs and others. The HERO entity must establish a governing body representative of each constituent group and with balanced stakeholder decision-making authority, along with appropriate sub-committees composed of participants, to collaborate on developing and coordinating the HERO’s planningactivities. With limited modifications to governance structure, some existing PPSs would be ideally situated to function as the HERO entity in a region. Moreover, local health departments could in some instances be well-equipped to serve as the regional HERO, as they already have some of the necessary data infrastructure in place, as well as relationships with other government entities participating in regional planning efforts around SDH needs, such as housing authorities.
NYS anticipates HEROs would extend beyond the period of the waiver and become self-sustaining entities that continue to act as coordinating bodies, engaging in stakeholder convening activities and research and data analytics on regional health equity issues.
Feedback: As I’ll express below – I don’t think the HERO layer in the program is necessary at all – and its description includes a repeat of some DSRIP 1.0 aspirations of true community collaboration that are unfortunately impossible in these days of narrow clinical networks and cut-throat competition in the medical domain among both health systems and health insurance providers.
We need a more pragmatic approach – and that means we scale back the dream that competing organizations will collaborate toward improved population health. Without explicit programs that require value-based purchasing, it simply won’t happen.
Planning. A seed fund for planning simply replicates much of what the PHIP was supposed to do – but never really did – largely because it was under-funded and had insufficient leverage.
HERO, therefore, opens the door to the same challenges we had with DSRIP. Since the release of the draft document – we’re already witnessing health systems and former PPS across the state – begin to quietly jockey for position here – even organizations that explicitly walked away from the DSRIP program when the well ran dry. These should be obvious disqualifiers for any HERO hopefuls – or organizations that seek to participate meaningfully in the waiver. Did the PPS or its parent(s) flush the money to itself and shut things down? If so – noooo. You don’t get to play this time around. You’ve explicitly demonstrated that you care more about institutional success than regional population health. Actions speak louder than … well … anything.
What I like about the idea behind the HERO is that there is one regional entity that’s accountable for population health. Who is best suited for this? To me – it’s obvious: government.Indeed – the government is the only organization explicitly committed to serving in the public’s best interest. The challenge here is that the state government doesn’t have the staffing, infrastructure, or bandwidth to engage regionally – nor should they. Yet regional governments – county departments of health for example – lack the funding, staffing, and experience managing matters that the HERO is imagined to curate. They’d need to staff up – and (alas) they are also subject to the regional political influence that the health systems have, and the proclivities of county executives. I’d not be confident that the counties could manage this seamlessly. New York City is an entirely different game – and I expect that the NYC Department of Health could manage such responsibilities – but there’s only one of these in the state. Perhaps – under NYC DOH’s strong supervision (a majority of Board votes?) – HERO could work in New York City. Elsewhere? No. It’s too much (governance diversity) and too much (fiscal responsibility) to be managed apolitically. Those with political power will retain it, and true public health decisions will be elusive.
More on what I think will work North of Yonkers after we consider the SDHN…
Investments in Social Determinant of Health Networks (SDHNs) Development and Performance
I’m tickled that DOH recognized Alliance:
“Examples of these developing SDHNs include the Healthy Alliance Independent PracticeAssociation (IPA), which described itself as “the first IPA in the nation entirely devoted to addressing social determinants of health;”15 the EngageWell IPA, which “was created by New York City not-for-profit organizations working together to offer coordinated, integrated treatment options that include addressing social determinants of health—housing, nutrition, economic security;”16 and SOMOS Innovation “a full implementation of the holistic care model” and “the next step on the path to culturally competent Value-Based [H]ealthcare.”
So what is it?
Each SDHN would consist of a network of CBOs within each region of the State (which should overlap with the regions and sub-regions that align with HERO development) to provide evidence-based interventions that address a range of SDH. The State would designate regions and select a lead applicant within each region, which may be a CBO itself or a network entity (e.g., an IPA) composed of CBOs. As mentioned above, a SDHN could also be a PPS (or a component of a PPS) that seeks to convert, or have already begun to transition, into a network entity focused on SDH.
The SDHN in each region would be responsible for: 1) formally organizing CBOs to perform SDH interventions; 2) coordinating a regional referral network with multiple CBOs, health systems and other health care providers; 3) creating a single point of contracting for SDH arrangements; and 4) screening Medicaid enrollees for the key SDH social care issues and make appropriate referrals based on need. The SDHNs can also provide support to CBOs around adopting and utilizing technology, service delivery integration, creating and adapting workflows, and other business practices, including billing and payment. These SDHNs will coordinate and work with providers in MCO networks to more holistically serve Medicaid patients, particularly those from marginalized communities, effectively wrapping a social services provider network with existing MCO clinical provider networks.
Exhibit 2: SDHN Structural and Funding Diagram
Social Care Data Interoperability Exchange
The New York eHealth Collaborative (NYeC) and 2-1-1 New York have received funding from the HHS Administration for Community Living to establish a trust framework and statewide governance structure to support collaboration and exchange of community information across existing networks and users. NYS envisions that this platform would serve as the basis for the social care data exchange that regionally-based SDHNs will use across the state, and would be aligned with national standards as they develop.
Well – this is valid but omits some important components of this initiative. As one who has worked very closely with ACL, ONC, and CMS, (and I chair the HIMSS SDOH Committee, where National work is being done to converge SDOH infrastructure) – I’ll remind /inform readers that ACL didn’t just award funding to NYeC for this. They converged three applications into one – and the NYeC / 2-1-1 project is just part of a unified project for New York that also includes Northwell/NowPow and Alliance/ Unite Us. I’m a bit confused by the (intentional?) exclusion of the other two equal partners in this project. It’s a good project, but I’m feeling a bit Rodney Dangerfield here, and – for the record – this project wasn’t selected as a Phase 2 winner.
Shared Learning and Sustainability
The State will leverage the learnings from the SDHNs in order to support the integration of high-value services into managed care contracts and VBP arrangements on an ongoing basis that extend beyond the life of the waiver. While there is ample evidence around the potential for SDH inventions to improve health, advance health equity and better manage health care costs, the research around the effectiveness of scaling the interventions to a regional and statewide basis has not been measured.
NYS anticipates that the demonstration evaluation would examine this question, in order to leverage findings for long term policy changes in NYS, as well as other states.
Well – yes and this is the core responsibility of the SDHN: to invest where investment is appropriate and not invest where it’s not. Since I’m occasionally accused of being anti-academic, I’ll give my detractors more fodder: I don’t think research is appropriate or necessary. This can be done faster with rapid feedback loops of interventions and measurements. Maybe this is just semantics – but the term “research” invokes years of study and papers written in academic journals. We need front-line, agile program definition, rapid-cycle outcome analysis and the ability to change course when the evidence directs us. My sense from the narrative is that DOH imagines that this work will be easier and harder: easier to define initial projects – and harder to know if they work. I disagree with both. SDHNs will make mistakes; they’ll make investments in programs that result in few positive outcomes, and they’ll invest in programs that result in fantastic outcomes. The program therefore needs to allow for (expect) such mistakes as positive steps toward long-term success. Indeed – one measure of early success could be that there were failures! Too few, and we know that SDHNs haven’t taken enough risks. Too many – and – well we need to learn more/faster. Healthy Alliance IPA has been doing precisely this work for five years. Perfect? No way. Getting closer? Yep. Learning every day. But there’s a big missing part. Read on.
Investments in Advanced VBP Models that Fund the Coordination and Delivery of Social Care via an Equitable, Integrated Health and Social Care Delivery System
With the HERO and SDHN infrastructure established, advanced VBP arrangements will support the mid-to long-term transformation and integration of the entire NYS health care and social care delivery system by funding the services needed to address SDH at scale.
Incentive awards would be made available to MCOs (that have participated meaningfully in HEROs) providers and organizations in qualifying VBP contracts approved by DOH. MCOs would be required to engage in VBP contracts with an appropriately constructed network of providers for the population-specific VBP arrangement.
The VBP funds through this waiver proposal would encourage the evolution of the MCO- network entity agreements into more sophisticated VBP contracting arrangements that incorporate health equity design, fund the integration with social care, adjust risk to reflect both the health care and social care needs of their members, reward providers’ improvements in traditional health outcome measures as well as advanced or stratified health equity measures informed by the HERO, and/or use fully prepaid payment models that fortify against fluctuations in utilization based on pandemics. In particular, using socially risk adjusted payment—whether through accurate use of z-codes or the data collected from the uniform social care assessment tool described above—can incentivize and appropriately reward plans and providers for caring more holistically for these vulnerable populations.Prepayment approaches would also be available to providers who are not the lead VBP contractor but are providing care to the lead contractor’s attributed members through a downstream targeted or bundled arrangement.
Additionally, this component of the waiver would seek specific authorities for NYS to utilize global prepayment payment models in selected regions where these arrangements logically apply; that is, where there is a lead or dominant health system or financially integrated provider-based organizations with demonstrated ability to manage the care of targeted populations in that region. In a global model, the lead health system VBP entity—whether part of an integrated delivery system or clinically and financially integrated IPA or ACO—would extend successes and performance across payor types, including Medicaid fee-for-service (FFS), Medicaid managed care, Medicare FFS, Medicare Advantage, and/or commercial plans.
Well .. there’s quite a bit to this part, which is the problem. The foundation here is the SDHN and the HERO, and now – as with DSRIP 1 – DOH wants to bolt on the health plans (rather than incorporating them meaningfully in the foundation) – requiring them to craft VBP arrangements that may be tied to the HERO and/or the SDHN.
Confused? Yeh – me too. It’s a bowl of policy spaghetti – and the drum solo at the end is regional global prepayment – a thinly veiled effort to re-boot the NCIP – which failed to get community support (or CMS support) and died.
Let’s simplify. We have to start at the beginning.
In very dense areas, with highly capable local government – HERO may fit. This is the case in NYC and perhaps a few counties just beyond NYC. Make the government (which is explicitly accountable to the taxpayer) the majority governance authority – and allow that entity to rapidly define health needs and regional priorities. Minimal (if any) planning dollars should be allocated. Get to work. Pay for outcomes, not planning, convening, gathering, establishing or any other gerund.
In “rest of state” (as those of us beyond NYC are sometimes referred to) – there is no need for the HERO – as we’ll see below. County governments – the primary organizations responsible for public health – should receive funding to enhance their human and technical resources – connecting them tightly to the SDHNs and HIEs in their regions – adding epidemiologists, informaticists, and program managers who can help connect regional policies to SDHNs, health systems, health plans, and CBOs. What do we call this? The GRHEO (pronounced “GREE-OH”) – the Government Regional Health Equity Organization. GRHEOs will require (much) less funding than the HERO defines – and will have less responsibility – focusing only on need definition and coordination of county health and prevention services with SDHN and HIE/QE activities. There should be no funding for planning – nor an attempt to govern regional VBP or SDHN activities. These activities can/must be self-governing or they will be neither sustainable nor agile.
The SDHNs should receive zero funding directly from DOH. Yes. Zero. Rather, the SDHNs should receive 2.5% of premium dollars for each attributed member from all MCOs that serve the SDHN’s region – and each of these dollars should be matched by the waiver for the initial three years of the waiver (flowing through the MCO) – falling to 1% for year 3 and 0.5% for year 4 so that by year 5, the programs will have demonstrated clear return-on-investment to the MCOs and they will be expected to maintain 2.5% PMPY contribution to the SDHN ad infinitum, so long as the SDHN performs well. This puts the MCOs right in the mix – where they should be. They are the benefactors of improved health, and the (secondary) victims of persistent fee-for-service. By passing SDHN dollars through the MCOs, DOH aligns their goals with the goals of the SDHN and leverages the SDHN as a trusted broker rather than the passive recipient of funding from the state. The SDHN will have the autonomy – in collaboration with regional government leaders – to select initiatives for investment, primarily by collaborating with CBOs to provide essential services that address SDOH.
It’s essential to understand that SDHNs – by aggregating health plan SDOH investments regionally – will eliminate many of the inefficiencies that exist today, primarily caused by well-intentioned siloed efforts wherein health plans make SDOH investments that are disconnected from each other – and only apply to their own members. For example, one MCO might invest in food, and another in housing. Now – depending on the color of an individual’s insurance card, they can get either food or housing but not both. Yes – I’m over-simplifying, but these problems – expressed well here – can only be truly solved by a convergence of fiscal resources so that they can be rationally apportioned for all.
Redesign the VBP Roadmap to Address Health Equity and Regional SDH Needs. NYS will develop a comprehensive range of VBP arrangements for the HEROs, SDHNs, and MCOs to consider adopting based on the specific populations and needs within each region.
OK .. details matter. We’ll see how this flows.
Advanced VBP Contract Requirements and Funds Flow
The provider agreement entered into by the MCO and VBP network entity would need to implement or build on HERO programs with a specific emphasis on prepaid or global payment models, and address local needs based on priorities identified by the HERO. NYS envisions that not every VBP arrangement will utilize SDHNs as the vehicle for CBO contracting, especially in areas where there is a strong cohort of existing CBOs or IPAs that are already successfully managing the needs of specific populations. However, under the waiver, NYS would give funding preference to arrangements that utilize SDHNs.
Well, this seems awfully complicated. Again – without the HERO, and with direct $$ from MCO to the SDHN (and of course by extension the CBOs) incentives should align perfectly – eliminating the need to prefer organizations that use the SDHN. Medical providers would be crazy not to participate with SDHNs – and health plans can further motivate them. We don’t need DOH or HEROs trying to pick and choose. VBP will happen if (and only if) DOH (and by extension CMS) makes fee-for-service hurt enough. As Adam Boehler said a few years ago when he was Director of CMMI: “I’ve never seen ‘no downside’ work.” Let’s heed Adam’s advice. A pinch of downside risk and this whole thing falls into place. Keep tiptoeing around? We’ll get the same “we’re trying, it’s so hard” excuses.
Leverage Ongoing Primary Care Investments
While moving to health equity-focused and advanced VBP contracts, these models will continue to recognize the important role primary care plays in care management and service coordination. The role of primary care is evidenced by the significant investments that have been and are continuing to be made through the New York State Patient-Centered Medical Home (PCMH) program.
Well, if we’re being evidence-based, let’s carefully consider whether PCMH has really gotten us very far. Most of the principles of PCMH are table-stakes in 2021. It’s a program that’s been around over fifty years. There’s nothing progressive about PCMH anymore – let’s not pretend there is. Primary care – with downside risk, level 3 contracts, and high-bars for quality? Yes! That’s progressive. Plans and providers should receive compelling PMPM adjuncts for increasing levels of risk – making primary care providers engaged participants in understanding and reducing unnecessary acute care episodes, unnecessary medications, diagnostics, and therapeutics.
Capacity Building and Training to Achieve Health Equity Goals
Workforce and training are critical foundations to achieving the health equity goals under this proposal and to developing delivery systems of “well care” capable of serving the whole-person. To provide the SDH interventions through the SDHNs, NYS will need to expand the number of community health workers, care navigators and peer support workers, particularly drawing from low-income and underserved communities to ensure the workforce reflects the community they serve. Workforce training will also support regional collaboration under the HEROs, the SDHNs, and the move to advanced VBP models.
Yes – and all of this can be managed through the funds-flow model(s) I define above rather than through an intricate – over-designed (and likely too-prescriptive) model defined and enforced by DOH and or a HERO. With the right incentive structure, the MCOs, the primary care providers, and the SDHNs can make the workforce investments. If there are jobs, the training programs will occur, and with sufficient funding, the SDHNs can (as PPS did in the past) collaborate with community colleges to create training and/or certificate programs. Why SDHNs and not MCOs or GRHEO? Because the MCOs only rarely collaborate (so training would be siloed) and GRHEO would be too slow to respond to workforce needs. It has to be the agile, committed SDHNs that would lead this work. Input from others? Yes.
Ensuring Access for Criminal Justice-Involved Populations
Based on historical data in New York, approximately 83 percent of incarcerated individuals are in need of substance use disorder treatment upon release. Meanwhile, the share of individuals in New York City’s jails who have mental illnesses has reached nearly 40 percent in recent years, even as the total number of incarcerated individuals has decreased.Incarcerated individuals with serious health and behavioral conditions use costly Medicaid services, such as inpatient hospital stays, psychiatric admissions, and emergency department visits for drug overdoses at a high rate in the weeks and months immediately after release. This population can then be more effectively served as part of the health equity-informed VBP arrangements described above. With this purpose in mind, NYS seeks approval for the following eligibility changes:
Reinstate Medicaid Eligibility and Enroll Incarcerated Individuals 30 Days Prior to Release
Therapeutic Residential Treatment Pilot
While I agree – this section begins the “kitchen sink” part of the waiver draft. Nothing is bad here – but I wonder if these could be folded into the above narrative to allow regions to address these issues with sufficient clarity and sensitivity to local needs.
Goal #2: Developing Supportive Housing and Alternatives to Institutions for the Long-Term Care Population
Overall, the initiative has shown a reduction in the number of emergency department visits and inpatient hospital stays. On average, Medicaid claim costs declined by about $6,800 per person with high utilizers of the programs having an average savings of $45,600. Programs that transitioned individuals from nursing home settings saved an average of $67,255 the first year and $90,239 the second year in housing.
NYS seeks to extend this effort through additional supportive housing programming, which the State expects will be necessary to address downstream effects of the COVID-19 pandemic, such as additional instability in housing for many Medicaid-eligible individuals and families and an urgent need for supportive housing for people experiencing homelessness.
Investing in Home and Community-Based Services as Alternatives to Institutional Settings
Local & Statewide Planning & Coordination through HEROs
This coordinated approach to housing will utilize HEROs outlined in the earlier section, as we anticipate housing to be a universal need. HEROs would conduct an inventory of supportive housing programs in each region and identify the gaps that exist, mapping existing efforts and any gaps by area and vulnerable population.
Statewide Housing and Home-Based Services Initiative
Through this waiver, the State will establish a Statewide Housing and Home-Based Services initiative to consolidate and expand its array of supportive housing and medical respite programs. This initiative will be coordinated across state agencies and result in the development of a comprehensive and unified supportive housing and respite services menu. The services provided could include, among others
Medical respite models of care for post-hospitalization discharges and transitional housing;
Case management and care coordination, including tenancy assistance, rental assistance, transitional support services, and referrals and linkages to care;
Behavioral health supports, including substance use disorder services;
Environmental supports and accessibility modifications;
Employment and vocational services; and
Additional SSI state supplemental funding for high needs populations.
NYS will also reach out to community partners to solicit additional and innovative ideas for new types of services that can be piloted and tested for their ability to enact long-term improvements.
Again – this is another example of DOH separating an initiative that should be converged. Housing insecurity is a social determinant of health. A simpler approach here is therefore warranted, leveraging the 2.5% PMPM payment from the MCO to the SDHN. Regional needs assessment would be performed by the GRHEO and the SDHN, with investments made by the SDHN where indicated. So – yes – we agree completely that DOH and other agencies should coordinate well here – but this shouldn’t be a separate narrative, funding stream, accountability cascade, or governance matter. Keep it simple.
Specific Supports for Individuals with Behavioral Health and Substance Use Disorder Needs
Enroll eligible individuals in Medicaid 30 days prior to discharge from a correctional facility
Authorize Medicaid reimbursement for Critical Time Interventions models to help people transition across levels of care
Expand available services to support reintegration into the community
Yes. This all makes sense – but (again) why create a new silo here? Make reintegration an element of the SDHN’s commitment to DOH and the MCOs. Done. How this gets done will vary by region, because the challenges and available resources (or lack thereof) of reintegration vary by region.
Goal #3: Redesign and Strengthen Health and Behavioral Health System Capabilities to Provide Optimal Response to Future Pandemics & Natural Disasters
Although this waiver demonstration’s primary focus is to address disparities in access to quality health care and social care and achieve an equitable pandemic recovery, the COVID-19 pandemic also revealed that NYS must have a ready-to-execute strategy to respond to a significant increase in demand for acute care services. This includes a greater volume of hospitalizations, higher intensity of care services, and the need to replace disrupted acute and chronic healthcare services that are attributable to a pandemic. Redesigning the healthcare delivery system to efficiently achieve better outcomes in underserved areas during non- emergency times must be done in a manner that also supports rapid mobilization of resources for pandemic response demands on hospital capacity, workforce, supplies and continuation of essential healthcare services and quality care during an ongoing crisis.
(Sigh – note that this section was clearly written by a different team – as they use “healthcare” rather than “health care.” As noted above, the latter is correct.
Pandemic Response Redesign
Physical and IT Infrastructure Preparation and Planning
Training in Order to Respond to Needs and Minimize Disruption to Delivery of Needed Healthcare Services
Develop a Strong, Representative and Well-Trained Workforce
Even prior to the COVID-19 pandemic, areas of NYS were experiencing workforce shortages across the health care continuum. Building on the work from the prior waiver demonstration that ended in March 2020, proposes a substantial reinvestment in Workforce Investment Organizations (WIOs) to focus on the needs of their respective regions and coordinate with the other WIOs across NYS to facilitate a cohesive approach to workforce development and share best practices. Planning efforts will involve a variety of stakeholders, including government entities, labor organization, provider organizations (inclusive of former PPSs with proven workforce strategies), and CBOs. Importantly, this investment would both expand capacity through a well-trained and culturally informed workforce and recognize that training investments themselves function as an important SDH, related to job insecurity and unemployment. Funds would support initiatives targeted at addressing workforce needs and the specific projects outlined for this waiver demonstration, and would include:
Recruitment and Retention Initiatives
Develop and Strengthen Career Pathways
Expanding the Community Health Worker and Related Workforce
Standardize Occupations and Job Training
The workforce components of the waiver draft all seem appropriate elements of the right strategy and yet – gosh – I can’t quite put my finger on it – how we get this all done may (or may not) be through the methods expressed in the draft. For example – I’ve already mentioned above that Community Health Worker expansion may happen organically when(if) SDHN/MCO investment in this domain grows. But we know well that one size doesn’t fit all, and it’s possible that Community Health Workers aren’t what a given market needs. Market forces will be more sustainable – both for expansion and (if necessary) standardization. Several communities attempted both (g) and (h) above through DSRIP, with suboptimal results. This part of the waiver proposal should be re-expressed as a strategic goal – with SDHNs and MCOs collaborating with GHEROs to define roles and then hire the people – eliminating much of the up-front cost and delay of funded planning activities. As I’ve said above – pay for outcomes and expect regional work to define and implement the right programs. If the methods are defined in some office (or home office) of DOH staff, and negotiated with CMS staff, we’ll propagate waste and miss the opportunity for efficiency and truly effective programs.
And here we are – finally – something in my wheelhouse. For readers who haven’t tracked my career – I’ve worked in health IT for nearly 30 years – and (yes) I agree wholeheartedly that robust IT is an essential part of a healthy New York.
Goal #4: Creating Statewide Digital Health and Telehealth Infrastructure
A silver lining of the COVID-19 pandemic has been the opportunity for—and accelerated realization of—widespread consumer and provider use of digital and telehealth care, including tools such as remote patient monitoring, innovative care management technologies, and predictive analytics. Consumers report high satisfaction with telehealth options, with prominent surveys showing satisfaction levels of 86-97%, often higher than for in-person visits.
The State will therefore use waiver funding to create an Equitable Virtual Care Access Fund to assist such providers with these human capital investments, resources, and support.
Significant additional planning and investment is critical to create a robust infrastructure for telehealth, telephonic, virtual and digital healthcare. Through a statewide collaborative group, the State will identify local strategies/solutions for mutual assistance and to also inform statewide standardization of technical requirements, workflows, as well as training and technical assistance to further build the necessary infrastructure to meet the immediate and long-term needs.
The details expressed in this section outline the many advantages of telehealth, e-consults, etc. The Equitable Virtual Care Access Fund would assist medical, behavioral health, and (presumably) other parts of the safety-net such as CBOs, to invest in the human and technical infrastructure so that telehealth becomes a “new normal.” Yes. But once again, the DOH proposal involves quite a bit of planning and rather little trust in the entities that would (see above) have been empowered to address these issues and in fact have already done this. We’ve seen this movie before: in 2009, the HITECH Act, part of the American Reinvestment and Recovery Act, funded incentive money for medical providers and hospitals to invest in information technology. The program(s) – often described as the “Meaningful Use Incentive Programs” – or “MU,” provided incentive dollars for medical providers who made meaningful use of certified EHR technology. The plan was that there would be three stages: 1) Adoption, 2) Connection (interoperability), and 3) Improvement. I was an HHS leader for three years during the heart of these programs, and therefore learned a great deal about how (and how not) to implement policies to accelerate adoption of new technology and new ways of providing health services. Stage 1 worked incredibly well. With the help of Regional Extension Centers (RECs) – thousands of practices selected, purchased, implemented, and optimized information technology. The goals of the stage were clear and yet sufficiently flexible. (Stages 2 and 3 were much more difficult for reasons we’ll not go into now.)
So if the goal is to provide support for service providers to implement and optimize telehealth – why not emulate what worked in the past? Let’s sidestep the potholes on this road ahead, limit “planning” and statewide committees – and use a framework that will get us there without building from scratch and learning the lessons learned before: simply create explicit, simple methods for organizations to apply for Equitable Virtual Care Access Fund assistance for:
Selection and implementation of telehealth tools
Service provider training and optimization
Ongoing Software-as-a-service fees
During the pandemic, Healthy Alliance IPA supported many CBOs and behavioral health providers in the transition to telehealth by purchasing licenses to secure video conference services and donating laptops where necessary. This isn’t difficult. The tools (as any pandemic-era 6th grade student can confirm) are now commodities and after some early security hurdles – are secure, reliable, and ubiquitous. Let’s just do it.
I do see a bit of telehealth myopia here and wonder if there aren’t additional opportunities to assist CBOs and behavioral health providers in the procurement and implementation of functional health information technology. (These folks were left out of the federal incentive programs.) Products offered to these organizations are often not aligned with the ONC Standards and Certification regulatory framework and therefore these organizations can’t participate with health information exchange (the verb, not the noun) as can medical providers and others who participated in “MU” back in the day. Within the allocation to the SDHNs – these organizations could request funding for health information technology to support day-to-day operations, and such funding could be tied to implementation of only products that meet the ONC’s ISA. By invoking a federal standards framework, DOH sidesteps the work required to define and enforce criteria, and aligns New York with HHS priorities and objectives. This is self-evident (to me) yet absent from the draft proposal.
The 2021 1115 Waiver proposal from New York DOH describes an ambitious agenda that does improve on the DSRIP program that was implemented from 2015 – 2020. How does it fare in the context of our “too many, too few” evaluation framework?
Too many organizations. Too many targets.
✅ If we can compress (or eliminate) the HERO – and have very few SDHNs – I think we can check the fist box easily. SDHNs need geographic scale to be effective. Healthy Alliance IPA has been working – through partnerships – in three markets (Capital Region, Adirondacks, and Central New York) and this has worked quite well – making infrastructure investments more feasible and spread over a broader service area, while maintaining “local flavor” of CBO interactions and service optimization
✅ Again – devil in the details, but if SDHNs – in collaboration with MCOs – in a true “trusted broker” model – can define measures of success autonomously – this will work well. The draft proposal does recognize the limitations of medical measures of success (HEDIS and others).
Too many choices.
✅ By avoiding the mistakes of DSRIP – this program avoids the laundry list of tactical programs and would allow regional efforts to define and then focus on what’s important.
🟨 Too many dollars (going to the wrong places). We’ll have to see. The HERO model concerns me – and if left as-is, there is simply too much responsibility put in its hands – with high risk of misalignment with true public health priorities. With modifications of the HERO model as I express above – and funds flow from DOH ⇒ MCO ⇒ SDHN, we solve this. ✅
Too few outcome objectives.
🟨 I don’t see any clear outcome objectives and this concerns me – as does the frequency with which “planning” is mentioned as a solution to our problems. Some strategic planning is always necessary – but as a step 1 toward implementation. The outcomes here that we seek are clear and achievable: All New Yorkers are healthy and happy. How do we measure this? We may be ignoring an easy method: just ask.
🟨 Too few governing organizations.
We’ll see what happens. I’m optimistic that DOH understands what happened and won’t repeat it – but the structure of the HERO could very well replicate flaws of the previous iteration. My GHERO idea – putting local government in control will be a big step in the direction of fixing this – though I do have a nagging concern that politics could still interfere. We have certainly seen this with Covid-19, where elected county leaders made decisions that were in conflict with public health objectives. We will therefore need a way to protect county public health leaders from political consequences – protecting them and making them accountable to DOH.
Too few dollars (going to the right places). ✅ “Safety Net” is mentioned several times, but it’s still not clear if this means what it meant for DSRIP. If so, we have a problem. If we can expand the definition – so we don’t have the 5% problem that we had before – we’re good here. I’ll be optimistic.
So there we have it. It’s a great effort and I suspect that the work is the product of quite a bit of political needle-threading for our colleagues @ DOH. Hopefully, we can sand off the edges, collaborate well with CMS, and get this thing kicked off ASAP.
BLUF – in October, Circulo acquired my little company, Huddle Health. We are now fully integrated into Circulo – and it’s time to describe the rationale for our convergence and some of what comes next.
Years ago, I was on the faculty at Albany Medical College. We had a course called Health, Care & Society wherein students were challenged to learn and think about ethical issues, health policy principles and engaged in conversations on the role of medical providers in our communities. It was a “soft” class that many students seemed to feel was peripheral to what they would do as physicians. They didn’t take the course as seriously as biochemistry, pharmacology, or anatomy.
And this is a symptom of our problem.
Physicians are taught medicine – not health. This is why it’s called medical school and not health school. Our training prepares us well to diagnose problems, respond to those in need, order testing and treatments, prescribe medications and other therapeutics. Notice that much of what we are doing is reactive – focused on managing illness rather than optimizing health.
Over the last few decades, we’ve marketed medical services as the center of our communities’ health lives. But medical services are not the center of any community – and with good reason. As Clay Christensen expresses, our people, products, and processes weren’t designed to optimize health. Rather – they were designed to optimize care (and the revenue that care creates).
This is hard for many of us to really understand. “You mean my doctor wants me to be unhealthy?” Well – no – of course not. We hope. Some consider Fee-for-service to be evil. I won’t go that far. Let’s stick with “misaligned incentives.”
Why does this happen? More volume = more revenue. Incentives generally aren’t aligned.
But there is hope, Luke Sykwalker. As more medical service providers have migrated to value-based payment, interest in health (rather than just care) has grown.
This is good! But it’s just one step on a long path.
Over a decade ago, Eric Dishman described the “shift left” as a way to “get more people on the end of the health continuum with lower levels of chronic disease, lower levels of functional impairment, lower costs of health care, and a higher quality of life.”
His focus was the self-evident migration away from the hospital and toward the home as a focal point for health, but allowing for other service locations and other kinds of services along the continuum. Rather than waiting for problems to worsen enough to merit a trip to the medical office or hospital, Eric argued that the shift left would also enable us to prevent problems – reducing both cost and suffering.
Iora Health started 10 years ago and developed an extraordinary model of person-centered care. Iora’s visionary leader, Rushika Fernandopulle, led the company through a series of saltatory phases of growth and discovery.
ChenMed was built on the foundation of a small practice in Miami and has grown to serve thousands of members in the southeast and mid-Atlantic markets.
Oak Street Health launched in Chicago and focused on value-based person-centered primary care for Medicare Members.
VillageMD empowers primary care practitioners to participate in value-based payment arrangements.
Aledade has built a broad network of independent and medium-sized primary care practices that share analytics infrastructure, processes, and other resources to optimize care experience, quality, and cost.
Each of these companies is taking a different approach, and while one might view them as competitors, we see them as co-travelers – bushwhacking through the forest of fee-for-service in search of a better model.
Most medical providers haven’t let go of fee-for-service, in part because they don’t have the opportunity. These companies (and a handful of others) have forged a way to the future. Yes – they compete a bit with each other, but as a group, they demonstrate to the majority of others a better way.
Huddle Health was created to learn from our predecessors, question the healthcare industry’s assumptions (who/why/how problems are solved), and work hard to meet the needs of the people we serve. Especially members of underserved communities – Medicaid Members and the uninsured. Learning from time that several of us spent at Alliance for Better Health – we knew that we need to focus on social determinants of health as a key element of our work – not just bolted-on as an adjunct or afterthought – but at the core of our work. What we had was a great team and a great model. There is a better way.
Circulo was created to express two guiding principles: first, information technology in general and automation, in particular, is an essential component of the future we seek to create. Things that weren’t possible in the days of paper are possible now. Yet, much of the technical infrastructure created has remained focused on maximizing efficiency and, therefore, the volume of care rather than optimizing health. Therefore, we have demonstrated that technology and automation could change things, but so far, we’ve aimed them at the wrong targets. Second, the needs of Medicaid members and the uninsured have not been well addressed. We can/must/will do better. We need to reinvent Medicaid. There is a better way.
See a theme? Me too.
Our shared sense of urgency, our impatience to make things better, and rejection of the status quo are the ties that bound Huddle Health to Circulo.
We are now one team – committed to making the world a better place as Circulo Health.
Stay tuned for the next post – how we will do this!
Progress is impossible without change; and those who cannot change their minds cannot change anything.” ~George Bernard Shaw
I was asked by a member of my new team (more on that to follow) to share some resources that might be helpful as we migrate toward perfection. Rather than plopping this into a Slack message – I’ll share here so he’s not the only one to benefit.
Since humans are imperfect, any convergence of humans will also be imperfect – as will the products of our shared work. Nonetheless – our goal will always be to make our work product(s) as close to perfect as possible.
Step 1 – figure out where is the organization is now
This is a review of the people, products and processes in place. Are teams in place? are they well aligned? Is there clarity of vision?
For this step – we use the Strengthsfinder 2.0 – available here (digital – test only) or here (hardcover book – includes test). It’s important to really understand what this does (and what it doesn’t do) – and how to use it well. If you don’t have someone with experience guiding you through administration of this – please read this first.
We use Strengthsfinder to identify team balance. Hiring managers will often subconsciously hire others like themselves. This is human nature and natural and unavoidable – without a tool like Strengthsfinder. Consider the strength domains:
Likes attract likes. So a strategic hiring manager will hire strategic thinkers, a “relationship building” leader will hire more relationship builders, etc. The key here isn’t that one strength is better than another. Rather – great teams have balance.
Here’s a team I worked with a few years ago. Each row is a person. Can you guess what the CEO’s strength profile looked like? Yup. Relationship/Execution. No Strategy. Where did the org suffer? Strategy. They were DOING but there was no North Star. The teams were confused and challenged.
And then .. a year later – after some strategic hiring – still biased toward relationships but much more balanced:
Teams that have this balance will support each other well, build trust and develop interdependencies. as they traverse from competition to collaboration. Strengthsfinder is therefore the foundation of organizational maturity. What’s next?
Step 2 – chart a course to Stage 4 of the Tribal Leadership model.
David Logan, John King and Halee Fisher-Wright published this book as a product of work to best understand how to differentiate high-performing companies from those who are more challenged. Here’s the visual:
Ask someone how things are going – and you get the phrase quoted in each stage above.
Very few orgs live at stage 1 (they’d just die) .. nor do many live at Stage 5. The vast majority of organizations live at Stage 3 – which is normal – but suboptimal.
At Stage 3, we put energy into competing with each other internally – in order to find affirmation from superiors and/or stand above our peers.
At Stage 4 – we put all of that energy into collaborating with our peers – maintaining internal drive (yeh – ok – another book) and achieve great things together. Here’s the fun/fascinating part. Many visionary leaders live at stage 5. They don’t notice/understand that their teams live at stage 3. But a rule of thumb is that communication across more than one level is impossible. When a Stage 5 leader communicates their vision, their aspirations, their objectives, level 3 teams hear “compete with each other” and work hard for affirmation – so leaders need to learn to speak in language that their teams can hear. If a team or team member is living at stage 2 (angry) – then we need to offer affirmation and encourage the egocentrism of stage 3! This is counter-intuitive – given that stage 4/5 culture is our goal. But nobody leapfrogs from 2 to 4 .. we need to maximize stage 3 to motivate the traverse to stage 4:
Step 3 – optimize, integrate, maintain focus. Are we finished yet? Well – no. But we’re started. And that’s good. Other stuff to weave in:
I’ve been writing a blog post on this topic for a few months.
It’s gone through several iterations and has survived a half-dozen friendly editors. This post isn’t that post, which still needs honing and will follow in the coming days. This post is the personal prelude – the why that perhaps is important to share before the what.
My decision to go to medical school was long-delayed. Indeed – I took no science classes in college – assuring myself that I would not follow the path of my father and grandfathers – all of whom were physicians. Yet the magnetism of this profession was compelling, once I let it pull me. I vividly recall wanting to do work that was useful and helpful. Auto mechanics seemed appropriate. I rebuilt my VW’s engine (twice) and helped others fix their cars.
But something was missing.
The human part.
And yet – when I finished residency and joined the faculty in the Department of Family and Community Medicine at Albany Medical College, I knew that something was still missing. My idealistic view of our profession was conflicting with the real-world experience: payment was an overlay on nearly everything we did – influencing what we document, how we document, and what decisions we made for (with?) the people we serve. One example: the annual physical. It’s a tradition that still hasn’t died – yet it offers almost zero value, yet the annual physical occupies as much as 20% of the work that’s done in primary care today.
In addition to doing things that are unnecessary – we still don’t do necessary things with sufficient frequency. Consider that about 65% of people in the United States who should have colon cancer screening actually get it. Organizations that accomplish rates of 75% are deemed wildly successful. How has 75% success (a “C” in most educational institutions) become synonymous with great achievement? This makes no sense to me.
Finally – service. While this 2010 video may be starting to show its age, much of the egocentrism of care delivery organizations persists. We medicalize normal variants of human experience, we ignore (or fail to act on) social determinants of health, and we schedule interactions where/when/how it best meets the needs of the providers (most often physicians) rather than the people who are being served. This 2019 Advisory Board survey found that net promoter score for primary care in the United States is -1.2 and notes that “… more respondents said they probably or definitely would not stay with their provider over the next 12 months (45%) than said they definitely would (40%).”
We must do better.
I’ve written previously about why words matter. Some have asked me why I don’t care about care. Oh my. I do! We need a great care delivery system that’s efficient and effective and compassionate. But “care” is not why our professions exist. It’s not (and should never be) our why. Rather – our why is health. If there are better ways to facilitate health than care (there are) we should embrace those alternate paths – rather than propagate the idea that more care = more health.
And recall that the WHO defines health as “complete physical, mental and social well-being and not merely the absence of disease or infirmity.”
So our goal is (and should always be) to put ourselves out of business and facilitate the achievement of health in the people we serve.
This is why – in two posts to follow – I’ll explain why my next career engagement will be the pinnacle of my life’s work – to realize the idealism with which this all started. The world is finally ready for what comes next: the turn of our wheel to change the words and – by extension – everything we do. I will no longer be a primary care physician. My future – and ideally the future of many others – is to practice primary health.
I suspect that you have seen the drawing and blog post describing the difference between equity and equality. It’s a compelling image. Obviously, the shortest child, given equal access to view the baseball game will benefit rather little from such equality.
Yesterday, along with several dozen others, I volunteered at a local county Covid-19 vaccination site. The experience was both uplifting and concerning.
Uplifting: despite an allocation of vaccine that was (much) less than expected, the team – a hodgepodge of retired and semi-retired doctors, nurses, county employees, lawyers and other non-clinical people assembled to build our community’s immunity to SARS-CoV-2, the virus that causes Covid-19. I was impressed with the dedication, attitude, and commitment of the team from the county health department. I was touched by the gratitude expressed – as hundreds of people patiently and thoughtfully filed into the facility to get their vaccines. After giving the vaccine – I was thanked by many for “saving my life.” Alas – my part was was likely the smallest contributor to this – yet, of course, the most poignant 7 seconds – as I delivered the vaccine to its final destination. Indeed – the hope of this event was itself infectious: after giving our first injections, I reflexively attempted a high-five with the nurse (who happened to be a former colleague of mine) at the next station. She appropriately offered her elbow as a substitute to the high-five. It was a good day – filled with good moments that serve as a tangible milestone toward the end of the pandemic.
Concerning: in this county that is ~ 75% white, I saw very few people of color. 100% of the people who received their vaccine from me were white. All of them arrived by car, and all of them had signed up to be vaccinated by using the Internet. While one might argue that the underserved members of our community had an equal opportunity to sign up for the vaccine (now look back at the drawing above) – I would offer that they certainly didn’t have equity. Indeed – a sobering observation one of my volunteer colleagues shared with me was that we saw nobody from the neighborhoods adjacent to the facility we were in – everyone we were vaccinating seemed to be from the suburbs.
I offer this observation without judgment. The state and county leaders are focused on getting as many people vaccinated as possible. Vaccine supply is limited. They are doing their best – and I don’t think we can/should change the great work they are doing, or question their motives and commitment to health equity or social justice.
Yet we – as a community – can do better. We need to create an adjunct to the programs that now exist – to allocate vaccine explicitly for the underserved and implement outreach that meets them where they are: create equity.
So we will. With the counties, the federally qualified health centers, and community-based organizations – we’ll begin work yesterday to create this equity and get our underserved communities protected.
Re: journalistic style. Is it ‘health care’ or ‘healthcare?’” I use the rules of the “AP Stylebook” for journalists with few exceptions, but one of those is that I write “healthcare” as a single word. I don’t have a strong feeling either way , but the one-word variant saves space without sacrificing (although I acknowledge that (“medicalcare” or “hospitalcare” don’t work).
The difference between these two terms is about more than house style or personal preference. The term healthcare–one word–refers to an industry and the system of providers within it. But health care–two words–is about improving health and caring for people, especially when it comes to treating populations. The current trend toward population health is about making communities healthier by supporting preventive care and wellness. The goal is to provide health care–in order to keep people out of the healthcare system.
And while I can’t deep-link to the AP Style Guide (paywall) … they offered a tweet about this almost exactly two years ago:
We've changed our style to one word for “homepage.” We added “smartwatch” and “timeshare” as one word. But: “health care.” #APStyleChat
The short answer is that “healthcare” has taken on more meaning as a closed compound word to describe the system/industry/field than is captured in the two separate words “health” and “care.” “Health care” does not sufficiently capture the increasing demand for nuance and specificity in referring to topics surrounding the practice and facilitation of services to maintain or improve health. Healthcare represents the political, financial, historical, sociological, and social implications of a system that provides health care to the masses.
I disagree with Jodi and Victor that “healthcare” refers to an industry and a system of providers, though this opinion often appears when one does a google search on this topic. I also disagree with Jodi that “the goal is to provide health care.” No. The goal is to improve health. Sometimes the way we do that is to provide medical care, but let’s not assume this is the only way to improve health. Indeed, we know it’s not.
But I agree with most of what Jodi writes and her conclusion is spot-on: words matter.
I don’t believe that “healthcare” should be used at all. There are many (better) ways to describe the industry: the people, the providers, the practitioners, the care delivery organizations, etc. Indeed, lumping this all together, as Victor argues, loses the nuance and specificity that these other terms express.
: regard coming from desire or esteem a care for the common good
:CHARGE, SUPERVISION under a doctor’s care
: a person or thing that is an object of attention, anxiety, or solicitude The flower garden was her special care.
: to give care care for the sick
So it’s clear that health and care are different. Alone, this isn’t reason to avoid a neologism. Indeed, many words do just that woodpile, headache. As Victor notes above, a closed compound word is one that combines two things (usually nouns) that now assumes a new meaning by itself: basketball, keyboard, popcorn. I’ll acquiesce that if folks are arguing that “healthcare” is a benign compound word that describes an industry, they’re grammatically correct. But we choose not to use many words and phrases that are grammatically correct. (I’ll avoid the hot water that a few examples here would get me into.) Grammatical correctness can’t be only bar; the words need to help us say something meaningful.
Indeed, the words we use convey the world we see (or the world we wish to have).
Let’s look past the naiveté of “benign compound word.” This is the point that Victor and Mr. HisTalk seem to miss: when we separate the words, we share an important message, reminding ourselves and those with whom we communicate that health and care are not synonyms. As a physician, I see the semantic conflation every day in my peers and (sadly) in our medical students and residents. One of my hypotheses is that it is the very egocentrism of our profession(s) that cause us to conflate health with care. If people could be healthy without us – what are we here for? We remind ourselves (and our communities) of our importance by suggesting that care is a necessary precedent of health.
“Of course we don’t do that” you say …
Consider the so-called “annual physical exam.” This is well documented (summaries here, here and here) to increase the quantity of care, yet cause no positive health improvement. Yet its tradition has taught generations that more care = more health. Think about the phrases we use: (that Covid-19 is making us reconsider) … “come back to the office if you’re not better in 2 weeks.” “I can’t refill your prescription because you haven’t had your annual physical.” “It’s probably nothing but I need to do some tests so let’s schedule one office visit for the tests and another to discuss the results.”
This is “healthcare” – the compound word. In connecting these concepts linguistically, we propagate the flawed principle that care causes health, and while care may in many cases be necessary, our goal is better health. There are many examples of how more care is not more health. Great health economists and health journalists have documented this eloquently.
We have evolved language to reflect our evolving (improving?) sensitivity to race, religion, sexual preference and gender. For example, when I am careful to clarify or seek clarification of preferred gender pronouns, I send an explicit message of my awareness of the importance of these preferences to many people. It’s a movement. When we all do this, we remind each other to move past our decades of assumptions so that we can speak (and think) in a manner that is inclusive and respectful.
So the separation of health and care is a similar movement. It’s a linguistic statement that reminds us of a policy goal: these are different concepts and they must be separated culturally, politically and economically. If we are successful in doing so, we’ll make different (better) decisions that will improve health and reduce unnecessary care.
This is why it’s so important to cleave “healthcare.”
Prognosticators offer narratives of what the post-pandemic world will look like, and we see leaders invoke Rahm Emanuel (or was it Winston Churchill?) in their expressions of how they will “Gretzky” this.
Here’s my take. None of this is particularly prescient, but I’ve been asked a few times what I think comes next. My real answer? I don’t know. Some guesses below – all brought to you by the letter p.
Place – where things will happen will never be the same. The assumptions we have made about where things need to happen will evaporate, as many of them already have.
Where do we see a physician? I can vividly remember telling a group of medical students as recently as three years ago that they would practice virtually. They disagreed, parroting what they had been told by their mentors: this “video medicine” thing would never work. “The patients need to come to the office.” What have we learned from the pandemic? At least 40% of the time, a video conversation is just fine.
Where does learning happen? E-learning has been around long enough that we know not to call it e-learning. It’s education. Education happens when people test hypotheses together, make commitments, finish projects. Learning stuff isn’t education. We know that much! Non Satis Scire. If you’ve not listened to this episode of Hidden Brain, please do so. We’ll wait for you here.
Where does business happen? Sign a document. Have a meeting. Meet with the Board of Directors. Hire an employee. Notarize a document. Get married.
Poverty – we have seen only the tip of this growing iceberg. The economy won’t recover right away, and we know that despite the science that SARS-CoV-2 infects all humans equally, we also have learned that COVID-19 harms the underserved much more than it does others. Is the pandemic going to (finally) cause us all to screen for and make the necessary investments to address social determinants of health? I sure hope so.
People – “social distancing” is in fact a misnomer. We’re physically distancing. Social connections can, should and must continue to be close. Vivik Murty’s new book teaches us that we need each other.
We need connections, we need to listen, to love, and learn from each other. We needn’t be in the same room for this to happen.
My uncle turned 85 last month and our extended family all gathered for the affair – from California, New York, and Austria. This wouldn’t have happened before: those of us who weren’t present would have “missed” the party.
Video conference meetings @ work are vastly better than conference calls. Now that there is an expectation that we see each other, the fidelity of conversations is better. Indeed, in many cases, I’d argue that it’s better than a big meeting room with people 18 feet apart. We can see each others’ faces. The nuances of reactions / responses are not lost.
I’ve had a few conversations recently with elected state officials, and I’m reminded that speaking plain language always helps. Here goes:
We all agree that fire stations are a good thing, right?
And we agree that we don’t want them to be busy …
So if the firefighters are always watching Three’s Company reruns, that would be good. We still pay for the fire station. We still pay the salaries. Happily.
Therefore – paying firefighters more for fighting more fires would be silly: their financial success would align with hardship in the community.
But this is how we pay medical providers: more sick people = more $$.
We have a social compact: everyone agrees that we should pay for fire stations (infrastructure) and firefighters (humans) to be ready for fires. We all pay for this with our taxes. It’s the most efficient way for us do this.
Shouldn’t we have a social compact that would cause everyone to agree to pay for hospitals and medical offices (infrastructure) and medical providers (humans) This would be efficient and effective. Then if the medical providers were idle most of the time – it would be because the community is healthy. Nobody would complain of reduced revenue due to low volumes of emergency department visits. Kinda like what Maryland did. Seems simple. Why not?
.. and now for something completely different. For me, writing a blog isn’t about getting clicks, earning ad revenue (no ads here) or getting tweeted. I write here to share insight that may be helpful to others. I started writing this in 1999. Topics vary, but I don’t think I’ve blogged yet about car repair. My last big home improvement project (replacing the tank water heater with an on-demand tankless one when the former died suddenly) was well covered on Facebook. I think my rationale there was: “hey friends, look what I did!” Facebook is good for that. Many people have made the tank-to-tankless conversation. The Internet didn’t need to learn that someone else did it.
But I don’t know that anyone’s done what I did yesterday and I can’t imagine that I’m the only one who has experienced the predicament. So a blog is the best way to share a new solution to a common problem. Others will search for the topic and some day, someone will use the information I post here and their life will be better. That is (ideally) what blogs are for.
The problem. We have two cars and a two-car garage. As anyone with a two-car garage knows, (especially with 20 years of accumulation) this is by definition a tight fit. A few weeks ago, the passenger mirror housing of our 2017 Toyota Highlander was damaged (the identity of the driver is not relevant to our story). The mirror itself was ok, but the plastic parts and the turn signal light were broken. This mirror has a “puddle light” (shines down on the ground when entering/leaving @ night) and is heated and has a blind-spot monitor and has a camera for the parking assist camera system. There’s a lot in this thing.
A new mirror assembly, part# 87910-0E292 is $1290 from Toyota or $863 from Toyotapartsdeal.com. I found some used for ~ $500. Why so much? Because of all the “stuff” this mirror has in it – especially the camera, which can be purchased separately for many $$.
There are aftermarket mirrors for as little as $65, but they just have the mirror. No camera, no wiring for the camera, no blind spot monitor. Some have heat, which is valuable here in Upstate NY, and others even support motorized folding, which could have prevented this, but I’m not sure how we’d integrate that feature and control it from inside and these mirrors were missing features we have. The car’s computer complains when stuff it expects (camera especially) are not there.
As I looked carefully at the Toyota parts manual and studied the Toyota service manual (I purchased online access to it for 2 days to do my homework) it became clear to me that the parts I needed (the plastic backing, the plastic “visor” and the (mostly plastic) turn signal light) were all identical to those in the “basic” model of this mirror, part #897810-E143. $244 from the dealer and $173 from Toyotapartsdeal. What’s the difference (other than $690) The less expensive mirror has few of the extras: no puddle light, no camera, no blind-spot monitor (really just a light that connects to the computer). The plastic housing is the same with two exceptions: a) At the base of the housing, there is a hole into which the assembly for the puddle light and camera fit. b) In the back of the housing, there is a hole for where the camera wiring harness plugs into the wires that come from the door.
Here’s a photo of the hole in the bottom. The lower right corner is gone (due to the collision with the garage door frame) and in the upper right you can see some of my practice cuts. More on that shortly. This hole needs to be precise, so the camera housing fits in properly. Misalignment of the camera is bad: it will mess up the collision avoidance system and the images that the parking assist monitor won’t work. The other hole isn’t as important: just need to have a hole there so the cable can be attached/detached.
So the absence of a ~ 3″ x 2″ hole in the bottom of a plastic part is the difference between spending $173 or $863.
I ordered the $173 part. The first thing that happened was that the (very good) support team at Toyotapartsdeal.com noticed that this wasn’t the right part for my car and sent me a message:
The proper RH mirror is 87910-0E292 @ $863.21 and the cap is 87915-0E040-A0 @ $52.90.
Would you like to change your order?
I don’t need the cap – I have one and it’s not damaged – all I really need is the black plastic housing and the partToyota calls the visor – neither of which it seems I can buy separately. All of the electronics work – so I’ll swap out the innards from the mirror I have and will need to cut a hole in the bottom for puddle light and camera. Oh well. Not perfect but better than spending an extra $700!
They checked again (I got the same email the next day) and called them to make sure we were on the same page.
The package arrived on Saturday morning.
Step 1: disassemble the new mirror to get the parts I want. The key to this step is to remove the mirror itself from the housing. This is easy but must be done right or you’ll break the mirror. Youtube helped some here, but if you try this, do it like this and not like this. The second way – you’ll break the mirror. I broke the mirror when I removed it from the new assembly, but fortunately, when I removed the old mirror from the old assembly, I didn’t break it (used method #1) so all was well. Be careful. Use your hands, not tools. Hold firmly. I also warmed it with a heat gun and sprayed some WD-40 in there too – thinking that softer plastic (subfreezing in the garage) and some lubrication might help. Too many variables to know what caused the better outcome. It worked.
Step 2: remove four torx screws. I’m guessing that these were torx #8. Pretty tight but came out after some coaxing. This holds the back housing to the visor – trapping internal parts: the mirror arm, turn signal light and the mounting base with adjustment motor/electronics. Once these four screws are out, the whole assembly can be (very carefully) separated with some plastic auto clip removal tools like this. $12 on Amazon if you don’t have the kit sitting somewhere in your garage (which is why it’s so full).
Step 3: measure, practice, cut. At this point, I did the same on the existing mirror on the car. What’s nice is that I didn’t need to remove the mirror assembly from the car, which means I didn’t need to remove the door panel, etc. I removed the mirror (see above) and the torx screws, and the cap (which wasn’t damaged so I didn’t have to buy a new one for $50. After disconnecting the wires (and taking photos so I could be sure that the wires go back in the same places), the visor, mirror and housing came off easily. Now I could carefully measure and create a paper template for the hole that needed to be in the base of the housing. I then practiced cutting holes in the plastic on the old housing – to see what was the best way to cut the hole with maximum precision and minimal local deformation. I tried a soldering iron with “knife” tip but a dremel tool with a tiny cutting wheel (like this) did the trick. These things break easily as they’re very thin. I had five of them and used all five. As you can see from the photo above – the opening has a little step-off shelf that the camera-puddle light assembly fits into. I did my best to recreate this with a dremel grinding tip. It almost worked: when installed, there remained a ~ 2mm gap at the leading edge of the camera assembly because the plastic clips that hold it into place didn’t “grab” tightly into the housing base. I probably could have made the shelf deeper but I didn’t want to make it too deep as this would have weakened the plastic – might have broken it.
Step 4: make things snug. To help this fit tight, I clamped the parts together and used epoxy to hold this thing in place forever. Yes. Forever. I won’t be replacing the camera assembly. Once the epoxy cured, I remove the clamp and was pleased to see that – while not perfect – it was pretty close. An astute observer would see that the little shelf the camera housing fits in is a bit rough – definitely not factory-made. Oh well. Can’t see it unless you bend down and look under the mirror.
Step 5: put it all back together. Place turn signal light in its little slot. Go to car. Housing goes in the back, visor goes in the front, sandwiching the arm and electronics. First, plug in the light .. then the camera – making sure the wiring harness goes through the right little slots so wires don’t get caught when mirror moves. Next, replace the four torx screws – pulling everything together. I screwed them all in halfway – then made sure all the plastic parts lined up well – then screwed them in the rest of the way. All good. Now replace the mirror: attach the wires for blind-spot warning light and heater, then snapping it into place with a gentle but confident push. Finally, the cap goes on the back and it’s done!
Tested. Everything works perfectly. The manual says we should recalibrate the collision avoidance system (camera alignment may not be the same). I don’t have the software for that – so if we do it- we’ll have to go to the dealer. Not sure how much that is or if it’s necessary. More homework. The images that the parking assist monitor creates are the same – no blurry gaps etc – so I think the camera – if not in the same position – is almost in the same position.
Total time from opening the box to completed project: 7 hours including dinner break, dog walk, thinking/practicing hole-cutting. If you have to do this, I suggest: a) practice hole-cutting ahead of time. If you have a friend with a router (ideally one mounted or mountable in a table) this would help make a perfect hole with the right step-off shelf.
If you want the parts I didn’t use/need – grab ’em on ebay. I’d rather not throw them out.
Final note: Toyota – why don’t you sell the plastic parts by themselves?! This would make such a repair quick, easy and very inexpensive. I’d have gladly paid $100 for these parts (that probably cost $5 to make) that we know you make every day but (for some reason) won’t sell unless they’re part of a $1200 (list price) assembly. Argh.
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