Social Care Networks – NY

The initial RFA for New York was posted weeks ago and got rather thorough coverage so I didn’t need to discuss it here – though (predictably) I have many thoughts on the matter.

Hot off the press today is an addendum. It’s a pdf but I’ve chopped it off so the link over there 👈 is just the 1st two pages of the addended document – all of which is here ICYMI.  I’ll review the addendum (changes in red) below with some commentary:

AddendumMy Comments

Note that this constrains the participants. Removing “including” means that others need not apply – clearly this precludes hospitals, health plans, or BHCCs from applying unless they were PPSs before.

I think this one just fixes a typo / forgotten word.

I’ll take this opportunity to get on my soap box to reiterate the reality that this requirement is a big deal, and a very good policy decision that DOH made in the crafting of this RFA.

More than 1/2 of the governance needs to be from CBOs. 

This would disqualify the vast majority of the DSRIP PPSs from the previous waiver, unless they play some sort of jujitsu by creating new daughter entities in (very) short order and have those entities do the application.  The policy goal here is clear: take the control away from the incumbent (medical) enterprises that still generate the majority of their revenue from fee-for-service care and therefore have conflict of interest with the policy goals of the program – which is to invest upstream – thereby reducing the quantity of fee-for-service care – especially acute care.  We saw (and felt) this all-too-often in DSRIP.  It’s great to see that DOH is taking this seriously.

DOH will be on the lookout for the jujitsu governance shenanigans and will disqualify applications that lack transparency of true CBO controlled governance.

Relaxing this requirement a bit – which I agree is appropriate.  Federal EINs are easy to come by – and this adds agility to the SCN.  Agility is necessary.  SCNs will need to be able to add and delete entities quickly so they can respond to the dynamic needs of their communities, and to hold their collaborating entities accountable.  Without this agility, SCNs will fail to accomplish their objectives (as did many PPS).
a) Removing 3 meals a day without constraints.  This may have been seen as a loophole too-big-to-retain, and may not have sufficient evidence to support trie ROI for the program with reduction in total cost of care.

b) Specifying that MTM is expected and that there needs to be a clinical justification for such comprehensive food assistance.

c) $1M as an upper threshold for CBOs would eliminate several of the effective CBOs such as Jewish Board in NYC and Catholic Charities upstate.  

 

Health > Care, Border Runs

November will mark the beginning of the 24th year of this blog.  

While my posts are far from frequent, I hope that each one is helping others in some way. 

That’s always been my goal.  Along these lines, I’ll offer the answer to a question I was asked by a start-up health IT company yesterday, and will also outline the process for the Costa Rica ==> Nicaragua ==> Costa Rica border run, which is both necessary and relatively easy.  

Health > Care

“Dr. Reider – why are you interested / willing to help our little company?”

Some context – and then my response. 

(After – “hey – don’t call me that.  Dr. Reider was my dad!”)

I have worked @ the intersection of health and technology for nearly three decades.  I am now realizing that despite my nearly adolescent playful demeanor, this makes me an old-timer.  I have participated in nearly every kind of endeavor in the industry:  I’ve worked for investors, served on boards, started companies, killed companies, worked for government, worked for large publicly traded companies, health systems, and have served as an advisor to companies of all shapes and sizes.  In June of 2023, my wife and I moved to Costa Rica – taking advantage of the sabbatical she had earned in her role(s) at an academic institution for the previous decade and a half.   I have expressed rather publicly that “work is overrated” and started only doing things I enjoy 100%.  No collaboration with people who are hard to be with, no working for a paycheck just to do something.   Avoiding “work” is not the same as being idle.  We’re both very active and even though we’re not technically working – we are both doing things – some of which generate revenue.  But we’re picky about what we do.  We need to be doing things that are perfect fits for our values, for our strengths, and for our own well-being. 

It’s an incredibly privileged place to be. 

I get that.

And I am grateful that we’ve been able excel professionally in a manner that enables us to do this. 

We can be picky.

So what are the criteria?

  1. Health > Care.  This is my shorthand for how a company prioritizes its work.  Are we trying to maximize revenue?  Or are we trying to maximize the health of the people we serve – and (no margin no mission) earning money as a product of better health?   In this era of value-based payment, one would think that it’s easy to find companies with a PRIMARY focus on health (and therefore less of a focus on maximizing care / service / encounters, etc.) but this is actually quite rare.  Even companies that purport to participate on VBP programs – when one peels back the covers – can have transaction models that rely on selling more of something.  More things sold (encounters, DME, band-aids, etc.) means more sick people or more needs == more revenue.  This may be pragmatic and I respect the needs to do this – but it’s not where I want to spend my time.  So I say “no” to anything that violates my “Health > Care” criterion.
  2. Good people.  I don’t just mean kind people or nice people.  I also mean: people who are easy and fun to work with.  If we are not having fun – no-go.  I only collaborate with fun people.  And – yes – of course – no ass holes.  
  3. Learning.  I’ve been at this nearly 3 decades, but I have a ton more to learn.  So if there isn’t an opportunity for me to do something novel – learn a new culture or a new skill – then it’s probably better for me to say “no thank you.”  And so I do that too.  

 

That’s really it.  Three criteria that I apply to every opportunity.  If all three are 👍 – then we are ✅ and I’ll do a consulting/advising thing with the company.  Right now, I am doing this with ~ a handful of companies, and I don’t even think of it as work.  It’s all fun.  I need no more.  It’s perfect.


Border Runs

This section is written for a different audience, but (I hope) is equally useful.  US Citizens who live in Costa Rica have a few options for how to manage things.  Technically, until we are residents, we are tourists.  Tourists are allowed to own cars and homes and businesses.  It takes time (and quite a bit of paperwork) to become a resident – so while that process is ongoing – one remains a tourist.  Tourists are allowed to be in the country for 180 days. (This recently was changed from 90 days.)   If you overstay your visa, there is a hefty fine and the next time you try to re-enter the country, you might be denied.  So what does one do?  The border run.  I did that yesterday with two more experienced friends.  Here’s what to do.

a) Drive to the border.  For us, this was driving the ~ 2.5 hours from our little town of Brasilito to Peñas Blancas, the border town on Route 1 – the Pan-American Highway, a road that starts in Prudhoe Bay, Alaska, USA, and ends in Ushuaia, Argentina. While it’s incomplete in the Darién Gap between Panama and Colombia, it is roughly 19,000 miles long.  We were on it for about 100 kilometers.  The last 8 kilometers there were tractor-trailer trucks backed up on the side of the two-lane highway – making it into a one-lane highway in many places, despite bidirectional (two lane) traffic.  The trucks are all waiting in line to pass through the border on their way North.  The delay is not hours but days that these truck drivers wait in line to pass.  Step #1 is therefore to carefully drive past the trucks while not ending up in a ditch.  

b) Navigate the Costa Rica side of the administrative process. 

Follow along on the map:

1) Begin by parking your car.  Yesterday, we parked under a tree at the red circle.  There were some guys there hanging out doing who-knows-what.  A tradition in Costa Rica is that a local with often volunteer to watch your car for a fee.  You generally pay the fee afterward when you know your car has been safely guarded.  1000-2000 colones is fair in 2023.  I can remember when 500 colones ($1) was common but it’s more now.  We parked and a guy motioned to me that he would watch the car for me and I nodded and told him I’d pay him when we return. 

2) Walk South (back into Costa Rica) about 30 yards to a little green building.  This is where you pay your exit tax – which is $8 – payable in either US dollars or colones.  Get the receipt (the guy there put it in my passport) and now proceed to immigration.

3) That’s the green circle above.  It’s a white building with BCR (Banco de Costa Rica) signs.  There’s a BCR ATM there – maybe that’s why there are signs.  Inside – proceed to the desk, present your passport with the exit tax receipt and Chunk Chunk – get it stamped and you have now legally departed Costa Rica.  No questions here.  Super easy.


4) Walk North along the road.  Dodge cars and trucks if necessary.  Now you are leaving Costa Rica!

The green circle is here for reference – that’s where we left the Costa Rica Immigration office.
Walk North along the road and at one point (orange circle) there will be a person or two waiting for you.  Hand them your passport.  They will look at the photo and at you and hand it back to you.  Keep Walking.

5) Nicaragua immigration.  The white building (light blue circle) is your next destination.  About 200 meters past the technical border – where you showed your passport. At the door, there is a person collecting the tax for Cardenas Rivas, the local municipality. This tax is $1 US.  You should have ones with you.  They can give you change if you have a five but it’s best to have some ones handy. You’ll need another later.  They will give you a receipt but nobody will ask to see it.  Wait for a minute in line (my wait was a minute but it can take an hour as well – so YMMV). Answer the usual immigration questions (What is your profession? Where are you staying, etc.) I told the guy I was walking back to Costa Rica in 5 minutes and he nodded.  Chunk Chunk.  Stamps on the passport and pay a $3 US fee.  Get receipt.

6) Nicaragua departure.  After immigration, walk through to the other side of the building and back in the (other) front door and pay the municipality tax again for $1.  Get receipt again. Now back to an immigration officer at the window.  Fewer questions this time.  More Chunk Chunk.  $3 fee.  Another receipt.  Done.  

7) Walk back to Costa Rica.  At the physical border, you may (or may not) have to show your passport to a Costa Rica immigration officer.  We did but my travel partners said that’s unusual here.   Now back to the other side of the Costa Rica immigration building for re-entry.  No fee here.  Show the passport and show (on your phone if necessary) proof of a ticket that you have purchased (bus or plane) to depart Costa Rica at some point.  You can buy a refundable plane ticket and cancel it tomorrow.  Seems odd that they do this since they know you may just cancel whatever ticket you have and stay 179 days and come back here to the border but they want to see it.  I showed by receipt for a flight two months in the future on my cell phone.  The officer looked at it and Chunk Chunk – stamped my passport and wrote in 180 days and I was done.

Now walk back to the car.  Pay the guy whatever you like (2000 colones made him very happy) and brace for the scary 1st 8 kilometers home.

On our way South, we stopped at the beautiful Mirador de La Cruz for a quick drink and then a perfect lunch at teeny tiny Soda Sazon Cruceño.  Both highly recommended and only moments off Ruta 1.

ChatGPT Builds a Scan Server

Printers share attributes with fiberglass boats in that they do last a long time – especially if well cared for. 

We’ve had an HP Laserjet 1320 in the house for decades and it’s been quite reliable.  Our challenge is that it’s a USB (or parallel port) printer and we’ve struggled with the network contraptions I’ve built to connect it to our home network – so when I found a printer that uses the same toner cartridges, low page count, embedded scanner and networking capability on eBay – I jumped and spent $80 to upgrade us to another (very) old printer.

So long as the hardware works – we’re good – right? 

No.  What I learned from this little escapade is that unlike the Day Sailer – printers can be made obsolete by the companies that built them by making the software incompatible with the legacy hardware.   

(You may wonder why I chose this path.  The short version is that toner is expensive and we have plenty of it, I don’t like inkjet, we only rarely print things but when we do, it needs to just work, and I like the thought of a low-stress MFP that can scan and (gosh) even fax or copy.)

Things started well:  the printer has an RJ-45 jack and I plugged it into the network, it got an IP address and the computers in the house were able to find it and print quite easily using native drivers.

Scanning was another matter – hence this post.

a) The device is an HP M2727nf MFP
b) HP has software for scanning that runs on Macs and PCs.  It looks like it’s going to work (it “sees” the device) but it does not work – and HP’s site confirms that this printer isn’t supported by HP Smart – the software that seems to be replacing all previous products.  
c) Neither Mac OS nor Windows 11 will let me install older versions of HP scanning software

So … what to do to scan?

The sort version:

a) Find Raspberry pi in basement
b) Reinstall the OS
c) Install SANE (Scanner Access Now Easy) 
d) Install Dropbox (so I can get the scanned files from anywhere – even when not @ home)
e) Make a script that scans:

#!/bin/bash
DATE=$(date +"%Y%m%d_%H%M")
scanimage --format=pdf > ~/Dropbox/Scans/$DATE.pdf

e) Automate the script with a cron job
f) Fix, enhance.

Bottom line: this works. Plop paper in the feeder, wait 59 seconds or less (the cron job runs every minute – checking to see if there is paper) and it scans, uploads to dropbox, deletes the local file. It works remarkably well. I even made a little web page to manage the settings. Here’s the code on Github. The API doesn’t work yet … but it will soon – then Alexa integration (its already connected to a cloudflare tunnel.)

Oh – and – yeh – ChatGPT wrote 95% of the code for this and helped me debug it. I couldn’t have done this without this assistance.


Pulling The Rope

Dan used to say to me that we needed to motivate our teams to pull the rope.  

At first – I wasn’t sure what he was talking about.  

Why would they pull?

What rope?

But then ..

What’s the opposite of pulling a rope? 

Pushing it. 

Think about how successful you will be when you do that.  Yeh – pile of rope on the floor.

 

When / how / if people pull the rope is a product of two things:

a) Their motivation

b) Our inspiration

It’s impossible to inspire people who have no interest.  It’s also impossible to inspire people without a compelling mission / story / reason.

If we have both – amazing things can happen.  

And they will!

 

Primary Health! Now from Circulo

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.

If you haven’t read my short essay on Primary Health, please go read that first.  We’ll wait.

Ok … back?  Great.  Now, let’s resume the story.  

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. 

And this is the shift we are ready to make.   As William Gibson offered, “The Future is here – it’s just not evenly distributed.” Let’s consider a few examples of the future:

  • 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!

Organizational Optimization

 

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:

The secret of getting ahead is getting started. The secret of getting started is breaking your complex overwhelming tasks into small manageable tasks, and starting on the first one.” ~Mark Twain

 

What is Primary Health?

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.

Simon Sinek says we should start with why. 

Here goes:

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.

Because everyone deserves this.  You too.

 

 

Health Equity

The young man in the purple knows just how important the difference between equality and equity can be.

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.

….

Healthcare vs. Health Care

Well, it’s finally happened.  Mr. HisTalk and I violently disagree.  His note today includes:

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). 

For reference – see the HHS web Style Guide:

Health Care
Not healthcare, except on an agency or organization title.

And in this insightful note from Jodi Amendola (with which I mostly agree):

Healthcare versus health care

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:

So Mr. Histalk’s rationale is that he “saves space without sacrificing.”  I’d argue that he sacrifices quite a bit. 

I’ll also offer Victor Galli’s remarkably thorough summary of the topic and his equally remarkably illogical conclusion that “healthcare” is preferred:

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.  

Stepping back … 

Definition of health from the WHO

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

of the 16 definitions of care from Merriam-Webster, these are most relevant:

regard coming from desire or esteem
care for the common good

:CHARGESUPERVISION
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). 

Words matter. 

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.”

 

Three Big Changes

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.

  1. 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. 
    1. 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.  
    2. 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. 
    3. Where does business happen?  Sign a document. Have a meeting. Meet with the Board of Directors. Hire an employee. Notarize a document.  Get married. 
  2. 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.  
  3. 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. 
    1. 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.
    2. 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.
    3. 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.

And .. of course .. purpose.  But that’s not new.