by Tony Chen

All this talk about health care policy, healthcare blogging, and hospitalk, sometimes it's easy to forget that we are talking about real people, real sons, daughters, fathers, mothers, wives, husbands, and loved ones.

Yes, we have to run tight ships financially to ensure the long-term sustainability and advancement of our hospitals. Yes, we need to learn the business of healthcare. Yes, we have to think aggregate in numbers. But let's always remember that we are serving individual people, many who are in the most scaring, vulnerable moments in their lives.

I ran across this story at Blog, MD about Derek Madsen, a 10-year patient who had a rare childhood cancer. Please take a moment today and go through these 20 gripping Pulitzer prize photos of his journey.

Also, we've collected a few other patient stories here.

by Nick Jacobs

Back in 1963 my philosophy professor challenged me to prepare an analysis of intrinsic (taking) versus altruistic (giving) behavior. My conclusion at that time was that there clearly was no such thing as altruism. No one did anything unless it was good for them. Even those individuals who so generously gave of their time, money or wisdom, did it because it made THEM feel a little better about themselves.

Interestingly enough, that sophomoric knowledge (I was a sophomore.) did not keep me from embracing a life in not for profit management. Throughout my career in the various nonprofit organizations with whom I have worked; education, arts, economic development, and healthcare, it has been clear to me that there are two types of people who volunteer, the givers and the takers.

When questions are raised regarding how much is personally too much to those individuals who are the takers, the answer is obvious, “You can never have too much.” But when the same question is posed to the givers, the answer is entirely the opposite, “We enter with nothing, and we should leave with nothing. We are here to serve mankind.”

Well, over the last thirty plus years, it has also become clear to me that controls are necessary in order to keep the takers in tow because, many of them have no boundaries in regards to their material needs, and not for profit organizations are not the appropriate setting for pursuing those endless needs.

After Enron there appeared to be a glimmer of hope relating to controlling these takers, and there also appeared to be a strong movement toward a Sarbanes-Oxley-type legislation for nonprofit's. That proposal has now evolved into a new proposal called the Nonprofit Accountability Bill. Unfortunately, it does not yet have enough teeth to be really meaningful.

Let’s examine carefully the rolls of our nonprofit board members and simply track back the amount of business done by their companies within the nonprofit corporation for which they volunteer. Then check to see if bids were solicited, if influence was not placed on executives in charge through board compensation committees and if the business/member excused him or herself from the meetings when these issues were being decided. The Nonprofit Accountability Bill proposed certain limitations regarding the amount of business that actually constituted a conflict of interest, but, it is relatively clear that those numbers have also not been activated.

Bottom line? Ask questions about your nonprofit boards. Thankfully, for the past ten years I have worked for a board that is free of conflict, but this clearly is not the norm.

The difficult proposal that requires you to buy board member products, embrace their services, and use their consultants in order to ensure that they will be good board members is not acceptable behavior in a world that needs our help.

by Nick Jacobs

Why 2034? It’s actually the date that my actuarial has indicated that my individual involvement in this discussion should no longer have any viability. In other words it’s the projected date of my passing, but, believe me, there will be tens of thousands of we boomers contributing to this discussion until then.

A few years ago, during a scientific mission to Boston for a conference at MIT, it was my privilege to participate in a conference directed toward the challenge of keeping our senior citizens viable, active and out of long term care for as long as possible. We met with several health care professionals, engineers, and scientists who had taken on the challenge of miniaturizing every known type of monitoring system for the human body.

They had begun the effort to successfully decrease the size of these devices to the diameter of a nickel, the relative thickness of a potato chip and a cost of about twenty five cents each. We saw demonstrations of some of these miniaturized devices in actual use. They were adapting systems for monitoring the heart, blood pressure, brain function and respiratory system. With all of the flexibility that wireless communication can deliver, the unencumbered participants would be literally, wired for sound, as they moved freely through the special apartment that had been constructed for this research.

Each and every movement could be monitored all day, every day. The signals generated from the participants various organs were sent directly to a computer that was housed at a physician’s office where any missed beat could be reported through an alarm system that immediately notified the physician in charge.

Think of it. Pappy gets up from his chair, feels a little dizzy, sits back down, and the videophone rings with a healthcare professional checking to see if all is well.

Because of the 1984 feeling that some of we 1960’s free spirits might feel from this “Big Brother” type monitoring, it was suggested that the grandparent might also like to have her sibling monitored as well, thus giving the affect that they are indeed checking on each other.

Think of it. This system could very well keep us out of some offensive, under staffed, insufficiently reimbursed nursing home for at least an additional year or two.

In closing, however, I did receive an e-mail the other day with this suggestion. If you like to cruise, it would be more fun to live on the Pacific Princess for the rest of your life than in the Sunset Valley Nursing Center. The cost is similar, and when you trip and break your hip, they will upgrade you to a suite and deliver meals to your room.

by Nick Jacobs

Having been an observer of scientific research projects for the past seven years, I have recently made an observation that undoubtedly proves irrefutably that parallel universes do exist. On a recent beach trip, six young mom's in our family and our extended family decided to send their hunters off to deep sea fish for Father's Day, leaving two grandfathers and a four year old boy behind to protect the house.

Because he was not included in the fishing trip, the boy would have been crushed, but the old dudes bailed out his dad and mom by inviting him to go fishing with us. Neither of us had been fishing since we were young dads, about thirty years ago, so the day was already predetermined to be interesting. We strapped the little guy into his car seat and left in search of a fishing pier. It took us about forty minutes and fifty four dollars for gasoline, a bottle of Superman apple juice, some Halloween candy corn and a piece of beef jerky.

When we arrived at the fishing pier and entered the main building, it was like a time warp. In a large glass case there sat a talking humanoid Pirate that told fortunes. Then we passed 70 different pinball, video, basketball and bowling machines. When we finally arrived at the cashier's corner, eight more bucks lighter; we saw reality in a completely different light. Renting two poles with sinkers and hooks required an $80 deposit. Miscellaneous fishing fees were $48, and that included a bag of blood worms. Our wrists were then stamped, and we went out onto the pier and into the blazing, morning sun.

We were instructed to cut the blood worm which contained what seemed to be about a pint of blood. The little boy became very quiet, looked at me and said, "You're killing him." At that point I taught him about regeneration. Then we launched the baited hooks into the Atlantic Ocean and five minutes later caught a four inch fish which we promptly threw back into the sea. After about 90 seconds more, the little guy looked up and said, "Poppa, I want to go home now." He turned and started walking toward the exit.

On the way home he cried out for a toy, we stopped and bought him a little pirate, armed to the teeth, and a motorcycle for a grand total of $5.34. When we walked into the beach house, he opened his motorcycle and the wheel fell off. He stopped crying 20 minutes later when his mom convinced him that it would go to the broken toy hospital and be fixed.

If you're wondering about my introduction to parallel universes, it should be perfectly clear to you by now that this trip was exactly like scientific research. You start out not knowing where you're going; spend lots of money trying to get there; have great expectations; end up with much less than you or anyone had anticipated; have to throw it back in, and too many times, the wheels fall of.

Parallel universes.

by Nick Jacobs

It's amazing to me how much and yet how very little has changed during the past ten years. The subtleness of the metamorphosis is similar to the 212th degree, the point at which water goes from hot to boiling. First, you're hot, and then you're cooked.

Today I put on a new suit. It was the same size, same cut, same style and same manufacturer, but today, I looked like a watermelon in a silk stocking. That extra pound must have been the tipping point. After 20 years, the 42 Regular was not happening. If the coat button had launched and become airborne, it could have killed someone.

Another thing happened today that was totally my fault. My words took the moment to a boil.

Many of you have read about my periodic consternation relating to scientists and the world of science. Sometimes, just sometimes, as they apply science to living, the participants view of life becomes a little skewed. Sometimes the brilliant scientists think about things too long, or they get into too much analytical detail, but the characteristic that is the most worrisome to me is that they come from a world where normalcy involved feeding, holding, loving and talking to bunnies for months, and then cutting them open to see what impact the experiment had on their arteries.

It was because of this trait that I decided to hire some hard working, fun loving, spirited, people to liven the place up a little. So, a few years ago, four terrific people joined us to bring additional life, spirit, fun, and spontaneity to the institute.

At 3:55 this afternoon, I was running out of the door on my way to a doc meeting in the hospital when I noticed something for the third time that week, new paper signs. No one could ever fully appreciate my hatred for paper signs unless they had spent the past twenty years living inside of my suits. You see, I had a boss who scoured the eight floors of the hospital building where I had worked to find these paper things, and then, rather than take them down, he just screamed at me. You see, paper signs represented transience, instability, poverty and unsupervised spontaneity to him and now to me. These signs in question had been breeding over the past few weeks, like the flimsy metal hangers that the laundry gives you. You start out with two, and by the end of the week you have a laundry bag full.

So, as I left the building, I turned to one of my happy souls and said, "What the heck are these signs doing here?" Unfortunately, she took it personally. She had been asked to help make the signs, and, as an artist, she took pride in her work. It was as if I had screamed, "Hey, your kid is ugly!" As Joe Lieberman would say, "Bipartisanship means never having to say you're sorry." Why couldn't I just have said, "Let's get some permanent signs?" Maybe it would have been better to have said, "This sign is so beautiful that we should get it memorialized by having it bronzed?"

Anyway, I was later informed that I had upset my friend very much. Running out the door with three other people who observed my despicable remark probably didn't help.

So, I'm dedicating this blog to all of those people who have been hurt by my curt, CEO, verbal shots. In Shakespeare's Twelfth Night, he writes, "Life is full of sadness. The best years of life are short. Events are cruel. And other people are cruel. In such a world, it is your DUTY to find and cherish whatever real happiness you can."

So, Cathy, and all the Cathy's I've boiled, I'm sorry. It wasn't personal. It's just that those paper signs are killin' me.

by Nick Jacobs

Almost every week someone says to me, "How did you make the transition from being a teacher and professional trumpet player to running a hospital and a research institute?" In so many ways, it is exactly the same job. Clearly, the human mind sometimes has trouble grasping non-traditional career paths. As a young man, my passion was for helping people through education. It was clear to me that you could change a person's life almost completely with enough information.

There is no question that my journey was out of necessity. During the 70’s and 80’s the area where my family decided to settle we experienced the highest out migration of any city in the United States except for East St. Louis, Missouri. This was due largely to something called the Johnstown Flood. Unemployment reached 19% and my most demanding job was to find a way to continue to be employed to care for my family. So, at age 40 with a B.S. and an M Ed in hand, I headed back to Carnegie Mellon University for a second Masters in Public Management/Health Systems Management. It was a good decision, a unique program and a very different approach from the typical MHA or MBA because it exposed us to all aspects of public management. After that the Executive Program for Health Systems Certification at Harvard put some meat on the bones, and finally, the Fellowship from the American College of Healthcare Executives finished the credentialing journey. It took nearly a decade in total and almost more hours than a typical day held, but it provided the ticket to passage.

Would I do it again? Truthfully, my desire to nurture and care for people has been fulfilled in every way. The gift of healthcare delivery is second only to helping a lost kid find their way through education. Am I disappointed in the Medical Industrial Complex? Sure, but nothing that man has touched is perfect. My only advice to the student readers is that sometimes the hard way is more meaningful. All but my B.S. degree were attained while employed. It was extremely difficult to put in a 70 hour week and then drive to Pittsburgh two hours each way after work, but the experience was very rich because of the direct applicability to my job on a daily basis. School is great, and continuing education is a must. Don’t stop.

by Nick Jacobs

The general public is totally dependent upon people in my position to stand up and take responsibility for running a competently staffed hospital. Each and every one of us is dependent upon those individuals trusted with our lives to be kind, competent, capable and sure of their skills.

There is no reason for staff members to treat you poorly. There is absolutely no rationale for anyone to ignore, talk down to, or mistreat either you or a loved one. Do not be afraid to stand up for yourself or your loved one. There is no reason for you to receive poor treatment. Allow yourself to become empowered.

You should not be exposed to unnecessary infections. You should not be subjected to an ineffectual physician or staff member. You should not be kept in the dark about your treatment. Your loved ones should not be kept away from you. You should do or have done what you want.

That’s my story, and I’m stickin’ to it.

by Nick Jacobs

Each and every day hospital CEO's are faced with the reality of the sometimes overwhelming responsibility of ensuring that life is carefully delivered, maintained and, eventually transitioned. We are ultimately responsible for the appropriate allocation of funds for addressing all of these life transition situations.

Each day we face the challenges of probability and statistics as we attempt to deal with whatever the odds parse out. Some days the chiller stops and the house heats up. Some days we have a crush of sick people who all hit the emergency room at the same time, and each time we think the day is running smoothly, a major piece of equipment breaks or one of our twenty plus regulatory agencies shows up with a check list. It's all part of the day.

When you think about running a $50M, $100 M or $1B business with 500, 1000 or 30,000 employees, consider that each one of them typically represents a family of four. Consider the fact that each and every one of those family members in some way, shape or form also come under the umbrella of your responsibility.

If that isn't enough for you to consider, then look into the eyes of a family member who's loved one died because of something that one of your physicians or employees might have either done or forgotten to do.

Bottom line, if you're thinking about trying to make it to the Big Show, just remember that you've gotta pay to play.

A post by Andrew Barna

So we are all on board with price transparency in healthcare, right? Well maybe it is not so simple. Apparently, a John’s Hopkins study has found that specialized cancer facilities have higher costs at the time of service, but they “yield lower cost per quality-adjusted life year” in the long-run. That is a mouthful, but in a nutshell, it means you are going to pay more for cancer treatment at a Sloan Kettering or a M.D. Anderson, but you will probably live longer and with a better quality of life. I think this would make sense to most Americans – you get what you pay for – but the picture is not so clear when you look at hospital/physician comparison websites.

Most of the websites I have seen have been pulling quality data from the CMS quality demonstration project. This is not a bad start. The CMS measures cover some of the highest volume procedures and they draw attention to practices that promote better outcomes. And by “better outcomes,” they mean you are more likely to leave the hospital alive. I am not knocking the CMS measures. I think the CMS Demonstration project, as well as the IHI campaign, have created systematic improvements in patient safety and outcomes… but…these measures do not necessarily give consumers an indication of the long term value of the services they are purchasing.

Let’s go back to our health economics class. The value of a healthcare intervention is measured in terms of lengthened life or improved quality of life. Indeed, this is how a lot of medical research is done. One treatment is shown to have better long term impact than another. But by their very nature, the CMS measures focus on short-term outcomes that can be measured during your hospital stay. So on one of the hospital comparison websites you could find out that the in-hospital mortality rate for your heart procedure is lower at Hospital A rather than Hospital B. OK, easy choice go with Hospital A. But what does that outcome mean relative to cost. Are you willing to pay an extra $5,000 for less of a chance to die? Or could you save a $1,000 and take a tenth of a percent in additional risk? Now the decision is not so clear. We aren’t typically equipped to make such a call.

Americans are expert consumers and we want to know every detail about what we are buying. I won’t even buy a CD until I know how other people who like similar music like that CD. When we have the right information about what we are purchasing, we make better choices (I should say that we make choices that we are happier with). Granted that purchasing healthcare is not equivalent to purchasing a CD, but it is not different on this point. The more that hospitals can demonstrate their overall and long-term value, the more consumers will make better choices.

Post Script: I just received the spring copy of Frontiers of Health Services Management and the featured topic is “Price Transparency: Meeting the Market Demand for Clarity”. So as I read the articles, I am sure I will be writing posts retracting the comments above. Hey Tony, your old boss Richard Clarke wrote the lead article. It looks good from the summary.

by Nick Jacobs

Let me begin this week’s post with a disclaimer. On the anniversary of my father’s death, I decided that I would take one shot at our readers to help me help the people that I love. Consequently, this is not a light column, but please continues to read it.

It started with a pesky cough. The cough came from what everyone thought was the remnants of a nagging chest cold. My parents were on their first extended vacation to Florida with her brother and sister in law. Dad had just turned 56 years of age, and both of their kids were out of college, married and doing just fine. For the first time since 1941, my folks had both freedom and a few extra dollars to enjoy life a little.

Dad had stopped smoking at or around 1964, ten years earlier, when the new surgeon general had the backbone to declare that smoking was “bad for your health.” Dad had smoked since he was a teenager, and, because his life had been filled with numerous unexpected challenges; a terrible accident that resulted in a broken back, the job challenges created by a collapsed economy, the loss of twin sons and some very unsophisticated and difficult bosses in a number of impossible jobs, he had hung onto those cigarettes as his 20 best friends each day.

I was only about 26 when he returned from his vacation and was diagnosed with a tumor, an unknown tumor in his lung. Over the next few months he went through various tests, but finally, he was urged to have an exploratory surgery on that lung. We followed him to the hospital for his surgery. It was scheduled for 6:30 AM, and when they wheeled him out, we all hugged and smiled and knew he would be okay. Four and a half hours later, we were told that, indeed, he was not okay. He had a very rare type of lung cancer that was extremely aggressive. They had removed his lung.

We were shocked. We were horrified. We were devastated. The journey to his death took us through 18 months during which we experienced, sorrow, depression, misery, hopelessness and desperation mixed with deep love, hope and strength.

He was a wonderful man. As his cancer spread first to his bones and then to his other lung, he looked me in the eyes time after time and said, “If only I had known, I would never have smoked, ever. I want to stay here with all of you.”

He left us about two months after my daughter was born. He did get to hold her, and love her, but he never got to influence either her or my son. He wasn’t there to provide his knowledge, kindness, guidance, love and his emotional support for any of us. He was not there to help anyone, and, most importantly, he was not there to enjoy our family as it grew and prospered. Why? Because the tobacco companies had mastered the art of combining just the right mixture of ingredients to contribute to an addiction that some have said is worse than that of heroin.

So why did I write this? I wrote this because I have friends and family members who, thirty two years later, are smoking. Holding my father in my arms as he died from an addiction that was manifested upon mankind by corporate America was sad, wasteful, and painful, but watching it happen to people who I love who, unlike my father, know without a doubt that more men and women die from lung cancer than any other type of cancer each year is unbearable.

In 2002, lung cancer accounted for more deaths than breast cancer, prostate cancer, and colon cancer combined. In that year, 100,099 males and 80,163 females were diagnosed with lung cancer, and 90,121 males and 67,509 females died from lung cancer. We also know that tobacco smoking is by far the leading cause of lung cancer. More than 87% of lung cancers are caused directly by smoking. Don't quit out of fear. Quit because of love. We love you.

A post by Andrew Barna

Well it has been a few months since I last posted on Hospital Impact, but with the new year, Gov. Schwarzenegger's plan to cover the 6.5 million uninsured in CA, the President's tax incentive plan is being dusted off again, and pretty much everyone is joining a coalition to tackle the problem of the uninsured, it seemed like time to rejoin the conversation.

I have perused the Schwarzenegger plan and frankly I am skeptical. Here are a few initial impressions.

First of all, the plan to tax hospitals and physicians in order to fund a MediCal increase just doesn't make sense. As the saying goes, why rob Paul to pay Peter? There just doesn't seem to be a point to tax providers. They are at the end of the food chain, so no new money is being added to the system that wasn't already there. There is no doubt that MediCal is severely underfunded - it pays between 9 and 13 cents on the dollar - but taxing providers is equivalent to cutting reimbursement.

One of the other big funding sources for this plan is a mysterious $5B coming from the federal government, but where is this money coming from (does the federal government match state medicaid dollars?). I know we have left SCHIP money on the table, but $5B is a lot of money.

The requirement for businesses with 10 or more employees to either provide insurance or pay into a state pool is not a bad idea on its face. It puts new money into the system and puts that money to good use. Unfortunately, CA is already a difficult state to do business in and this will be seen as putting an unfair burden on employers.

As for the President's perennial tax shifting scheme to help people pay for insurance coverage, I have said it before and I will say it again: unless the working poor see more money in their paychecks each week, they won't be able to buy insurance. The promise of less taxes/more refund on April 15th will not give the working poor the cash flow to pay monthly premiums.

The relatively good news is that more and more people are acknowledging the problems with our health system and jumping on the bandwagon to fix them. Perhaps a Democratically lead Congress can make healthcare a priority, but we still need to resolve some fundamental issues: mis-aligned incentives and who ultimately is going to pay for the healthcare we want.

by Nick Jacobs

Today, I opened the Sunday newspaper to see an article by David Wallechinsky that very carefully challenged us to look at ourselves as a nation. Under the realm of leadership the question has to be: When will our leaders begin to address these issues in a meaningful way? We have no national health care policy. We have no viable energy policy. We are still not open minded enough to even elect a female to the Presidency. Yet, according to Wallechinsky, we remain the strongest country economically in the world. Too bad economic strength isn't representative of moral, ethical and social strength and commitment.

As I sit with my children and grandchildren today, I can only hope that their generation will take hold of these issue. After such a strong start, we Boomers certainly seem to have missed our major opportunity to make a dent in these socially challenging situations.

From "Parade:Magazine" by David Wallechinsky

The U.S. spends the most on health care but lags in life expectancy.

43 Countries have more physicians per capita than we do.

33 Countries, including Cuba, have lower rates of infant deaths.

Residents of 27 countries live longer.

We lead all nations in the consumption of oil, using a quarter of the world's annual supply.

Highest per capita rate of people in prison, 737 per 100,000 people or 2.2 million.

We perform the fourth highest number of executions trailing only China, Iran and Saudi Arabia.

Only South Africa and Canada have higher rape rates.

We also have the 15th highest murder rate

71 countries do better at electing women to national legislatures.

Of eligible citizens who vote, U.S. ranks 139th of 172 nations.

WE consume more calories per capita than the citizens of any other nation, and lead the world in the prevalence of obesity.

By Nick Jacobs

The day starts with a trip to Starbucks where they hand me my decaf, nonfat, grande, latte. Reaching for my car keys the foamed skim milk drips onto my black top coat and as the sleeved cup is carefully placed in the holder between the seats, the car lunges forward. When I fumble to place my Bluetooth headset back into my right ear, the excess foam drips onto the screen of my Treo cell phone, and it’s only 6:30 AM.

The lighted icon of a yellow skidding vehicle appears on the top of my odometer as the company car flies toward the first meeting of the day with the medical staff. This group prefers the predawn hours of the day more than any other time. (As a former professional musician, the only time I enjoy seeing the sunrise is when I'm coming at it from the night before.)

After the medical staff meeting, the next three hours are filled with meetings with my direct reports. If charted, these meetings would look similar to my last EKG as the personality types move from conservative to liberal, from detailed to ethereal from muted to encouraging. It's a roller coaster ride of emotions, issues, problems and potential solutions as they bare their souls in this hourly cleansing session, receive absolution where appropriate and move on with their work lives with the same passion and commitment that Rudy displayed at Notre Dame, that Armstrong demonstrated on the moon, that Custer . . . well, you get the idea.

At noon, lunch is consumed as almost an afterthought. It's vegetable or meat loaf, tossed a salad and a whole wheat dinner roll with a side of bottled water. Chewing and swallowing continues as we contemplate the fates of the various physicians who have applied for privileges to work at our hospital. All are considered as the names are discussed by the various physician leaders. Their credentials, their recommendations, their history, their record with the Physician data bank and, when appropriate, the side of their head on which their hair is parted, are issues for discussion at this meeting.

After this working lunch, there is a one hour teleconference with six CEO's from other hospitals where we discuss governance issues for our regional organization.

All of the earlier meetings lead to the high light of my day, the marketing meeting. I'm sure that my peers from finance probably have a similar high from meeting with their number's jocks, but, for me, it's the right brain creative's, their interns, their assistants and subcontractors.

This group gathers in the conference room with a high level of positive energy, usually not exactly on time, usually not in an orderly fashion, sometimes with late lunch in hand. This group is filled with our dreamers, the positive, not usually too serious, creative types. They plan the press conferences, the television commercials, the employee parties and the strategic acceleration that will produce dynamic marketing surges for our various service lines. With this group it is about telling the positive stories, translating those complex medical issues into understandable human speak. Usually, these employees are fun . . . out of the box types who, without their input, would make my life a little more tense. In fact, I'm thinking that without this weekly meeting that grande, decaf, latte would include a couple of shots of something else!

Two more meetings with individual physicians and our Chief Operating Officer, a dinner board meeting of a local non profit, and then finally, at 9 PM the beginning of 90 minutes of e-mails that went unanswered during the day.

Bed finally arrives at 11:30 PM and the clock clangs again at 6 AM the next morning. Believe me when I tell you that, compared to many, this isn't a bad schedule.