It is good to see photographs of U.S. Rep. Gabrielle Giffords that became available to the public today. Few people know all the details of the kinds of care she received that made possible the near miracle of her survival and recovery. There are surely many physicians, surgeons, nurses and others who together made this possible. She is alive and recovering today because of the coordination of the efforts of many professionals. In other words, it was not only the skills of individuals who saved her life and promoted her recovery. It was the timely coordination of those efforts. In this case, the "system" of care worked. I want to believe it would have worked as well for any person who suffered her injury.
As I read some of the comments received by HHS regarding proposed rules for implementation of ACOs I see the strong expressions of good people who simply do not want government agencies to attempt to rationalize the healthcare delivery system. Some people are simply opposed to "socialized medicine" and/or define the proposed changes as a loss of freedoms won on battlefields around the world. Others are open to change but do not believe that the new law and the proposed rules will work. Rep. Giffords' recent experiences with the system could be cited either as evidence that what we already have can work; or to say that we can do better. I want to believe that we can do better for at least all American citizens, including the large numbers of people entering the Medicare program. I believe that the rationalization of medical processes can reduce costs and produce more consistent quality outcomes for all patients.
It is a safe guess to say that the implementation of the new law will produce unintended behaviors among providers. The system that produced the law is a political system. Democratic political systems cannot produce scientifically rational policy designs, as in the context of operations research which is rational in a more objective way. Politics is the art of what is politically possible. As we pray and hope for Rep. Giffords' continued recovery let us continue to hope that the new law which she supported in Congress with her vote backed by her courage can be implemented successfully. "Bureaucrats" have to run with what they are handed by others.
Showing posts with label public policy. Show all posts
Showing posts with label public policy. Show all posts
Sunday, June 12, 2011
Tuesday, January 11, 2011
Anticipating "Black Swan" events
Nassim Nicholas Taleb's best-selling book, The Black Swan: The Impact of the High Improbable(now in its second edition) regards the anticipation of low-probability, high consequence possible events. Managers generally focus their attention on the crisis of the day and on likely near-future scenarios. There are so many low-probability possible scenarios that it may not be a productive investment of time and attention to give them much thought. It is difficult to plan for a radical change in circumstances. And an executive or manager is not likely to be faulted for failing to anticipate an event that was very improbable before its occurrence.
But medical insights are evolving rapidly. For example, the discovery of a cure for aging, resulting in radical life extension, would certainly have huge consequences to medical institutions and societies at large. It would probably result in a large increase in numbers of people with chronic medical conditions and would surely lead to substantial population growth, further taxing the limited resources of the earth. It could happen. Many unlikely things of high potential consequence are possible. Some of the work being done in theoretical physics would surely have dramatic consequences if radical new ideas could be implemented.
But medical insights are evolving rapidly. For example, the discovery of a cure for aging, resulting in radical life extension, would certainly have huge consequences to medical institutions and societies at large. It would probably result in a large increase in numbers of people with chronic medical conditions and would surely lead to substantial population growth, further taxing the limited resources of the earth. It could happen. Many unlikely things of high potential consequence are possible. Some of the work being done in theoretical physics would surely have dramatic consequences if radical new ideas could be implemented.
Sunday, January 9, 2011
The Power of Memes
Many Americans and others around the world are trying to make sense of the killing of six people and wounding of twelve people in Arizona yesterday. We continue to think about and pray for all the victims and their families, including Representative Gabrielle Giffords. The tie to this blog, of course, is the fact that her support for passage of the recent health care reform legislation may be related to recent events. I have been thinking about why health care reform is such a sensitive issue and has such power to shape political and social divides in our nation.
A meme is an idea that seems to have a will to proliferate itself and to survive. We do not often think of ideas as having a will. But it can be insightful to consider them that way. Successful religions can be thought of as systems of memes that have evolved over time and that are especially good at reproduction and defense. For example, "go forth and multiply" is a meme and an important part of a meme system because a person's children are likely to carry the same memes as the parents.
Political ideologies are also meme systems. The virtue of gun ownership, for example, has apparently become a political meme important enough to be a criterion for the selection of president of the Republican National Committee. To the encouragement of the audience the candidates for the position recently either lamented their having an inadequate few guns or boasted of the number and fire-power of their personal collections of guns. The "gun ownership" meme is apparently thriving in at least one sector of American political ideology.
I am reaching here to try to understand why health care reform is such a hot-button issue in America today. Obviously, it is important because we realize the importance of medical care in our lives and we fear for the loss of access to costly resources. But, there is more to it than that. I believe that health care debates are intense in a democratic society because they involve the clashing of powerful meme systems.
This is like chemistry. I remember from childhood experiments that the mixing of the content of two containers can have very dramatic results. Memes and systms of memes have powerful survival instincts and when threatened defend themselves at all costs. I don't know exactly what the "powers and principalities" phrase in the Bible refers to, but memes, while hosted in "flesh and blood" are more than flesh or blood. It is the idea that you can kill a person but you cannot kill an idea. Responsible people who would become our leaders need to be very careful in the use of words and images. It is not just because there are some mentally unstable people out there. It is because memes can be like dangerous biological viruses. Substantial numbers of people cannot deal with complex reasoning and take what may be intended figuratively as literal.
The Internet is the ultimate meme machine. It puts democracy on steroids, for better or for worse. The "market place of ideas" argument is that in a free-for-all among all kinds of ideas the reasonable, rational ones will win. Not necessarily. The memes and meme systems most carefully designed for replication and survival will win. From the perspective of a meme, we are only hosts. Meme systems are complex and adaptive and exist in a common ecology of thought-space. I am concerned by what is happening in the thought-spaces of humanity and I see evidences of "bad chemistry" in many events including the shootings in Arizona yesterday. Public policies are shaped by competions among ideas and the formulation of public policies exert pressures upon highly defensive meme systems. Our leaders (and all of us) need to be careful in our use of words and images.
A meme is an idea that seems to have a will to proliferate itself and to survive. We do not often think of ideas as having a will. But it can be insightful to consider them that way. Successful religions can be thought of as systems of memes that have evolved over time and that are especially good at reproduction and defense. For example, "go forth and multiply" is a meme and an important part of a meme system because a person's children are likely to carry the same memes as the parents.
Political ideologies are also meme systems. The virtue of gun ownership, for example, has apparently become a political meme important enough to be a criterion for the selection of president of the Republican National Committee. To the encouragement of the audience the candidates for the position recently either lamented their having an inadequate few guns or boasted of the number and fire-power of their personal collections of guns. The "gun ownership" meme is apparently thriving in at least one sector of American political ideology.
I am reaching here to try to understand why health care reform is such a hot-button issue in America today. Obviously, it is important because we realize the importance of medical care in our lives and we fear for the loss of access to costly resources. But, there is more to it than that. I believe that health care debates are intense in a democratic society because they involve the clashing of powerful meme systems.
This is like chemistry. I remember from childhood experiments that the mixing of the content of two containers can have very dramatic results. Memes and systms of memes have powerful survival instincts and when threatened defend themselves at all costs. I don't know exactly what the "powers and principalities" phrase in the Bible refers to, but memes, while hosted in "flesh and blood" are more than flesh or blood. It is the idea that you can kill a person but you cannot kill an idea. Responsible people who would become our leaders need to be very careful in the use of words and images. It is not just because there are some mentally unstable people out there. It is because memes can be like dangerous biological viruses. Substantial numbers of people cannot deal with complex reasoning and take what may be intended figuratively as literal.
The Internet is the ultimate meme machine. It puts democracy on steroids, for better or for worse. The "market place of ideas" argument is that in a free-for-all among all kinds of ideas the reasonable, rational ones will win. Not necessarily. The memes and meme systems most carefully designed for replication and survival will win. From the perspective of a meme, we are only hosts. Meme systems are complex and adaptive and exist in a common ecology of thought-space. I am concerned by what is happening in the thought-spaces of humanity and I see evidences of "bad chemistry" in many events including the shootings in Arizona yesterday. Public policies are shaped by competions among ideas and the formulation of public policies exert pressures upon highly defensive meme systems. Our leaders (and all of us) need to be careful in our use of words and images.
Friday, January 7, 2011
Democracy as faith
I see the next few years as a critical passage for America's experiment with democracy. The Republican Party is being pulled further toward absolutist perspectives by Tea Party members. The election of a President Sarah Palin in 2012 is a real possibility. Her "death squads" references (as related to healthcare policy) hit a chord among many people.
Around the world we see examples of people in Western Democracies assuming a childish perspective that government can and will make life easy. Reality is not simple and political leaders have limited abilities to, "make it better," like mommy kissing a hurt. At some point, fiscal conservatism is going to run headlong into social conservatism. Medical realities demand difficult choices. It is not possible to maximize quality, accessibility and affordability all together. I am concerned that the nature of political discourse in the United States in the near future is going to strain the fabric of democracy.
Around the world we see examples of people in Western Democracies assuming a childish perspective that government can and will make life easy. Reality is not simple and political leaders have limited abilities to, "make it better," like mommy kissing a hurt. At some point, fiscal conservatism is going to run headlong into social conservatism. Medical realities demand difficult choices. It is not possible to maximize quality, accessibility and affordability all together. I am concerned that the nature of political discourse in the United States in the near future is going to strain the fabric of democracy.
Friday, December 31, 2010
Kidney donation a condition of release?
This news story appears to me to raise ethical questions.
http://www.cnn.com/2010/CRIME/12/30/mississippi.sisters.prison.release/index.html?hpt=Sbin
Apparently, two sisters in Mississippi received life sentences for an armed robbery that netted $11. Having each served 16 years in prison they are now each consider rehabilitated and no longer a threat to society. One sister's dialysis treatments three times per week is costing the state $190,000 a year. Governor Barbour's decision is apparently being well-received by all.
But ethically, an organ donation must be voluntary. Not even a court of law can require a person to become an organ donor even if a specific death will result for lack of a suitable organ. If this were a research proposal being considered by an Institutional Review Board (IRB) I think the IRB reviewers would be hard pressed to believe this is not a coerced consent. The state has apparently concluded that the sisters should not be in prison. Assuming the sister receiving dialysis will be eligible for Medicaid upon release, it is in the financial interest of the state for her to receive an organ transplant. From an ethical perspective, it seems to me that the better sequence of events would be to immediately release the two women and then ask the potential donor if she wants to make the organ donation. Is it possible that the prospective donor has refused to make the donation unless both sisters are first released from prison? If this is the case, does this amount to selling one's organ, which may be a violation of law?
Does this news story suggest that in the future a convicted criminal's "debt to society" might be paid by "voluntary" organ donations (to unknown others) in Mississippi? It seems to me that the state has a conflict of interest regarding the medical care of the sister needing dialysis and that making release contingent upon the organ donation may not be ethical or wise.
http://www.cnn.com/2010/CRIME/12/30/mississippi.sisters.prison.release/index.html?hpt=Sbin
Apparently, two sisters in Mississippi received life sentences for an armed robbery that netted $11. Having each served 16 years in prison they are now each consider rehabilitated and no longer a threat to society. One sister's dialysis treatments three times per week is costing the state $190,000 a year. Governor Barbour's decision is apparently being well-received by all.
But ethically, an organ donation must be voluntary. Not even a court of law can require a person to become an organ donor even if a specific death will result for lack of a suitable organ. If this were a research proposal being considered by an Institutional Review Board (IRB) I think the IRB reviewers would be hard pressed to believe this is not a coerced consent. The state has apparently concluded that the sisters should not be in prison. Assuming the sister receiving dialysis will be eligible for Medicaid upon release, it is in the financial interest of the state for her to receive an organ transplant. From an ethical perspective, it seems to me that the better sequence of events would be to immediately release the two women and then ask the potential donor if she wants to make the organ donation. Is it possible that the prospective donor has refused to make the donation unless both sisters are first released from prison? If this is the case, does this amount to selling one's organ, which may be a violation of law?
Does this news story suggest that in the future a convicted criminal's "debt to society" might be paid by "voluntary" organ donations (to unknown others) in Mississippi? It seems to me that the state has a conflict of interest regarding the medical care of the sister needing dialysis and that making release contingent upon the organ donation may not be ethical or wise.
Sunday, December 26, 2010
Medicare end-of-life conversation regulation
The lead news item in today's edition of the New York Times is the Obama administration's decision to create a new Medicare regulation regarding paying physicians to discuss end-of-life issues with their patients.
http://www.nytimes.com/2010/12/26/us/politics/26death.html?pagewanted=1&_r=1&ref=todayspaper
Given the Administration's need to work with Republicans on a host of important issues I am sure that this decision is not a political strategy intended to enhance President Obama's prospects for reelection in 2012. It may actually have at effect, however. I think it increases the probability that Republican leaders will be unable to prevent Sarah Palin becoming the party's presidential nominee. In a race in which Palin is the Republican nominee for president, Obama is more likely to win.
We are certainly going to hear increasingly angry statements about "death squads" from the far right and characterizations of President Obama in the most negative ways, often couched in fundamentalist religious frames. For many, this is not about reason. For many, this is about government's intrusion on the sacred domain of the Almighty. Years ago, little could be done to prolong the lives of terminally ill people. Following death, doctors spoke the words, "we did all we could." And that was it. No one, and certainly not "bureaucrats" working for the national government were held responsible for "killing Grandma." Now that the burden of financing medical care falls increasingly on government, government itself is a risk of being blamed for the intensely personal consequences of the necessary rationing of medical care.
I have at least three concerns. One, I am concerned for our nation. It is not written in stone somewhere that the United States will always continue to exist in its present configuration. Issues that deeply divide the nation which some citizens see as nonnegotiable are a threat to the fabric of our nation. Two, creating policies/regulations regarding what conversations are reimbursed and what conversations between physician and patient are not reimbursed seems to me to be a bit troubling. I mean, do we really want to create a situation in which primary care physicians may say to a patient, "I am sorry but we have only fifteen minutes and I would prefer to talk with you about some topic for which my group practice will get reimbursed." Third, creating a system by which physicians are paid to talk to patients about end of life issues is one step away from specifying by regulation what the patient can (and cannot) be told by his or her physician.
The reality is that a large percentage of what is spent for medical care in the United States is spent to lengthen the lives of people who are near death in any case. This is a difficult call because in many situations the nearness of death is uncertain. It is likely that new technologies will increase the percentage of near-death spending in coming years. The potential need for medical care is almost infinite. Resources are finite. Rationing by some means is necessary. People do not want to make hard choices. We want it all. In the name of social equity, we want it all for everyone. It is "easy" for me to write this now working from what I perceive to be a rational perspective. It is more difficult to face these things in situations in which rationality may not be the primary criteria for decision.
http://www.nytimes.com/2010/12/26/us/politics/26death.html?pagewanted=1&_r=1&ref=todayspaper
Given the Administration's need to work with Republicans on a host of important issues I am sure that this decision is not a political strategy intended to enhance President Obama's prospects for reelection in 2012. It may actually have at effect, however. I think it increases the probability that Republican leaders will be unable to prevent Sarah Palin becoming the party's presidential nominee. In a race in which Palin is the Republican nominee for president, Obama is more likely to win.
We are certainly going to hear increasingly angry statements about "death squads" from the far right and characterizations of President Obama in the most negative ways, often couched in fundamentalist religious frames. For many, this is not about reason. For many, this is about government's intrusion on the sacred domain of the Almighty. Years ago, little could be done to prolong the lives of terminally ill people. Following death, doctors spoke the words, "we did all we could." And that was it. No one, and certainly not "bureaucrats" working for the national government were held responsible for "killing Grandma." Now that the burden of financing medical care falls increasingly on government, government itself is a risk of being blamed for the intensely personal consequences of the necessary rationing of medical care.
I have at least three concerns. One, I am concerned for our nation. It is not written in stone somewhere that the United States will always continue to exist in its present configuration. Issues that deeply divide the nation which some citizens see as nonnegotiable are a threat to the fabric of our nation. Two, creating policies/regulations regarding what conversations are reimbursed and what conversations between physician and patient are not reimbursed seems to me to be a bit troubling. I mean, do we really want to create a situation in which primary care physicians may say to a patient, "I am sorry but we have only fifteen minutes and I would prefer to talk with you about some topic for which my group practice will get reimbursed." Third, creating a system by which physicians are paid to talk to patients about end of life issues is one step away from specifying by regulation what the patient can (and cannot) be told by his or her physician.
The reality is that a large percentage of what is spent for medical care in the United States is spent to lengthen the lives of people who are near death in any case. This is a difficult call because in many situations the nearness of death is uncertain. It is likely that new technologies will increase the percentage of near-death spending in coming years. The potential need for medical care is almost infinite. Resources are finite. Rationing by some means is necessary. People do not want to make hard choices. We want it all. In the name of social equity, we want it all for everyone. It is "easy" for me to write this now working from what I perceive to be a rational perspective. It is more difficult to face these things in situations in which rationality may not be the primary criteria for decision.
From systems understanding to systems design
I have always been interested in analysis. As a child this was evident in multiple adventures in taking things apart in order to try to understand how they worked or why they were not working. As an adult my interest in analysis has been manifest in terms of studying object-oriented software, relational databases and service-oriented architectures. Understanding how hospitals function and why public policy often produces unintended results fits the pattern of my interests.
It is all about systems and about dynamic complexity. The basic challenge in hospitals is the existence of two competing basic needs -- the motive to serve and the motive to survive. These two needs play out in patterns of scenarios involving many stakeholders who themselves embody these two needs. The pattern is fractal. In public policy, the core problem is that stakeholders tend to feel threatened by new legislation and can usually find ways to modify their behaviors in ways not intended by those who created the legislation. Plus, our political system itself is in a dysfunctional state such that rational policy making is often not possible. Insight into why things are as they are is one thing. Learning to become a player in the existing system is another. Hoping to improve dysfunctional systems is quite another. As a child I was often frustrated by my having a greater ability to take things apart than to put them back together again. Now as an adult I hope to gain additional abilities not only to understand but to play and to possibly to help design complex systems. My hope is that the field of Public Administration becomes more of a design science, as I think Herbert Simon suggested.
It is all about systems and about dynamic complexity. The basic challenge in hospitals is the existence of two competing basic needs -- the motive to serve and the motive to survive. These two needs play out in patterns of scenarios involving many stakeholders who themselves embody these two needs. The pattern is fractal. In public policy, the core problem is that stakeholders tend to feel threatened by new legislation and can usually find ways to modify their behaviors in ways not intended by those who created the legislation. Plus, our political system itself is in a dysfunctional state such that rational policy making is often not possible. Insight into why things are as they are is one thing. Learning to become a player in the existing system is another. Hoping to improve dysfunctional systems is quite another. As a child I was often frustrated by my having a greater ability to take things apart than to put them back together again. Now as an adult I hope to gain additional abilities not only to understand but to play and to possibly to help design complex systems. My hope is that the field of Public Administration becomes more of a design science, as I think Herbert Simon suggested.
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