Food for thought...

Jeffrey S. Flier
11/17/09

As the dean of Harvard Medical School I am frequently asked to comment on the health-reform debate. I'd give it a failing grade.

Instead of forthrightly dealing with the fundamental problems, discussion is dominated by rival factions struggling to enact or defeat President Barack Obama's agenda. The rhetoric on both sides is exaggerated and often deceptive. Those of us for whom the central issue is health—not politics—have been left in the lurch. And as controversy heads toward a conclusion in Washington, it appears that the people who favor the legislation are engaged in collective denial.

Our health-care system suffers from problems of cost, access and quality, and needs major reform. Tax policy drives employment-based insurance; this begets overinsurance and drives costs upward while creating inequities for the unemployed and self-employed. A regulatory morass limits innovation. And deep flaws in Medicare and Medicaid drive spending without optimizing care.

Speeches and news reports can lead you to believe that proposed congressional legislation would tackle the problems of cost, access and quality. But that's not true. The various bills do deal with access by expanding Medicaid and mandating subsidized insurance at substantial cost—and thus addresses an important social goal. However, there are no provisions to substantively control the growth of costs or raise the quality of care. So the overall effort will fail to qualify as reform.

In discussions with dozens of health-care leaders and economists, I find near unanimity of opinion that, whatever its shape, the final legislation that will emerge from Congress will markedly accelerate national health-care spending rather than restrain it. Likewise, nearly all agree that the legislation would do little or nothing to improve quality or change health-care's dysfunctional delivery system. The system we have now promotes fragmented care and makes it more difficult than it should be to assess outcomes and patient satisfaction. The true costs of health care are disguised, competition based on price and quality are almost impossible, and patients lose their ability to be the ultimate judges of value.

Worse, currently proposed federal legislation would undermine any potential for real innovation in insurance and the provision of care. It would do so by overregulating the health-care system in the service of special interests such as insurance companies, hospitals, professional organizations and pharmaceutical companies, rather than the patients who should be our primary concern.

In effect, while the legislation would enhance access to insurance, the trade-off would be an accelerated crisis of health-care costs and perpetuation of the current dysfunctional system—now with many more participants. This will make an eventual solution even more difficult. Ultimately, our capacity to innovate and develop new therapies would suffer most of all.

There are important lessons to be learned from recent experience with reform in Massachusetts. Here, insurance mandates similar to those proposed in the federal legislation succeeded in expanding coverage but—despite initial predictions—increased total spending.

A "Special Commission on the Health Care Payment System" recently declared that the Massachusetts health-care payment system must be changed over the next five years, most likely to one involving "capitated" payments instead of the traditional fee-for-service system. Capitation means that newly created organizations of physicians and other health-care providers will be given limited dollars per patient for all of their care, allowing for shared savings if spending is below the targets. Unfortunately, the details of this massive change—necessitated by skyrocketing costs and a desire to improve quality—are completely unspecified by the commission, although a new Massachusetts state bureaucracy clearly will be required.

Yet it's entirely unclear how such unspecified changes would impact physician practices and compensation, hospital organizations and their capacity to invest, and the ability of patients to receive the kind and quality of care they desire. Similar challenges would eventually confront the entire country on a more explosive scale if the current legislation becomes law.

Selling an uncertain and potentially unwelcome outcome such as this to the public would be a challenging task. It is easier to assert, confidently but disingenuously, that decreased costs and enhanced quality would result from the current legislation.

So the majority of our representatives may congratulate themselves on reducing the number of uninsured, while quietly understanding this can only be the first step of a multiyear process to more drastically change the organization and funding of health care in America. I have met many people for whom this strategy is conscious and explicit.

We should not be making public policy in such a crucial area by keeping the electorate ignorant of the actual road ahead.

Nelson's Mama - Back in Action

Through the years, I'm guessing that I've made well over fifty trips to the Panhandle of Florida and Alabama; somehow in all of those adventures I've missed visiting the lovely towns of Fairhope and Point Clear, Alabama on Mobile Bay until this weekend. I am now officially in love with the area and may forsake the beach forever.

And we found the perfect little place to buy, a Bay front fixer upper, built in 1955, 2-bedroom, 1 bath, 900 square feet. When we run across an extra $2.6M that baby is ours!

Rea's Cotillion Autumn Ball was this weekend; Danny and I missed it - but here she is having a HORRIBLE time!

Dang, wish I could have had such a HORRIBLE time when I was twelve.

Pa, what's for breakfast?

This is my Dad. Known as Ronald to most, Pa to a few and even Sonny to a dwindling minority.

Ronald starts his day at the crack of dawn by making a pot of coffee and consuming nearly all of it - black. He drinks most of the coffee while performing his morning rituals, which mostly involves going out to his shop, feeding the dogs and cats, checking on his garden in the summer, watering the plants, taking Leana to school, plus a variety of sundry tasks, missions and mysterious objectives that most of us have yet to figure out.

Around about mid-morning hunger creeps up on old Ronald and he heads to the house and he starts looking for some food. And while you and I would probably go for a bowl of cereal or perhaps a bagel, maybe even some toast - those things just don't cut it for my Dad.

He's a forager - and as Danny says he's like "an old black bear ambling from garbage can to garbage can." You just never know what combo he's going come up with, it's an amazing thing to watch. Sometimes it might be Ritz crackers with his special homemade peppers, or saltines with salsa. Occasionally he'll cook up a little sausage and fry himself an egg, but I can bet you my first born child that it won't involve cheese...the man despises cheese.

Just this Sunday morning at 9:30 my Mom reports that his breakfast was an appetizing choice of leftover turnip greens, sweet potatoes and purple hull peas.

And lunch today? White beans with potato chips accompanied by a bologna sandwich on the heels of white bread.

Sounds yummy huh?

Arrangements incomplete...

Yesterday was so hard and sad. But also incredibly uplifting and heartwarming at the same time; we got so many phone calls and emails from family, friends and neighbors who all loved our sweet Shelley and shared our loss with us. I got beautiful flowers from my Mom, Rea got brownies from Ash and a cake shaped like a dog from the Copeland’s.

We have no regrets about Shelley’s life and if she could speak to us now, I am convinced that she would tell us that she lived her life exactly as she wanted. Her life was better than that of millions of people around the world – and in my small town.

And even in death, Miss Shelley went out in style; yesterday when I left the vet’s office I didn’t bring our beautiful girl home. Nope. I took her to the Brand New Funeral Home. In fact, the Brand New Funeral Home tried to pick her up at the vet's office, but we got our wires crossed, so, I delivered her myself.

Danny made arrangements with the Director of the Brand New Funeral Home to gussy Our Girl up and drive her to Nashville to be cremated. He deferred on the offer of a casket and we haven't made a final decision on an urn.

Today, the Brand New Funeral Home will drive back to Nashville and get Miss Shelley's cremains.

By the way, services are private, family only kind of thing. Don’t worry about food or visitation ;-)

Shelley ~ 1995-2009

Today our heads made a decision that our hearts just don't like at all; a decision that hurts way down deep - but one that we feel was completely right for our beautiful girl.

Not many dogs had a better life than she; we can reflect back on hers with little to no regret, knowing full well that we gave her everything that a dog required and whole lot more - and then today, we offered her the ultimate gift.



“You've given your heart for a dog to tear.” ~
Rudyard Kipling

Halloween/Ho-Ho-Ho

Halloween night was clear and cold here in our town; I got to spend my favorite holiday in a perfect way - with tons of friends, pots of chili, jambalaya, Brunswick stew and literally hundreds of trick-or-treaters.

I love the sense of community at Halloween; all of the houses with their porch lights on, neighbors outside talking and visiting, people walking on the sidewalks and all the golf carts decorated with lights. I especially love the simple pleasure that Halloween brings children and adults, without all the other the top advertisement, money spent and preparation that seems to happen around the other "big holidays".

I hate the way the seasons are rushed today. Halloween is barely 48 hours old, but the Christmas decorations are already out. What happened to Thanksgiving?

When I was a little girl, it was a big holiday too; and heaven forbid, if anyone put a Christmas tree up before Thanksgiving; it was a social NO NO...something that you just DID.NOT.DO. (and on a personal note, I think it should be against the law).

When I reflect back to the days when I was school girl, the days between Halloween and Thanksgiving seemed to stretch forever; I so looked forward to Thanksgiving break and the days that followed it – there would be no signs of Christmas until Thanksgiving was officially over – Turkey Day was given it’s due and therefore Christmas was much more special when it finally arrived.

Nowadays, my girls could care less when they spot the first Christmas tree of the season; guess when people put them up for nearly three months before the big day, it’s hard to get very excited.

I noticed the other day there’s a house in our neighborhood that still has their tree up from last Christmas – complete with the Santa hat on. It’s waiting patiently in the front window to be illuminated; I do believe they are well ahead of the decorating curve this year.

Sorry Pilgrim People, you have been stomped on by elves...

Kreative Award

My friend Katie surprised me by nominating My Boy Nelson for a Kreativ Blogger award. My first thought was Wow! That's really sweet of her, cause I've never really considered My Boy Nelson as particularly creative. Irreverent, yes. Sentimental - occasionally. Sarcastic, quite often. Funny? Well, I try. But, creative? Hmmmmm.

Nonetheless, My Boy and I are quite tickled with the award!

Here's what you're supposed to do to pass on the award...

1. Thank the person who nominated you for this award.


2. Copy the logo and place it on your blog.


3. Link to the person who nominated you for this award.


4. Name seven things about yourself that people may not know.


5. Nominate seven Kreative Bloggers.


6. Post links to the seven blogs you nominate.


7. Leave a comment on each.

Thanks so much Yoga Gal, I truly appreciate the shout out!

1. I don’t trust people that don’t like dogs and cats – if someone can’t accept the unconditional love of animal I really think there is something wrong with their heart. Just sayin’.


2. I love to read, but don’t like to check the books out of the library; if I end up loving the book I have a physical need to own the book, I know it’s weird, but that’s just the way I am.


3. I will not eat green beans unless they have vinegar on them.


4. I salt my grapefruit, watermelon, apples, lemons and oranges.


5. I am blonder than I pay to be (for the record, I’m a brunette) and it frequently gets me in a lot of trouble.


6. I love impromptu parties; they always turn out to be a ton of fun.


7. Halloween is my favorite holiday; it’s not as much fun now, but when all the kids in our neighborhood were younger it was one big party.

Here are the blogs that I am nominating:

1. Endless Possibilities is a blog that I enjoy - Kim is immensely talented and if you want to start talking about creative, this girl has got it going on.
2. Smitten Kitchen. I love to cook and love photography -this blog combines both and does a wonderful job of each.
3. The Macs I started following The Macs back in January when their baby girl was diagnosed with cancer. My heart broke, along with all of the other readers, when Cora passed away a mere month later. Her parents have a new baby on the way and their painful journey is something we can all learn from.
4. This DVM's Wife My love of animals got me interested in this entertaining blog with it's beautiful photographs. Their life has taken a dramatic turn recently though, Yooper the DVM, was recently diagnosed with brain cancer - his wife writes touchingly about their struggles, hopes and fears.
5. Pam the Nomad I've had the opportunity to meet Pam and hear a little bit about what she does; she works for Blood:Water Mission an organization that partners with groups and individuals to empower Africans to build healthier communities through sustainable clean blood and clean water solutions. Pam travels to Africa frequently and details her trips on Pam the Nomad; I love to travel vicariously through her blog.
6. Stuff Christians Like. Jon Acuff is hilarious, thought provoking and preacher's kid. Need I say more?
7. God's Blog This is a favorite, it's totally irreverent and laugh-out-loud funny at times. One of the most creative that I've read.