Getting Over The New Normal

Barack Obama signing the Patient Protection an...
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Getting Over The New Normal

“It is not the strongest of the species that survives, nor the most intelligent that survives. It is the one that is the most adaptable to change.” Charles Darwin

In her 1969 Book, On Death and Dying, Dr Elisabeth Kübler-Ross describes the five stages of grief.  Over a 27 year career marked by mergers, acquisitions, and perpetual change, I have come to accept these five stages as necessary rites of passage that humans must endure as they navigate the inevitable shoals of change. It seems we all must endure denial, anger, bargaining and depression before we finally break through to acceptance.

While we all intellectually agree that our healthcare system is broken and is in profound need of change, most preferred that all the heavy lifting required to reduce healthcare costs as a percentage of US GDP, occurred on someone else’s watch.  As Woody Allen once quipped, “ I don’t mind dying.  I just don’t want to be there when it happens.”

We know that chronic illness, escalating costs, opaque and uneven reimbursement practices, and a $ 38 Trillion unfunded Medicare obligation would eventually bring the nation to its knees.  However, it suddenly felt like the confederacy of agents, brokers, and consultants were passengers on a bus with no breaks that was careening toward a cliff of profound change.  And then it actually happened: health reform.  Prognosis: Uncertain.

Denial – Most brokers and agents objectively looked at reform as a flawed proposition as it failed to address fundamental cost drivers that were clearly contributing to unsustainable healthcare costs.  Brokers were witnessing 20%+ increases for small business, a limited marketplace of insurers, huge barriers to entry for competing health plans and a supply side of providers that were up in arms over serial under reimbursement from the government and a Darwinian reimbursement environment where only the strong could survive.  Our employer clients were angry with increases, predisposed to market their insurance each year to a limited field of insurers, consumed with avoiding disruption and content to cost shift to employees through higher deductibles and co-pays.  It seemed no one was willing to touch the third rail of healthcare – affordability.

High performance networks, promotion of primary care, an emphasis on personal accountability for health improvement and value based plan designs seemed too complex, cumbersome and indecipherable for many small, mid-sized and larger employers who felt they little capital left with employees to impose additional changes.  This reticence to be early adopters of critical cost management programs and the nature of fully insured pooling by carriers for smaller employers, conditioned employers to consider health insurance a commodity. Most brokers happily moved at the speed of their reluctant clients and remained in step with their insurance partners.  Instead of focusing on risk identification, and mitigation, the industry focused on risk transfer, a generation of brokers and agents built wealth but did not seem willing to risk provoking clients out of their own death spiral.  An entire industry was in denial.

Anger – As the Obama administration shifted its strategy from health reform to insurance reform, denial turned to anger as the industry found itself in the vortex of a poison populism. As insurers were pilloried for for-profit practices, and other third party players were painted as parasites draining the system of its sustainability, brokers felt their blood pressure rise.

The seeming hypocrisy of underfunded Medicare obligations, deficit financing by states facing billions in debt, a generation of consumers on the slippery slope toward chronic illness, employers overwhelmed and averse to change and an opaque and increasingly inflexible oligopoly of insurers – – led brokers to feel victimized and marginalized in the debate.

On the other side of the aisle, legitimate questions arose around broker value as critics witnessed commissions that rose with medical premiums and a lack of transparency on base and contingent compensation.  There was difficulty in determining value for services that did not seem to bend the medical trend curve, and seeming relationships of mutual convenience between insurers and brokers that created potential for conflict of interest.

When reform recently passed, brokers gazed across a horizon line of regulations and did not like what they saw.  Brokers recognized legislation as the first step in addressing fundamental flaws in the system but understood clearly that the Patient Protection and Affordable Care Act was uniquely focused on access and insurance market reforms.  It would not materially change the trend line impacting private employers – – in fact, it could very well make it worse in the near term.  Insurers driven by demands as public companies and possessing fewer levers to pull to impact rising medical loss ratios had become less flexible and defensive.

Brokers also recognized incentives in the new legislation that could accelerate the erosion of employer sponsored healthcare as costs would inevitably rise from increased adverse selection, government cost shifting, a new vouchers system allowing individual opt outs and less onerous penalties that could create tempting incentives for employers to drop coverage.

Questions are now being asked: Will the minimum loss ratio calculation pressure carrier’s retentions to where they will begin to unilaterally cut commissions?  Will insurance companies attempt to disintermediate us? Am I prepared to defend my remuneration in the brave new world of transparency? If I convert my larger clients to fee based remuneration will my margins be severely impacted?

Will my lack of size or premium with insurers make me less relevant and more susceptible to unilateral actions? Do I possess the resources necessary to compete in a world where impacting claims costs will be more relevant than entertaining, shopping insurance and adjusting plan design options? Will state connectors attempt to supplant my role as an advisor?

As costs increase in the near term from mandated plan design changes, underwriting restrictions, Medicare cuts and minimum loss ratios, will companion legislation not be far behind that establishes a state or federal rate authority to artificially control prices? Judging from the insanity in Massachusetts – a market exclusively managed by non-profit insurers, universal coverage has led to an affordability crisis and the most expensive healthcare in the US.  Are we headed over this same cliff?  Will a public option reemerge if we cannot reduce barriers to entry for new players to offer employers more choice? Am I going to end up living in a card board box ?

Bargaining and Depression– Career professionals are already beginning to rationalize.  “ We have until 2014 and many of the impacts will not be felt until 2018 and beyond. “  Others whistle in the dark, “ I just need to make it until my kids graduate college.”  This period of bargaining is a mental feint to prolong change as long as one can to avoid the pain of conforming to a new normal.

Some brokers may just sit down in the middle of the road resigned to a belief that if the insurers do not get them in the form of reduced compensation that employer sponsored healthcare will slowly erode and an increasingly crowded and qualified mid-sized and larger employer brokerage and consulting market will leave them little if any role to play.

Some are taking these changes very personally.  These brokers are becoming lightening rods in their local markets and catalysts elevating the discussion and debate about what next needs to happen to achieve access AND affordability.

They have accepted the axiom that any unsustainable trend eventually ends and that it has now happened on their watch.  Attention is focusing on how they can become focal points for local, regional and national change, They recognize they are not bystanders and third wheels but they are key influencers and the nexus between the supply and delivery sides of the business.  They recognize that they must write the next chapter of health reform and not merely be waiting to read each subsequent installment. Their grief has been brief, their anger channeled, their bargaining and depression endured and their entire focus now is on shaping the next stages of change.

Acceptance – Eleanor Roosevelt once said, “each person has a choice to either light a candle or curse the dark.”  The best and brightest in the brokerage community understand that to broker is to consult and to consult effectively, one must enjoy a trusted relationship with a client.  Any practice that erodes that trusted role should be avoided – especially if it is a legacy practice of an industry did not do a good job in changing our opaque and disconnected third party payer system.

Transparency creates enormous opportunity to delineate value.  If value is defined as “outcomes divided by cost”, the successful post reform broker will delineate their services, the outcomes they hope to achieve and the costs of the services they will provide.  Historically, many commission-based clients did not always know broker remuneration, did not employ service contracts and judged a good outcome as the absence of service disruption.  The world has changed.

Consolidation will create odd bedfellows and strange alliances.  However, in the brave new world, advisors must drive value across an entire employer organization.  While insurers will be struggling to dispel the notion that they are not worthy of margins beyond those of a utility, brokers will need to convey value and if they cannot achieve the critical mass and resources required to compete, they will lose business.

The pressure to create competition and choice may help lower barriers to entry in markets and create new competitors to traditional carriers.  More choice for employers requires more advisors to assist them in navigating through the minefields of competing carrier practices.  As companion legislation continues to evolve, the need to serve clients as a legal and compliance interpreter will be essential.  Merely copying new laws and emailing complex regulatory language to customers will weed out lower performers.  Clients want to know: How and when does this effect me?  What should I be thinking about?

Clients will require help in attacking the last frontier of healthcare – employee health and well-being.  The desert of good intentions is littered with the skeletons of ineffective wellness plans that merely nudged individuals toward healthy lifestyles.  True risk mitigation will require leveraging every aspect of the law to intervene to improve public health.  The best and brightest will recognize that a healthy worker is less likely to file a workers compensation claim.  A healthy worker will miss fewer days reducing absenteeism and costs associated with replacement workers. Population Health management will become as standard as loss control for property and workers compensation programs.  It is motivating to think that by structuring a preventive care plan properly, we can detect asymptomatic illness and significantly reduce the rate of lifestyle based chronic illness.

A Brand New Day: Health reform is not terminal.  However, it will require everyone to change.  We are entering a strange, new universe forged out of intended and unintended consequences.  However reform is also a relief because it is the beginning of a process (however unsavory) to arrest an unsustainable trend.  As citizens, free market capitalists and parents, we do not want to leave our children holding the bag with record deficits and massive public debt.  We always knew the process of taming entitlements and changing a dysfunctional third party payer system would be messy.  As most in Congress lack the political will to take on affordability, it will fall to us.

Regardless of the twists and turns in these first few chapters of what will most certainly be a Dickensonian saga, there will always be a role for smart, motivated, transparent and intellectually curious brokers and consultants.  The sooner each of us concludes our stages of grieving and gets on with accepting the new normal, the better chance we have to lock arms and demonstrate that we can be highly influential in a creating a better and more efficient healthcare system for tomorrow.

Night of The Bureaucrats

Everyday Life - 2010-03-14
Image by Terretta via Flickr

Night of The Bureaucrats

And God said, ‘Let there be light’ and there was light, but the Electricity Board said He would have to wait until Thursday to be connected.  – Spike Milligan

The first omen was a door that was practically ripped from my hands as I attempted to enter Zumbachs Coffee for my noonday latte. Although midday, a sinister pall of slate gray twilight had descended over the south side of town.  A plastic bag whirled in tight frenetic circles as fat rain-drops began to splatter across the hoods of parked cars.  It seemed as if everything was suddenly holding its breath.

After a winter of discontent, an uneventful two days of rain seemed a modest down payment towards spring.  The Doppler radar on the weather channel had shown bright bands of swirling concentric green and orange driving up the eastern seaboard and circling counter clockwise from west to east.  It was a classic late winter nor’easter but with forecasted wind gusts of 40mph it was hardly March roaring like a lion.  It would be a fine day to make a fire, be worthless in my favorite chair and annoy my spouse.

As it was the weekend, I was assigned drop-offs and pick-ups.  Around 3:45pm,  I shuttled my youngest son over to a sleep-over, a mere milk run mile from our home.  The wind had picked up and the road was littered with the leaves, rotten sticks and broken branches pruned and tossed aside by a mysterious hand lurking somewhere west in nearby woods. I noticed a tree had fallen in my neighbors yard – its roots completed uplifted in a great, gaping circle of sod.  It looked like one of those HO Scale trees that would fall over on your electrical train set when the glue finally lost its adhesive.  A little further up the road, I saw another splintered white pine with its branches weighing down a power-line to within a few feet of the ground.  White sparks flew from the wire.

As I slowed to rubberneck – indulging both my son and my inner pyromaniac, a 20′ long branch rushed down from the heavens crashing across the hood of my soft top convertible, shattering the side mirror and careening off to the driver’s side.  I slid to a stop and turned to my son asking him if he was ok. We realized that we had just missed being crushed through the canvas top.

As I gathered myself, another tree fell across the road.  Exhilaration and adrenaline suddenly arced into electric fear as my adventure disintegrated into the movie, “2012”. I was suddenly angry that I had not checked my Mayan calendar that morning. I would have seen that today was a dress rehearsal for the end of the world. At a minimum, I would have told the boys to wear clean underwear.

And so I became a hapless protagonist in some disaster film.  Would I be listed in the credits by name or merely as “Driver No 3″ – who is electrocuted into a burnt chicken about two minutes into the heart pounding disaster sequence.  I hit the gas and over the next 100 yards was pelted with flying debris, horizontal rain and even thought I saw a flying cow. I kept looking for the Four Horseman of the Apocalypse but realized they were in Washington trying to get the healthcare bill passed.

After getting my son safely to his destination, I spent the next 45 minutes trying to find an open road to my home. Every street was blocked.  Certified Emergency Response Team volunteers, already mobilized with chain saws and yellow crime scene tape were trying to redirect determined drivers from recklessly forging through the debris and possibly into downed electrical wires.

It did not seem to register with people that this situation was serious and beyond their control.  In fact, some drivers were visibly outraged at the volunteers as if the CERTS had somehow been off behind a barn playing with a Ouija board and caused all this to happen. I could almost hear the words from the angry man in the Mercedes.  ” I need to get through.” He shouted.  It was the same guy I see at the airport trying to cut to the head of the line because he is more important than the rest of us.   The volunteer was infinitely patient but I am sure was thinking: ” Unless you are from Cablevision and on your way to my house to reconnect my cable, you’re out of luck pal.”

My neighbor Charlie is one of those brave souls that gets calls in the middle of the night saying, “please go stand in the middle of some dark road and help inconsiderate people get home safely – oh, and be nice. Nice towns have higher property values.”  Personally, I’d rather stay in bed and be judged on my good intentions.  I am sure some people actually think these emergency response volunteers are on some kind of power trip.  Actually, it’s the opposite.  When there is no power, they get to take a trip – to some lonely ebony intersection and wait. It’s cold, thankless and dangerous as numb skulls drive right up to within two feet of your soon to be severed legs and ask impertinently ” how do I get home?” to ” how come I was not informed that a storm might prevent me from getting home?” What do I look like a Garmin to you?

I encountered more downed trees. Fences were ripped open and a barn was crushed under a massive hemlock that could no longer handle the 60-70 mph gusts.  I weaved a serpentine route through north Stamford and finally arrived on my street.  The wind tugged at my car door handle trying to get me to come out and play.

The entrails of my side mirror hung out like the guts of an injured buddy in some war movie.  I could almost hear my car, coughing and sputtering.  “It’s getting dark.  I can’t see your face any more.  Can you please just give me a little drink of water.”  I turn to the mechanic.  He shakes his head.  ” You can’t give a guy who is gut shot anything to drink.”

The shag hickories and pines raged overhead like run-away locomotives. I was now leaning over my front wheel like an octogenarian on a Sunday afternoon drive.  I finally rounded the final corner of my road and glided into my garage, a broken skiff barely making it to safe harbor.

As I entered the mudroom, the house was flickering like the haunted mansion at Disneyland – lights were dimming and suddenly glowing brighter. The roar of the generator brought both relief and annoyance as I knew our power had failed.

The generator was an expensive but important investment made over three years ago when a fierce January blizzard turned our home into a Finnish ice hotel.   Pipes burst and I slowly fell out of love with every material possession I owned.  I had new respect for the men of the Hudson Bay Company who lived and trapped along Canada’s great Hudson bay often enduring winters where an inch of ice would form on the “inside” of their winter log lodgings.

After two additional black outs and confirmation from neighbors that our street was what long time CL&P vets referred to as ” FOLO”  ( First out, last on ), I vowed to never again be given a wedgie by Mother Nature.  I researched generators capable of powering my home for weeks if necessary. When I realized these generators were the size of mid-sized sedans, I settled for one that could power a modest consumption of electricity for three days.

I had endured blackouts before in Southern California.  Most were short lived brown outs during heat waves – perfect storms of air conditioning units being activated at precisely the same time. It was there I got my first exposure to a public utility.

My father would later sarcastically explain to me that it was a “special” kind of person that chose to work for a utility.  I assumed he meant those X-men and daredevils that lived to go out in storms to rage against nature – wrestling with electrical wires spitting like poison Cobras, mending broken limbs and clearing fractured thoroughfares.

Dad was referring to the management back at the utilities’ home office. Seems the field force were rough and tumble, ready for action soldiers but there was always someone in the head office who had to deploy the teams.  They were, in his words, “bureaucrats.”

“Bureaucracy is the art of making the possible impossible” he ranted. It seemed harsh.  Perhaps they did not know any better – being forced to grow up playing little bureaucrat games,  “Ok, everyone, stand in a circle and the first person who does anything loses.”

I picked up the phone.  It was dead.  The Internet was out and cable was not functioning.  I now understood what it meant to be part of Cablevision’s Optimum Triple Play.  ” Buy three services from us and if nature hits a hard line drive, you are out — three times. ”  Being a baseball player, I should have remembered a triple play was a bad thing. I called the cable company from a cell that does not get reception.   ”

Welcome…push number…English…service…answered in the order…twenty minutes.”  I hung up.

On Sunday, I surveyed what appeared to be a series of bombs having been detonated all over town.  Yet, I did not see a single Connecticut Light & Power truck.  I saw the police and volunteers but no utility.  Perhaps CL&P were without power and waiting for someone else to come turn on their electricity.  I did not realize it at the time but the rumor eventually got out that some middle manager at CL&P would not release the X-Men and daredevils to clear our driveways and fix our wires because the utility did not want to pay their workers extra time for working on a Sunday.

Bureaucrats! I knew it!

Well, for the next four days we fell back a century. We played games, built roaring fires, and watched DVDs on our personal computers – just like the pilgrims.  I read an entire book.  We hosted a few friends who were in need of a hot meal and warm shower.  It was an adventure.

Driving to work the next day. I saw utility repair trucks from Massachusetts, New Hampshire, Ohio and even Quebec.  I spotted a CL&P truck on the Merritt parkway exiting off exit 31 to North Street. I guess once the threat of time and a half had passed, the bureaucrat allowed all to go back to work. One of my colleagues who lives in Stamford accused me and the other “rich” people of New Canaan of redirecting all the utility manpower from Stamford.  That one stumped me. ” I actually think all the CL&P guys are in Greenwich eating quiche as the bureaucrats started alphabetically, and everyone knows G comes before N and S. She was unconvinced.

We survived. The car has $2000 of damage but everyone is all right. I was lamenting my experience on a sideline at lacrosse last week. On the drive home, my son asked me, “Dad, what’s a bureaucrat.”

I thought for a moment and said, ” someone who does not want you to have electricity.” He seemed satisfied with my answer.

I mean, what else could I tell him.

Dear Dad

Senate Passes Insurance Industry Aid Bill
Image by Mike Licht, NotionsCapital.com via Flickr

I’m too young for Medicare and too old for broads to care.  – Broderick Crawford

Dad,

I got your messages about healthcare reform and your concerns over the future of Medicare. Sorry I did not call you back.  A gigantic tree fell on our entire town during a recent Nor’easter and our local utility, Connecticut Light and Power lost power.  They kept waiting for someone to come turn on their lights.  About four days into the blackout, a middle manager asked, ” isn’t that supposed to be our job?” Within 24 hours, the trucks were rolling.  More about utilities and Cablevision later….

A quick answer to your most urgent question:  I have read the Patient Protection and Affordable Care Act – (all 2400 double spaced pages )  and there is no “Zhivago” clause that will require you to house an entire family of illegal immigrants in the first floor of your home. I think that was a rumor started by Rush Limbaugh or someone else on Oxycontin.

How could Congress pass sweeping legislation at a time when we are supposed to be entering the age of austerity? How did this happen, you ask ? Politics has trumped policy.  This is more about claiming the moral and legislative high ground than it is about tough love change.  Yet, don’t panic. This reform is just the beginning and it will usher in a new universe borne out of intended and unintended consequences.  It may actually save some lives and eliminate some practices that have lead to massive inequity and imbalance in the system. Like it or not, reform has become the raison d’etri of this administration and Congress.

We all agree the healthcare system is broken.  Just ask all the men who now have glowing prostates from irradiation treatment.  One day they are being told their PSA counts are high and that they should count their lucky stars that it was detected early.  The next day, the test’s founder Dr Richard Ablin MD criticizes that 30 million men undergo PSA testing at a cost of $30 Billion and “the test is hardly more effective than a coin toss.”  He goes on to lament, ” I’ve been trying to make clear for many years now that P.S.A. testing can’t detect prostate cancer and, more important, it can’t distinguish between the two types of prostate cancer – one highly invasive and the other unlikely to spread.”  Given the risks for impotence and incontinence, just thinking about it makes me need to go to the bathroom.

Now, where was I ?  Oh, yes, Barak Obama actually started his 2008 Presidential campaign talking about healthcare reform not health insurer reform. He was talking policy and that captured the imagination of industry insiders who felt someone finally understood that you cannot fix the problem of covering more Americans without attacking some of the underlying cost drivers – fraud, oversupply, consumer demand, chronic disease, lack of primary care providers and cost shifting to the private sector by Medicare and Medicaid. And the waste ! Heck, my cardiologist has a toy drawer with Philippe Patek watches. And he is “in network”. Reform looked like it might have some bi-partisan legs.

Yet, the Republicans wanted no part of Obamacare.  It was not as if they had an actual comprehensive plan themselves.  They intuitively understood that if The President’s reform actually succeeded, the GOP would probably not be back in charge of Congress until the Knicks had made it to the NBA Finals. GOP Minority leader John Boehner was heard to remark, “Damn it, if we are going to further sell our souls to the Chinese, I would prefer to do it with tax cuts.” The House Democrats preferred to mortgage our kid’s futures by launching a healthcare plan that expanded coverage but avoided the harder conversation about cutting costs. The President initially kept away from the partisan food fight, choosing instead to sit outside Congress smoking a cigarette with Michigan’s 15th district representative John Dingell who would amuse him with stories about the good old days when Dingell was a freshman legislator under US Grant.  The fact that Dingell kept calling the President “Osama” did not bother him.  The fact that Dingell was not wearing trousers did.

On December 24th, the Senate passed a more conservative version of reform aided by flinty Republican Olympia Snowe. There were concerns from liberal Dems that the Senate bill did not go far enough. It did not include a public option, free diet soft drinks in the Senate kitchen, or a cosmetic surgery tax that would generate an estimated $ 50B but could cause California to lose it buoyancy and sink into the ocean.

Somewhere along the way, an ex-male model Republican named Scott Brown got elected Senator in Massachusetts replacing recently deceased Ted Kennedy (Ted did not look very good in swim trunks and in fact,  learned to swim much later in life).  With the new GOP underwear model, the Senate Democrats lost their precious 60th vote that had given them a super majority capable of defeating any GOP filibuster attempts.  Healthcare and other grand legislative ambitions were suddenly on life support.

The White House quickly abandoned health policy for health politics.  An angry populism was swelling among overweight and jobless Americans and it needed a flint and steel to ignite.  The steel would be the obscenity of 45M uninsured in America.  The flint must be a universally loathed symbol of bold-faced greed and social indifference.  No, we are no talking about AIG.  We are talking about – the health insurance companies.  The troika of President, Pelosi and Reid proceeded to tear a page from the Lenin and Trotsky polemics playbook.  In a brilliant audible, the President understood that to unify a people, you must create a common enemy.

Over a period of months and with the help of his brass knuckled Windy City capo, Rahm Emanuel, the President launched an amazingly effective push to galvanize Congress and the American people around tackling healthcare in two phases.  The first phase would be expanding access to all Americans and convincing them that we could pay for it with a series of stakeholder taxes and financial cuts that would not impact seniors, consumers, or increase the overall public debt.  At one point, he even promised free Cialis to anyone who was experiencing impotence induced fiscal anxiety.  Phase one would seek to curtail the nasty practices of those greedy, soulless insurers.  Many of those who agreed with the President ironically owned health insurer stocks in their retirement portfolios but were angry at the poor returns. The goal would be to punish insurers making them less profitable and turning them into happy, hamstrung utilities – just like Connecticut Light & Power.

Phase two would require the uglier duties of trying to cut costs.  This is the political equivalent of french kissing a cannibal – risky business.  This must involve Medicare fee cuts, reimbursement reforms, taxes on junk foods, raising taxes on individuals, means testing to determine relative costs of entitlements, regulating the necessity of medical services to ensure markets are not saturated – – all of which would antagonize powerful stakeholder groups and probably upset the balance of Congress at midterm elections. The mantra became “Get everyone under the tent”  (and then if costs get really out of control, we can always declare marshal law).”

The strategy would require forcing the House democrats to accept the Senate version of health reform passed as of December 24th, Dems could then pass a second bill that would give the House Democrats a chance at reincorporating certain elements of their original legislation. Ultra liberal and blue dog democrats were wary.  After all, it was a mid-term election year. They were not sure they could walk the plank for the party, risking their own reelection for the sake of voting against the wishes of the voters back home.  Meanwhile the GOP grumbled in the corner about “clean sheets of paper” and “starting over”.  The GOP tendered a late proposal to cover 3M out of 45M uninsured.  This number just happened to coincide with the number of uninsured Republicans.  Sarah Palin even started a rumor that global warming was being caused by excessive methane release from overweight Americans.  She suggested a “gas tax” that would charge $100 for every pound a person is over their senior year of high school weight.

The President needed to start “persuading” swing voters in the House.  He knew the original House legislation passed with only a five vote margin.  No one was sure how many of those Democratic “no” votes were genuine or whether a few blue dogs were given permission by the Democratic caucus to vote “ no” to manage the optics that they were standing up to the party. Would they take a bullet for the team ?  There were too many eyes on the legislation to pay people off in Louisiana and Nebraska pork. So, how did so many arms get twisted to push the ball into the red end zone ?

I have my own theory. Take my own representative, freshman blue dog Jim Himes representing Connecticut’s 4th district.  Jim voted “yes” for the House health reform package claiming that perfection was the enemy of progress.  He registered some concerns about the absence of cost containment provisions.  But I think the pressure got to him.  Put yourself in his shoes.  You’re new and don’t know anyone.  It’s like a big dinner party where everyone knows everyone else. Suddenly the days where you were the master of the universe playing paddle at Stanwich Country Club seem a lifetime away.

It started when Nancy Pelosi started staring at Jim in session.  As a freshman senator, he did not know that Ms Pelosi had not actually blinked in 12 years due to excessive botox treatments.  This unnerved him.  Harry Reid called Jim to encourage him to do “the right thing.”  The fact that Reid thought Himes was the Senator from Connecticut and kept calling him Chris is another matter. However, one chilly afternoon, Jim felt four cold fingers on his shoulder as Rahm took him under his wing and invited him for a beer at the White House.  It was here that the President assured him that he understood that as a blue dog, Jim’s constituents needed to see costs brought under control.

Freshman Jim was probably star struck by this point but unconvinced.  The President went for the jugular, “ You know, Jim, I am sure most voters do not remember that you made your fortune at Goldman, “ He paused  “ It would be a shame if in the primary, your own challenger made hay out of that fact.   I mean, I am sure that you and many others at Goldman were just smart guys doing your jobs.  But hey, the American people don’t know that.” Jim was getting the drift.  Just then Rep. Dingell shuffles in without his trousers and Rep. Eric Massa from New York jumps out of a closet and tries to tickle Jim.  The President realized two things – Jim was now very confused and he was not ticklish.  Jim asked one of his 12-year-old aides to do a straw poll back home and was told people were more concerned about daylight savings time than the affordability of the health reform bill.  It would be easier to risk reelection than to cross the party caucus.  Besides, the president promised that if he voted yes, that creepy NY tickle monster who invited him to move in with him and his five aides would be “taken care of.”

The House ratified the Senate bill and then immediately passed the sidecar bill which amended the Senate version.  The Senate used Budget Reconciliation to pass the House version and voila!, you’ve got the Patient Protection and Affordable Care Act.

The President will sign the companion House bill this week.  Nancy will be grinning.  Joe Biden will probably say the ” f” word again and alot of legislators will be grinning in the Rose Garden, including Mr Himes Goes to Washington.

The least our Freshman legislator could have done was to hold out a little longer like Mary Landreaux or Ben Nelson and get a few goodies for his vote.  I mean a “yea” vote ought to be worth getting Connecticut some money to offset our $ 3.2B budget deficit that will only grow with expanded Medicaid obligations. Perhaps we could get a few more cell towers, bigger public beaches, rerouted La Guardia air traffic or vouchers for purchasing electricity from out of state utilities. And Holy George Hamilton, Jim, repeal the tanning bed tax!

Dad, sorry to be so flip about something so important.   It is just hard to take Congress or the Vatican serious these days. More shall be revealed.   This reform pie is basically baked and I leave it to you to determine whether you find it palatable. I know you are worried about $500B in Medicare cuts.  If we are not careful Medicare will become like a Diner’s Club card with few establishments willing to accept it. Stay tuned.  My guess this is just the first two hours in an epic mini-series where America has to learn a tough lesson about the difference between expanding coverage and lowering costs.

I will keep you posted.  But remember, if anyone knocks on your front door claiming that native Californians now have imminent domain over your property, call the police.

It’s not part of health reform.

Steel Magnolia

Cropped screenshot of Julie Christie from the ...
Image via Wikipedia

Steel Magnolia

My mother said that I was being “truculent” and needed to be punished.

” Just wait until your father gets home!” She hissed.

Her irrational refusal to even entertain this all important sleep-over merely emboldened me. It was not just any overnight but 24 hours at the libertine household of Stephen, one of my more progressive friends whose mother had become the temporary focal point of all my adolescent fantasies.

“Because you already had a sleep over and you are dead tired.” She retorted. “You know the rules.” I was tired, having slept a total of 35 minutes in the last 24 hours. However, adrenaline and the prospect of seeing the angelic Mrs L – a woman who could have passed for the stunt double. for Julie Christie was too intoxicating.

My mother did not partake of  the poison gossip regarding Stephen’s mother who was rumored to be more liberal than a bordello madam. As a Southerner misplaced in a land of new money blue bloods and carpet baggers, Mrs L possessed a refreshing combination of self confidence, candor and beauty.

My mother  enjoyed her liberated and unfiltered assessment of our community. I occasionally overheard Mom defending the Crimson Tide interloper to some hypocritical country club maven who had declared “that woman” a threat to our cocooned decency.

With my parents going out with clients, I would be stuck with my brothers and our sitter Mrs Olsen, an angry, pruned spinster who baby sat for families with “difficult to mind” children. ( No one ever admitted to being a client of Mrs Olson publically. For with such an admission was to suggest that you did not have control of your own life – the home economics equivalent of an F. )

She was the scourge of the babysitting community – a substitute teacher packing a handgun and mace. Instead of laissez faire oversight by a blue haired lady that would raid your Dad’s liquor cabinet and fall asleep to Lawrence Welk, this prison guard did everything but give you a full cavity body search.

I was not going to remain in the captivity of this escaped war criminal when love and adventure awaited just blocks away. I had to find a way to surround myself with throw pillows, love beads and sitar music. Mom did not suffer fools and was conflicted at the thought of me spending too much time at a house that seemed to be permanently stuck in 1968’s Summer of Love. For all she knew, it was the east Los Angeles extension of the Hef’s Playboy mansion.

Her intuition was not all that far off. Their kids were allowed a glass of wine at dinner. The dog wandered the house and slept on the end of the parents bed. Mr L’s “gentleman’s” magazines lay brazenly on his office coffee table. They had a hot tub. Any adolescent boy would have paid his hard earned allowance to spend the night at the home of such French people. And I had been invited as a guest. Best of all, it was the home of the most beautiful Mom on the planet.

As is often the case with suburban families that do not neatly stitch into some xenophobe’s definition of the perfect nuclear damily, a divorce,unconventional lifestyle or counter cultural political orientation, could result in being undeservedly painted with a scarlet letter of disapproval.

Steve’s mother, Joanie, was a cool breeze of bell-bottomed pant suits, flowing floral blouses and earrings that fell in great hoops like rings at the playground. She was a Southern dervish of hair, diamonds and fingernails. She would enter the room followed by a jet stream of strong perfume while holding a cigarette with the world’s longest ash.

I adored her for an entire springtime – barely disguising a crush that would have had me run into freeway traffic at the mere flick of her finger. When Steve and I had once been caught spying on his older sister from the roof, she admonished me by calling me an “audacious rascal.” It was a priceless nom d’ guerre bestowed on a worthless prince by a magnificent queen.

Yet, between Sunday school and Lamp Unto My Feet adolescent guilt, I understood it was not appropriate to have impure thoughts about a friend’s mom. I tried imagining her mangled in an industrial accident. I considered her with a beard. Nothing worked. How could Steve’s dad even go to work in the morning being married to such a beautiful Alabama belle? I was befuddled and bewitched. I did the math of young men determining that I could attempt to court her in 1981 when I was 20 and she was 51. When I was 50, she would be 81. This could work.

Steve’s father was a creative director at a competing agency of my Dad’s. He had obsidian black hair that fell to his shoulders and lamb chop sideburns. He had drove a Porshe and mounted a massive Harley Davidson motorcycle on the weekends. He would rumble up to the soccer fields on a Saturday morning dressed in the Johnny Cash leather and black. He was every working man’s doppleganger – the other road, the riskier option and the life that you could have had if you had the guts. He was different and proud of it.

There were rumors borne either out of fact or petty jealousy that Steve Sr and the other creatives at this agency sat around all day smoking cannabis while getting in touch with their Super egos and that new secretary. While hip was very much in, too much hip meant dislocation for the men on the gray flannel suit generation. You go to one of “their” parties and you end up pulling keys from a community bowl, reading communist literature and living in a cheap motel estranged from the thing’s that matter most –church, family and community.

My crush was a source of great guilt and like most unexplained feelings of adolescence made me feel creepy. I was grateful at these testosterone times that I was not Catholic as I would have had to spill the beans in confessional and possibly spend the rest of my life making penance for my polluted imagination.

My only hope to win her would involve a series of improbable events starting with Steve Sr having a motorcycle accident, followed by young Steve being institutionalized in his grief. In her despair, I would be there, just like Gary Grimes was for Jennifer O’Neal in The Summer of ’42.

After finally getting my mother to consent to this all important sleep over, I drenched myself in English Leather cologne, combed my hair and was dropped off by my father. Steve Sr came out, ostensibly to chat but really to gloat over a recent account they had taken from my Dad’s agency. Joanie waved from the front door. I disappeared into the smoke, perfume and lava lamp light of Pleasure Island. It was on this night I had determined to profess my eternal love to my friend’s mother.

I recall Mrs L looking at me at dinner and sensing my anxiety. ” Michael, you look as nervous as a cat in a room full of rocking chairs.”

I screwed up my courage and followed her into the kitchen. I was 14, and could get a job. I would soon be a professional baseball player. Suddenly she understood my peculiar intoxicated state. She had seen it before. Sensing my imminent confession, she asked me if I wanted to see her wedding album. She described her first kiss with Steve Sr and how exciting it would be for Steve Jr and I when we found the right girl. “Be different. Remember you only have to please yourself.” Joanie smiled and I could see her eyes glistening with tears.

I had no idea what she was talking about and I recall the next morning waking up disappointed but cured of my infatuation.

Years later, I heard she had died. She had divorced Steve Sr for serial infidelity, moved away and ended up in Charleston becoming the prized wife of a wealthy attorney who adored her and gave her the freedom to express herself.

I imagine her grave at the foot of some great magnolia. The cemetery is a sea of sad sameness – a long gray line of slate sentinels. A head stone stands with an epitaph from Rick Nelson’s song ” Garden Party”. ” Well it’s alright now. I learned my lesson well. You see you can’t please everyone so you got to please yourself.”

Healthcare 2015

Healthcare 2015

This gets back to the fundamental lesson of political survival that Bill Clinton taught me, which is if you make it about the American people’s lives instead of your life, you’re going to be okay. Paul Begala

It’s March, 2015.  Healthcare reform has now been active for over five years with the majority of reforms kicking in as of january 1, 2014. Several amendments have been proposed and passed in the interim period including the All-Payer Act normalizing reimbursement rates for hospitals between Medicare, Medicaid and private insurance.

The American Family Practice Reimbursement Act promulgated minimum reimbursement levels for primary care providers acting as part of accountable care organizations and included a package of incentives for medical graduates and nurse practitioners to practice primary care.  A particular emphasis was paid to establishing federally qualified health centers in urban and rural areas where Medicaid statistics reveal high rates of chronic illness and minimal levels of compliance with requisite preventive care to arrest the erosion of chronically unstable patients into catastrophic illness.

A final legislative action – passed in December 2014, increased the individual mandate penalty for failure to purchase healthcare to be equal to the average of the lowest cost plans within state health exchanges.  The amendment was borne out of actuarial forecasts that health exchange healthcare plans were experiencing adverse selection – with younger, healthier workers choosing to pay the de minimus annual penalty of $ 695 in lieu of purchasing coverage whose costs exceeded this amount.

Healthcare costs continue to rise but are projected to moderate with Medicare forecasting its lowest trend in five years.  Private healthcare trend has moderated substantially for small business and individuals but it still plagued by rising expenses as employers resist adopting more aggressive lifestyle based population health management plans.

After hitting a high water mark for overall medical trends in 2012, hospital trends are forecasted to be increasing only 4%, specialty moderating to 3%, prescription drug costs are still hovering at 10% and are a source of great debate among those in Congress who are arguing for more efficacy and value based reimbursement.  Primary care costs have risen sharply but have been more than offset by less inpatient and specialty services consumption.

As we glance across the field of stakeholders, we can see how each is faring in a brave new world that is emphasizing prevention and consumer engagement.

Insurers – Insurers have ceded higher profit margins realized in the individual, Medicare Advantage and small group business as a result of the gradual reduction of their 14% Medicare subsidy and their participation in profit margin controlled health exchanges.  Insurer market share has increased overall but is more distributed as all payer reimbursement legislation removed barriers to entry for new consumer focused insurers to enter the marketplace. Insurers have shifted from opaque and complex provider contracting to focus on consumer activation, public health improvement and patient advocacy and satisfaction.

Insurers are now better branded and enjoy a more trusted role as a healthcare system ombudsman.  Aetna’s purchase of Athena Health and United’s acquistion of Web MD and Revolution Health demonstrate the commitment that insurers are making as the invest in health information technology and consumer/provider data management services.  Carriers are striving to drive value to be considered worthy of margins beyond utilities.  A key strategy has been the hiring and engagement of  B2C business professionals solving for the compromises that have frustrated consumers for years.

Insurers have worked with CMS to aggregate clinical data on quality and efficiency of doctors and hospitals to create a credible, non-partisan consumer report to help patients make more informed choices of providers. High performance networks have become the norm to ensure optimal value over an entire episode of care.   Primary care reimbursement has increased over 30% for family practice providers as insurer medical home and population health improvement incentive programs reimburse family practice providers to keep patients well or stable when chronically ill. Insurers have become better community stewards recognizing that healthcare is local.

Brokers/Consultants/Agents – Total transparency marks the year 2015 as broker, agents and consultants remuneration is shared with all employers. As small group purchasing consortia reduce administrative costs, brokers and agents consolidate creating four dominant brokerage and consulting firms representing employers as they structure their benefit programs.   Consolidation is a prerequisite to affording the resources necessary to add value to employers.

Insurance brokerage and consulting becomes less about relationship management, and annual marketing of insurance and more about serving clients as an extension to their Human Resources and benefits department. Many brokers and agents have failed to justify their role as an intermediary that impacts medical trend and have disappeared.  Those that have survived are distinguished less by the marketing of insurance and more by harnessing clinical, underwriting, administrative, compliance and population health management programs to advise small, medium and large employers on how to best manage and finance healthcare risk.

Hospitals – our most expensive delivery systems have endured substantial turmoil and change as all payer legislation and market forces have pushed facilities to focus heavily on outcomes and value. Hospitals have accepted  value-based healthcare and risk transfer through global case rates – helping actively manage the assembly line of care to patients being delivered by multiple providers within the inpatient setting.

Intensity of services have declined as well as inpatient days. Survivor hospitals have invested in outpatient treatment centers and now triage patients through a more coordinated disease management process.  Tied to accountable care organizations, hospitals remain integral partners but are less likely to be the first point of entry into the health system for critically ill patients. Waiting times increase in some markets as occupancy increases.  A private, non network of concierge hospitals begins backed by private equity firms expecting demand for private elective surgery to increase. Consumers continue to consider non US centers of excellence for elective procedures using medical tourism benefit plans that supplement traditional hospital coverage.

Big is no longer necessarily better. Outcomes are marketed over capabilities. It has been a turbulent time for the SEIU 1199 health workers union as hospital closures and restructuring resulting from reimbursement reforms linked to quality and efficiency have reduced oversaturation of services in certain markets.

Those hospitals once perceived to be most at risk due to their dependence on Medicare and Medicaid reimbursement have become models for business transformation as bigger systems struggle to change.   Total transparency of costs of services and clinical outcomes have become the norm.

A controversial but equally effective decision to regulate rates for certain types of admissions at academic medical centers ( teaching hospitals ) has also better aligned disparities in charges where improved clinical outcomes could not be proven.

Specialists – Specialists have reluctantly yielded to a brave new world of reduced reimbursement, consolidation and the first decline in new practice growth as medical graduates redirect back to family medicine. For the first time in 2015, family practice rates of graduation gain on pathology, radiology and anesthesiology from historic lows of 2% in 2009.

Specialty remuneration is now more closely managed as medical home plans reassert control of care, pre-empting self-referrals and overtreatment more characteristic of the early 2000s.  The expanded role of nurse practitioners and physician assistant further narrows the scope of specialists as basic care and triage for routine conditions returns to a medical home setting. Tension has increased between specialists and family practice only now the resentment has been reversed.  Specialists portend a huge capacity problem as Americans live longer with chronic illness and fewer providers are available to treat them.

Government – Federal and state agencies have made modest strides to controlling the  cost of existing entitlement through clinical and medical management services, not just through serial underpayment.  With improved oversight Medicare and Medicaid, States and the Federal government has successfully clawed back up to $35B a year in fraud and waste.  The additional savings coupled with higher payroll taxes for higher wage earners, global case rates for hospitals, effective disease management and fee cuts aimed at overtreatment has helped finance subsidies for the expansion of primary care.  Government will enforce Certificates of need  and moderate the medical device and specialty care arms race of medical device purchases and redundant care delivery.

States have redirected additional saving to increase Medicaid reimbursement rates improving the circle of providers willing to accept expanded roles of Medicaid based patients for treatment.  As more patients find a medical home and are stabilized, emergency visits reduce and incidence of preventible catastrophic illness improve.  States have adopted interest free medical school loans to students electing to practice primary care as part of the companion legislation in The  American Family Practice Reinvestment Act.

The government finally amends its weak individual mandate penalties and ties the minimum tax to the cost of the lowest price market option so that no incentive exists for individuals to game the system.  States are still struggling with obligations for retiree healthcare – specifically long term care obligations that were not addressed in prior health reform legislation.

Skilled nursing is costing states as much as $80,000 per participant.  State budgets comprised primarily of education and healthcare spending continue to look to the federal government to increase subsidies to cover sun-setting Medicaid support and increased cost of labor as unions have turned their focus to increasing wages to offset expected taxes on cadillac plans designs.

The $ 40B of investments appropriated during the 2009 fiscal stimulus package in health information technology and physician and hospital practice transformation has paid huge dividends in coordination of care and the reduction of waste. After digesting CMS and ONC regulations on ‘Meaningful Use’ and standards for the Electronic Health Record Incentive, an impressive 65% of medical records are maintained by providers and hospitals with outliers paying penalties of reduced reimbursement for failure to comply with 2011 HIT regulations.  While 15% short of the legislated goal of 80%, the information technology transformation has drawn the US closer to other industrialized nations for digital medicine and is hailed as an unmitigated success by the White House.

Government has finally struck middle ground with the all powerful plaintiff’s lobby to modify medical liability law focusing on practical changes designed to reduce the frequency and size of medical liability awards.  Particular attention has been paid to creating tighter controls over punitive damage claims when physicians have followed proven clinical best practices in the treatment of care.

Health tribunals and caps on punitive damages have become mandatory for plaintiff complaints where providers have been proven to follow evidence based guidelines.  Liability premiums have fallen 40%. The additional insulation from risk affords doctors greater confidence in avoiding expensive overtreatment and reduces clinical variability which results in billions in unnecessary care each year.

Congress has promulgated all payer reimbursement reform blending rates paid for Medicare, Medicaid and private insurance.  The National Reimbursement Parity Act was initially met with huge resistance from traditional fee for service hospitals but has helped eliminate cost shifting, create a more unified public/private focus on clinical outcomes, reduced variability of care, encouraged population health management and reduced barriers to entry for new insurers to compete for individual and small business.

The projected net present value of the Medicare deficit has been moderated by this reimbursement legislation and the projected savings has extended the life of the Medicare trust as well as bent the medical inflation cost curve.   US debt standing has improved which in turn, has reduced yields on treasuries – improving credit availability for many businesses, especially those restructuring old debt covenants forged during the tighter times of the 2011-2012 credit crunch. The dollar is slowly strengthening.

Consumers – Medicare recipients now accept medical home models as a necessary access point to the healthcare system. Focus is on personal responsibility and the elimination of barriers to care  (reversing  years of peanut butter spread increased co-pays and deductibles that characterized employer sponsored care in the late 90s and early 2000s).

Employers and providers now understand that they must engage consumers to keep healthy.  Consumers participate in health plans that can offer up to a 50% “incentive ” to participate and comply with expectations for regular care and maintenance. Electronic Medical records allow providers to better manage the treatment of patients with co-morbidities such as diabetes, cardiovascular disease and chronic pulmonary complications.

Compliance with tests such as A1-C tests for blood sugar are being embedded and monitored.  Home healthcare is delivered through accountable care organizations and federally qualified family practice centers that seek to reach underserved, high risk populations using telemedicine and nurse practioners whose roles have been broadly expanded in family practice.

Patients have slowly been socialized to routine compliance calls from nurse practitioners and physicians urging them to follow up with tests, maintenance drugs and check ups.  Patients understand their physicians will be rewarded for health maintenance and catastrophic cost risk mitigation restoring trust in reimbursement incentives and payers.

72% of Americans in 2015 are now accessing healthcare through a primary care provider and employers are seeing a steady reduction in ER visits for routine non-emergency treatment that characterized the early years of health reform where newly insured accessed care through hospitals due to an absence of primary care. Individuals now check their biometric health indicators through work site and public kiosks, health clubs and primary care provider offices to measure progress on key health management indicators.  Reductions in heath risks are rewarded with higher subsidies for individuals and lower costs of contributions to employer based plans.

Consumers are encouraged to engage in end of life care discussions with providers who are graduating medical schools with a greater focus on life quality versus life extension.  The hospice and alternative home healthcare industries have expanded to accommodate a new set of incentives designed to give patients greater control and dignity through the process of coping with catastrophic illness.

With healthcare guaranteed, job mobility increases as job lock due to healthcare is eliminated.  Small businesses develop in myriad industries and the economy begins to see a new generation of cottage industry workers evolve out of a model that offered the best protection for employees covered under employer sponsored plans.

Employers – Perhaps the most engaged stakeholders, mid-sized and larger employers have now accepted their reluctant role as the catalyst for market reforms. In striving for low single digit medical trends, employers have finally elected focused on population health improvement, compliance, value based plan designs, medical home, specialty services for key chronic illnesses such as diabetes, cardiovascular disease and orthopedic care.

Partnering with CMS and private insurers, employers have taken a front seat as the market force advocating the adoption of gate keeper, medical home models and high performance networks to reduce, streamline and rebalance secondary and tertiary care in America.  The C-Suite has finally realized that healthcare can be managed similar to workers compensation with loss control programs designed to eliminate, reduce and manage health risks in their population.  Improved productivity, lower medical and controlled workers compensation costs through a healthier workforce begin to roll into employer’s operating income helping improve  GDP.  States compete for businesses through tax incentives and by advocating a healthier worker population.

Pharmacy – Big Pharmacy and intermediaries such as Pharmaceutical Benefit Management firms have slowly seen margins squeezed. $ 4 generics through Walgreens, CVS, Walmart and others have narrowed margins considerably.  Specialty drug costs have been finally identified as a source of low value, high inflation expense and are being held to a higher standard based on value based efficacy.   A new piece of bi-partisan legislation, The RX Reimbursement and Parity Act will strive to normalize CMS and private insurance RX reimbursement and develop a common formulary for brand and generic average wholesale pricing.

Providers will no longer be able to buy drugs wholesale and sell them at as much as a 50% retail mark-up to patients as was the practice of oncologists in 2012.  There will be a slow push to close the gap between US retail pricing and non US wholesale pricing – mitigating the artificial subsidy that US healthcare patients finance for other countries consumption of US drug products. Legislators with large concentrations of bio-pharma industry are wary of this level of intrusion in the bio-tech markets.

Patent protection is now prioritized by social need and based on evidence of impact. Pharma salesforces have been pruned substantially to partially offset margin declines as physician decision support tools ushered in by a new generation of electronic medical records and health information technology has transformed doctors offices and better coordinated on and off label use of medications.

A False Positive ?

As we stare into our crystal ball, we wonder whether this vision is but a dream or a potential reality borne out of a confluence of public policy and market forces. In a free market economy, balanced symbiosis can be accomplished through a variety of careful interventions.  When ecosystems become wildly imbalanced, calculated adjustments are necessary to restore equity and efficiency.

2015 is about balancing public and private responsibilities. There are no victims or villains in this discussion. The conversation needs to shift back from politics to policy. Everyone has their fingerprints on the problem and can contribute to its solution. We need to excuse from the discussion those who choose to remain too committed to the status quo and those whose angry populism has compelled them to advocate massive public policy interventions without understanding the downstream impacts on quality and our economy.

It is unlikely that we there will be only one winner. In this fight for the future, we all win or lose together.

Stay tuned.

Lost in “Lost”

Lost in Lost

After enduring a year-long addiction to the serial television drama “24”, I voluntarily submitted to Serial Television Addiction and Recidivism Eradication therapy (STARE) at Silver Hill.  Serial TV addiction effects every demographic ranging from college students and women addicted to soap operas and weekly black comedies like Desperate Housewives to middle aged  “Nick-o-loadies” that spend days watching reruns of Dark Shadows and Peyton Place. Therapy was intense and included a 12 Step program written in the format of a TV Guide.  We were forced to learn the real names of actors and actresses, unsuccessfully locate places like Port Charles ( General Hospital) and watch eight consecutive of hours of Gomer Pyle USMC.  Aside from  a slight gag reflex every time I hear Jim Nabor’s sing Christmas carols, I have suffered no long term side effects from my Clockwork Orange shock treatment.

I have now sobered to the dangers of watching highly addictive weekly TV series. I break into a sweat if I watch the evening news for more than ten minutes. I took an oath to my “24” Home group to never again watch any show or film with Kiefer or Donald Sutherland.  Fanaticism is particularly harsh in this age of overloaded advertising.  The serial TV addict wastes hours on their habit – – often consuming thirty minutes of carbohydrate commercials just to get to the more meaty half hour fix of weekly programming.

My family had also succumbed to the intoxicating weekly dramas of “24” and “Heroes”. In 2009, our house transformed into a den of neglect and weak intentions. We were like something out of the disturbing A&E show “Hoarders” –  a bizarre world of shut-ins, trapped in denial where garbage was piling up, the dog had eaten the cat and bills had gone unpaid.

We resolved to attend therapy sessions as a family – agreeing that we would shake the dreaded vidiot monkey together. Initially, our intervention went well. Yet, I noticed my eldest son was restless and irritable in group therapy.  He took a month to concede that Jack Bauer and CTU were fictional characters but he remained insistent that President Obama was not a US citizen and that the Bermuda Triangle was indeed a real phenomena.  “There are places in the Pacific where electromagnetic forces can create alternative realities.” He asserted. I dismissed this as too much exposure to Bill O’Reilly.  That afternoon,  I blocked the Fox channel on our TV.

Yet, something was not right. I overheard my youngest son talking about some new friends: Jack, Hugo and Sayid. I heard my daughter discussing “The Others” and a “smoke monster”. As a high school junior, I assumed these were euphemisms for kids that were on the fringe of her social circle and a fellow teen with a nicotine habit.

I arrived home one Monday evening to an empty kitchen, family dog licking dinner plates left on the table and no sign of human movement. From a distance, I could hear mechanical thumping and screams as if a person was being mangled in an industrial accident.  I raced to the door of our bedroom and burst in on an opium den of junkies. In the flickering darkness, I found my four recidivists abandoned in the television series, “Lost.”

“I thought we agreed no more TV series” I said to my spouse, recalling our stolen evenings of 2009 as we watched 7 consecutive seasons of “24”. “Oh, don’t be such a poop.” She laughed. “Sit down and watch with us.”

“Shhhh!” hissed my oldest son. “What just happened?” She asked him anxiously.

“Your dinner is in the oven” she said absently not taking her eyes off the screen.

I sullenly shuffled to the kitchen with the family dog patterering behind me, a tri-color remora shadowing me in hopes of feasting on my leftovers. As I sat eating dinner alone, my Aussie rested his head on my loafer and sighed that deep heave that only a dog can muster. He understood the pain and abandonment of addiction as he had probably not been fed in days. Off in the distance, I could hear a muffled cacophony of mayhem as some mysterious mechanical monster savaged another castaway.

I mindlessly ate and pondered a future of weeks without companionship as my brood descended into scattered DVD boxes and arguments over who jumped ahead to watch another episode. It was not enough that they were in the grips of their own mania. They were determined to corrupt me. Like dime bag drug dealers they whispered. “Oh, come on. Try it. Don’t be afraid. You’ll really like it, Dad.” My youngest son grabbed my arm.  Even the dog was now intrigued by a Golden retriever that was regularly featured on each episode. Et tu, Brody?

As I resisted, I became alienated from them in little ways.  I resented their  private inside jokes and “Lost” conversations. “Mom, what is up with Locke and why did he not push the button?” “Do you think Libby is real or fake like Hurley’s other friend from the insane asylum?”. ” Who is Ben, really ?”

My wife tried to rationalize their addiction. She explained that developing this common time with our teens could create valuable paths of communication. I wasn’t buying what she was selling.

” That’s what you said about ’24’ and I ended up having dreams about wanting to cut my boss’s head off and carry it around in a bowling bag.I was convinced the guy at the convenience store was a hostile terrorist cooking enriched uranium in the bathroom.” It was true. Overexposure to Jack Bauer had left me convinced that torture was a perfectly appropriate way to discipline anyone – including a child or an insubordinate employee. ” You may not like my methods,” I would say to my victim, ” but this company needs people like me.”

I glanced at the TV screen as it flickered the letters L-O-S-T.  I became combative.”How do you expect me to believe that all these good looking people ( except Hugo ) were actually on the same plane? The average commuter flight is filled with overweight Americans all hit with the ugly stick.”

“Come on, it will be fun. It can be our date night.” She shoved me in between two boys and the dog.  My “date” then crawled back in between the corner of the couch and my daughter.

From what I could ascertain, in 1974, a clandestine research group was transported to an island in the South Pacific where they began to track, monitor and even tap into a mysteriously powerful magnetic pulse.The project — known as Dharma – flirted with Einstein’s theory of relativity and distorted concepts of space and time. It was on this remote cay that something went terribly wrong, resulting in a catastrophic vortex that wreaked havoc on the cosmos and an unfortunate commercial airline bound for Australia. The island and Flight 815’s seventy-one surviving passengers share sinister secrets and a bizarre relationship that feels as though every character has died and is somehow trapped in an inexplicable purgatory.

The scene opens to a torn fuselage of a jet resting on a tropical beach as passengers mill in indecision.  Two male underwear models, Sawyer and Jack, argue over some trivial matter. Ok, I now get why the girls are drawn to the show. Two seconds later a scantily clad girl removes her blouse to sunbathe while another twenty-something relives her checkered past in an action packed flashback.  Check! Now I get the boys’ motivation.. A golden lab trots down the beach. Our Australian shepherd tilts his head and gives a nuetered “woof” at the television. Yes, it seems there is something for everyone on this mysterious island.

I am worried about being manipulated by the producers of “Lost”. I know I am going to get sucked in to a somewhat plausible plot that will disintegrate into a plot line that ends up like the Weekly World News with a picture of an alien shaking hands with ex-President Bill Clinton or a Batboy on a rampage. The fear of losing all those precious emotionally invested hours to some fantastical Captain Nemo comic book plot compels me to leave the room. Must – re-sist-temp-ta-tion!

Our house is silent except for that incessant thumping and screaming. I pretend to leave, shouting.  “Ok, I’m going now. Cindy Crawford is at the door and we are running away together to start a beauty mark clinic in Laguna Beach! I won’t be home until 2019.

(Silence)

“Ok, I’ll see you guys next month. I’m off to film a reality TV pilot on latch key husbands”

(Crickets)

Disgusted, I plop in my favorite chair and stare at a vacant flat screen. Framing the television is a bookcase of classical literature whose protagonists are shipwrecked, shanghaied, imprisoned, cuckolded and left for dead. I rise and pick up Alexander Dumas’ The Count of Monte Cristo. I clearly recall my first reading of Edmond Dantes, his imprisonment and improbable escape from Marseille Bay’s island prison, Le Chateau D’If.  Yet, all I can think about is Jack Bauer. What would agent Bauer do to those French bourgoise after they unjustly jailed him? It would definitely involve a cattle prod.

My “24” addiction is returning. I can feel it. My palms are sweating. I need a fix. My family is not here to prevent my descent into a roller-coaster ride of adrenaline.

I suddenly recall it is Monday night. “24” will be on in less than a half hour.  Relief falls like soft rain. My nose stops running. I can almost hear Jack Bauer on his head set, “We’re ten minutes out. The Tac team is on its way. Hang on, damn it. Just hang on!”