Major Tom Comes Back To Earth

Though I’m past one hundred thousand miles, I’m feeling very still and I think my spaceship knows which way to go. Tell my wife I love her very much (she knows!) Ground Control to Major Tom, your circuit’s dead, there’s something wrong. Can you hear me, Major Tom? Can you hear me, Major Tom? – lyrics by David Bowie

On the opposite arc of three thousand nights is an ivy covered cottage illuminated like a holiday menorah – with motion and photobrightness coursing through the veins of every room.  A person could find 16 Camelot Close after exiting the Wimbledon Park tube station and walking up a steep, tree lined hill of silent uneven pavement. After a quarter mile, you take a left down a tiny, well manicured cul de sac to the cottage whose energy heat signature was brighter than Chernobyl. “The lights are on in every room of that house every night.  Only Yanks can waste that much electricity!” a British neighbor once joked.

I close my eyes and walk through that door over and over, shouting over a din of activity: “I’m home!”  A thunderous stampeding of bare feet would be followed by the screams, ‘Daaaaaaaady!!!”  I smile as I reminisce about a young family living abroad, balancing moments like spinning plates. Each week, I orbited across countries and continents but my favorite aspect of travel was my homecoming – a hero’s welcome from toddlers who would tumble down stairs like tennis balls sometimes wet and lathered with soap. I was a shining star hanging in a firmament that sparkled with a million possibilities.  After a week of being separated from my family, I would transform into Peter Pan derailing their evening routines, leaving my pirates wide eyed where only an impromptu story of Frog and Toad from the Wind And The Willows might sail my crewman off to the Land of Nigh.  

At times, I would surprise my wife and arrive home early. She would disappear for a moment, returning in running attire, holding a filthy child at arm’s length as if he were a drum of toxic waste –- which he was.  “I’m going out for a run” she chirped.  She would tap on the front door after an hour having found her happy place somewhere along the riding paths lined with horse chestnut trees on Wimbledon Common.  The novelty of my arrival would eventually disintegrate as I was expected to resume my role as an adult and partner assuming my fair share of domestic duties. I preferred to be an accomplice and partner in mischief. Each Monday, I would pack my bags only to return to plunge back into their lives, a father and a husband.

The years moved forward with the determination of a great blue glacier.  We left behind our innocence and our cottage, returning to America.  In time, the tendrils of teenage body snatchers invaded our home turning my adoring confederates into irritable changelings that would chafe at the sound of my breathing.  I went from indispensible deity and story teller to annoying traffic cop and money dispenser.

I now open the front door and fall back into my domestic life with a roller bag pregnant with a week’s worth of travel.  “I’m home!” echoes and falls to the ground of an empty foyer.  As I lament the dying light of my paternal star, I hear a bark of unrestrained joy as the dog sprints around the corner to greet me. He cannot arrest his momentum and comically slides right past me on an area rug and crashes into the wall. 

“He’s home! He’s home!” he announces as he grabs a shoe in his mouth and performs a twisting double axel jump. The family room is occupied by two teen boys hunched over a tangle of electronics and white entrails.  The dog seems incredulous at the indifferent reaction to my homecoming. He barks frantically trying to rouse them from their social media stupors.  “It’s him. He’s back. The silver haired alpha dog — the one that walks on two legs and offers food under the table when the she master is distracted.  Don’t you guys see? He’s here!”

One of my boys reproaches the dog.  “Shut up, Brody!” He glances up and sees me, momentarily breaking away from a text message sent from some slow moving adolescent whose corrupted grammar and syntax, by comparison, could make a village idiot pass for Wallace Stegner. “Oh, hey, Dad. How’s work?” He clearly has not noticed that I have been gone for four days.

My professional life of travel has grayed my temples, herniated an L5 disc and precipitated a predictable transformation where my broad mind and narrow waist have changed places.   But absence also made my heart grow fonder and I came to value every moment I could share with my family. I became keenly aware of the passage of time. I learned to celebrate quality over quantity. I learned personal premeditation to be sure that each minute together had the potential to become a memory. A marriage also benefits from travel. It’s a little known fact that most women marry men for breakfast and dinner but not for lunch.  Familiarity breeds contempt and while our presence is always welcome, we have a way of mucking things up when we are around too much.

My life of travel is now winding down and I am delighted to be waking up in my own bed. Sadly, I have observed with a degree of Harry Chapin irony that I am now coming home to a larger home with fewer people.  Everyone’s lives seem laid out like fiber optic lines. My one-time nuclear family has splintered into a closed social network where I act as a sort of financial server. My teenaged tenants now return home primarily to recharge batteries, ask for money or seek medical attention. I find myself like Brody, the family dog, craving their attention.  I want someone to play catch, go for a jog and rough house. 

Brody senses my restless ambition and watches me, trying to anticipate my next move. My wife seems genuinely excited that I am now entering a phase of my career where I will spend less time on the road.  However, it’s clear, that in my absence, everyone has grown up. I am a mere steward and my job is now to prepare them to forge lives of their own.  It all happened so fast.

As I exit my time capsule, an ancient Major Tom, I am arriving back on earth just in time to watch everyone getting ready to leave – out for the night with friends, away for months to college and into the distant cosmos of adulthood forever.   

At this moment, I just want to be on the ground with those toddlers again wrestling and breaking bedtime curfews. I can’t help but feel like a discarded toy.  I can relate to Brody.  If someone were to hold up a tennis ball and yell “fetch!”, I swear to God, I would chase it.

Black Hats and CAD Stents


Top 10 Catholic Health Care Systems
Top 10 Catholic Health Care Systems (Photo credit: Wikipedia)

When Steve Brill released his recent Time magazine article, Bitter Pill – Why Medical Bills Are Killing Us,, it was an overdue chapter in a critical primer to educate the American public on the perverse incentives plunging our healthcare system and our nation into dysfunction and debt.  The Time piece was the first major media effort in some time to shine a light on the factors beyond the insurance industry that contribute to costs that now eclipse 16% of our GDP. 

Brill’s article clearly touched a clear nerve as the American Hospital Association immediately issued a multiple page press release refuting many of the writer’s observations and complaining that billing practices were an outgrowth of a cat’s cradle of cost shifting and an increasingly Darwinian landscape where only the best equipped, resourced and positioned hospitals will survive. 

Yet, Brill’s facts are hard to refute.  Many not for profit hospitals are paying seven figure executive salaries and posting double digit margins achieved through complex and imbalanced billing practices that rival Egyptian hieroglyphics.  Time’s expose demystifies the complicated calculus of hospital billing and alleges that the system of billing and reimbursement is hopelessly broken leaving the most vulnerable of victims in its wake – those earning too much to qualify for Medicaid but earning far too little to afford coverage.  The stories are gut wrenching and identify a range of misaligned financial and care motives across high margin practices such as oncology, imaging, lab, emergency and pharmacy services. The findings also tie to a June 2009 Harvard study that found that 50% of all US bankruptcies were directly related to medical bills and/or illness.

When I crossed the proverbial River Styx from healthcare consultant to regional CEO of a health plan, I was plunged into a bitter and high stakes battle with large hospital systems demanding and often getting double digit unit cost increases. The result was a zero sum game where in my resolve to try to control double digit trend, I would attempt to extract steeper discounts from smaller providers and community based hospitals – ironically providers who offered lower unit costs and similar quality than bigger systems.  However, consumers demanded big name brands. The daisy chain of cost shifting punished weaker players and slowly drove primary care and small hospitals to the edge of extinction.  Meanwhile, the uninsured paid the most for healthcare – often paying 200%-400% more for care in healthcare’s most expensive setting, the hospital emergency room.

In 2007, I watched two regional hospitals engaged in an arms race for membership through aggressive marketing and sub-specialty expansion. When the hospitals both sought to expand their cardiology programs, the practice of inserting post angioplasty stents increased by 300%.  While the risk of stents outweighed the benefits for certain patients with (CAD) coronary artery disease, cardiac interventionalists routinely placed stents in their patients, not because patients always needed them but rather because they could earn more money. It’s a familiar story: The doctor tells the patient they need a procedure. The patient, fearful and accustomed to the notion that more health care must be better, consents.  To the degree, any payer attempts to disallow a recommended procedure as unnecessary, the payer is accused of bureaucratic meddling or worse, jeopardizing the quality of care for the sake of operating profits.  Years later, we are finally beginning to understand that whoever regulates costs, access and necessity of treatment in the healthcare system – be it a payer or a governmental agency, is automatically fitted with a black hat and labeled the villain.

The Time’s article focusing on certain hospital billing practices are a subset of a nationwide game of cat and mouse as facilities seek to balance highly variable reimbursement from Medicaid, Medicare and commercial insurance.  The fight over the true cost of care is often invisible to those footing the bill – employers.  Many employers have no line of sight into the thorny negotiations between hospitals and their insurer.  To make matters worse, if a large healthcare system threatens to drop out of an insurer’s PPO network, employers often urge their carrier to resolve its contract differences with the hospital to limit disruption for employees.  The insurer, concerned over losing membership if the PPO network loses a flagship provider, quietly caves and the cost of inpatient healthcare trends continue to rise. To make matters worse, employers have consistently resisted implementing narrower PPO networks that might otherwise force billing outliers back toward the mean costs of delivering care. It seems employers want to fly first class but only pay for coach.

The insurance industry has committed its share of financial and public relations misdemeanors during the two decade run up of healthcare costs. Yet, insurers were uniquely singled out during the recent debate leading up to the Affordable Care Act.  Politically, the black hat payers were easier targets than other stakeholders who have abetted the demise of our system: consumers with unrealistic expectations, doctors using malpractice avoidance as air cover to oversubscribe services, drug companies and PBMs engaged in intricate and difficult to understand pricing practices, employers who have remained parochial and disruption averse, the food and agricultural industries for practices that promote products that adversely impact public health, the government for its serial under-reimbursement of providers through Medicaid and Medicare and a range of stakeholders who ineffectively advise and assist the industry in its quest for an optimal balance between quality and affordability.

Steven Brill’s thoughtful rendering is an inch wide and a mile deep as it illuminates the need for hospital payment reform.  However, he stops too soon in his expose, refraining from identifying the other accomplices that drive these billing behaviors — including a Medicare and Medicaid system that enjoys low administrative costs but presides over an estimated annual $100B waste and fraud problem arising out of unmanaged fee for service care.  Medicare is beloved by seniors partially due to the simple fact that it does not manage care.  What Brill also misses is the private sector’s apathy in aggressively punishing high outlier unit costs charges by taking on some of our most sacred players – large teaching hospitals and system oligopolies that now dominate many regional landscapes.  As consultants, we have failed to convince employers of the merits of eliminating open access PPOs, increasing consumer directed health plans, using scheduled reimbursements for elective surgeries and enforcing a bi-lateral social contract around good health by requiring workers to see a primary care doctor and receive age and gender appropriate testing to better manage health status.

As with any stakeholder that feels singled out, the AHA response to the Time’s article was swift and predictable.  I’m sympathetic. Laying our affordability crisis at the feet of any one group misses the entire point of our issues in the US. However, the need for reimbursement reform and billing simplification is irrefutable.  Our system is in crisis. The question remains: will we move towards a delivery model that allows market based reforms and affords consumers a greater role in driving quality and cost effective delivery or will we wake up in a decade to a single payer that rations access and peanut butter spreads reimbursement.  One could argue our entire healthcare system can be best summed up by the average US hospital bill – opaque, misunderstood and bearing little relationship to true cost of the services.