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The Fickenscher Files, Vol. 17
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Quote Of The Week

"For me, the past 16 months have been quite an expedition; I feel like Marco Polo...[and]...If
it's going to help anyone, it has to be transformed into the specifications that
regulations and guidance documents...[and]...Put the patent fist, protect the disadvantaged,
start at scale, return the money, and act locally."

Don Berwick, sharing his experience and thoughts as the leader of the Centers for
Medicare and Medicaid (CMS) at the IHI National Forum in Orlando, Florida on December
7, 2011

"I'm also unemployed."

Mitt Romney, speaking to a group of unemployed workers in Tampa, Florida, June,
2011 [NOTE: Romney's net worth is, by some estimates, in excess of $250 million)

Consulo Indicium

Information for your consideration...

Don Berwick's Unfortunate Departure - Over the years, I've been an unabashed fan
of Don Berwick, MD and his many contributions to the healthcare field. Whether
through his work at the Institute for Healthcare Improvement or his firm admonition
to the industry that we can do better, he has always pushed us in new directions
for the benefit of society. I was disappointed with the position taken by the minority
related to Don's leadership at the Centers for Medicare and Medicaid Services (CMS).
He was chastised by the Republicans because he noted that there were elements of
the British Healthcare System that were "good". Having lived in the UK - I concur
- there are some good things about the British Healthcare System just as there are
with elements of most of the healthcare systems throughout the world (Oh, Oh!! There
goes my chance to be CMS Administrator). We all know that Don will not stop his
advocacy and, that's good for American healthcare. We should offer our thanks to
him as he helped to begin our move toward new accountable care methods by shepherding
us through the formative stages of healthcare reform.In an interview on his last
day as the leader of CMS, Dr. Berwick observed that "20 to 30% of health spending
is 'waste' that yields no benefit to patients, and that some of the needless spending
is a result of onerous, archaic regulations" enforced by CMS. He noted five reasons
that cause the waste, including: "overtreatment of patients, the failure to coordinate
care, the administrative complexity of the healthcare system, burdensome rules and
fraud." That's a list that deserves our attention. We should also wish the best
of luck to Marilyn Tavenner. We're going to continue needing advocacy and leadership
at this critical juncture in the reform of healthcare across America. Her leadership
and experiences will help us move in the right direction.

Aging and Diabetes - In a report published in early December in the journal, Age,
in the UK, the results of a study showed that people with blood sugar levels that
are higher than average looked older than those with lower levels. The study reviewed
602 people and found that every additional millimole per liter increase in the blood
sugar level added five months of ageing to the participants facial features (NOTE:
normal, healthy people average between 5 - 6 mmol/). The study went on to say that
healthy people with low blood sugars typically looked a year younger than those
with high readings and a year-and-a-half younger than diabetics. Remember this at
Christmas when the pecan pie is passed around...

Data Breeches and Healthcare Information Security -The Penemon Institute, an information
and security research group, reported recently that data breaches at US healthcare
providers are increasing. The increase comes at a time when hospitals are aggressively
adopting and deploying electronic medical records and mobile technology. The problem
seems to be the fact that these same organizations are not spending enough on security
to ensure patient privacy, according to the report. The Institute notes that "the
frequency of data breaches at health organizations jumped 32% in 2011 from a year
earlier, costing the industry an estimated $6.5 billion." Another interesting finding
from the study was that nearly half of data breaches were caused by lost or stolen
devices. In an age where it is very, very feasible to track devices of all types
- it's clear that the industry must do a better job of keeping up with the new
and evolving technologies which can easily manage security. It's not a matter of
technology but rather, of investment. The study went on to report that 29% of data
breaches resulted in medical identity theft, up 26% over the prior year. More than
40% of the respondents to the study blamed data breaches on employee negligence
such as not following data-handling procedures, using unsecure electronic devices
and, an additional 46% of breaches were due to third-party errors.

Irony of Ironies on the HHS Health Insurance Exchanges Grants - As expected the
Department of Health and Human Services (HHS) has begun the process of providing
support to the states in the development and deployment of the Health Insurance
Exchange (HIE) programs. Last week, the department announced that 13 states were
awarded nearly $220 million in federal grants to initiate the private health-insurance
markets. The HIEs are a central part of the 2010 healthcare reform law. The irony
of ironies; however, was the fact that 8 of the states who received funding under
the program were led by Republican governors who are opposed to the legislation
and have presented cases before the US Supreme Court to strike down the law. The
states which are opposing the legislation and which received grants include: Alabama,
Arizona, Idaho, Iowa, Maine, Michigan, Nebraska, Tennessee and Vermont. The remaining
four states - Delaware, Hawaii, New Mexico, and Rhode Island - have governors who
have expressed support of the healthcare reform legislation. With the latest announcement,
29 states are now receiving HIE funding. Of interest is the fact, that simply accepting
the money does not obligate the states to follow through by implementing an HIE
function.

The Regular, Ongoing But Delayed Medicare Pay Cuts - I've been following the physician
Medicare payment issue for months and months. Because of the recent failure of the
congressional debt panel in reaching an agreement physicians and hospitals are facing
a significant cut in revenue. The doctor and hospital advocates were immediately
activated and warned that the cuts - up to one-third for physician payments - would
have significant repercussions for American healthcare. The concern is that many
doctors would drop Medicare patients and hospitals would be forced to lay off staff
and consolidate facilities as a result of the payment reductions. But, it's likely
that Congress will simply kick the can down the road. Isn't that what they've
done for the last decade? Why should we see a change in behavior? At some point;
however, kicking the can will not work. I think we are very near that point in
time...

The Healthcare Spending Gap Among the States Grows Wider - The Centers for Medicare
and Medicaid issued a new report [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108952418996&s=6409&e=001R2mcTyvI7kiOkmFfy4xnHcP2L7Za3-S2aibPW4obVfi4iZ5etzWZ2EZgkLxZTYdb_pVZA0olsU-ZhqhXLylLd_4DuRv3wDv3Py3UaYkpQRYGXGMlJAa1Sdivm9Y17An5AWkc4fzgu2ls1Uy9vsluuxyzy4_EcxUU9Ud1x33TtnR5tFUYDONmJHNpvhaJWk0zwft7nIpajYZFFeJnsnQPH1P7YdPGKRxM4V8N6hAJy2o=]
noting that the gap in state-by-state healthcare spending is growing. The states
with the highest-spending patterns in 2009 were Alaska, Connecticut, Delaware,
Maine, Massachusetts, New Hampshire, New York, North Dakota, Rhode Island, and Pennsylvania.
The states with the lowest spending patterns were Alabama, Arizona, Arkansas, California,
Colorado, Georgia, Idaho, Nevada, Texas, and Utah. The report was notable for the
fact that the New England and Mideast regions, in general, had the highest levels
of total personal health care spending per capita - probably due to aging of the
population and other factors. Whereas, the Rocky Mountain and Southwest regions
had the lowest - again, most likely due to lower per capita incomes, younger populations
and more people without insurance. For example, Texas (26%) has the highest rate
of uninsured in the nation so that could be a factor there and, Utah (14%) has
one of the youngest and healthiest populations which could be a factor in that state.
At the very top of the spending list was Massachusetts which spent $9,278 per resident
on healthcare in 2009. In contrast to Texas and Utah, Massachusetts only had 5%
of its population without health insurance - a direction that the new healthcare
reform initiative intends to resolve among all of the various states.

We The People...We The Disappointed - We The Responsible

Thoughts on the acrimony that has beset our Nation's Capital in the last several
years....

As the current Congressional session comes to a close and the various Senators and
Representatives head home for the holidays, it seems that a bit of reflection is
appropriate on the state of our society. In the United States, we pride ourselves
on the democracy we have created - a society in which MoveOn advocates share the
stage with the Tea Party. As we all know from our history books, democracy stems
from the 5th century BC when the political systems [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108952418996&s=6409&e=001R2mcTyvI7kg_w4SAC8FBVsC27UUXfwXbxCpXwmtgsoGzRPO4Qx8zQLnylRJwedrSdjde2BzJolpzEBncp5eNaA5ByJnJgJQ8G-zS_fs-Ykkc6mCGX_2yaiEvlmMA8JKVqyHxS-qKRj9spJjsn8EFrw==]
of the Greek city-states evolved especially after an Athens [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108952418996&s=6409&e=001R2mcTyvI7kgXguEm88vCsNB_f5tDBGIQyMrEAt0_7TPE1ebTDPIotMhd8nGyBY3i0jJEfFe1UTSW5Rhq5OMI4oKBDJTFvTdXaKO4DF7ZbbGLWNPXKnsNcvC7Lgj31atPD5FoRwLzuAmaLlUfGkU5Ew==]
uprising in 508 BC [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108952418996&s=6409&e=001R2mcTyvI7khFZUbGEMYb97HuAo0zu4rh7sdJlpFUWedjjWfBr3uCUJcXGuwNcvv9cTBzC5gBtxkFj4oBRL29oARdNK4l-zspDHXNdIhZa9P9tmrSx-SqNML4eFhfQdhX].
The term, "democracy", comes from the Greek [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108952418996&s=6409&e=001R2mcTyvI7kiFOdSkjeMMhBORpFVB7zFfYixZUJmUUf0I_w6W9MjkUP9QgxAPagU9w1NBd7ciugCN4V_p1R8H6eJATyr6yNWpyb1GcymwljCT6efnet83KCwBao_fxn6Fez3gFSBsjVE=]
word dēmokratía or "rule of the people" - which is the essence of a society
that embraces a diversity of viewpoints - which brings us to our current state of
affairs in the United States of America...

In preparing this piece, I thought of John Adams - our second President of the United
States - who shared his perspective in Thoughts on Government which was published
in 1776. He said, "Government is instituted for the common good; for the protection,
safety, prosperity, and happiness of the people; and not for profit, honor, or private
interest of any one man, family, or class of men; therefore, the people alone have
an incontestable, unalienable, and indefeasible right to institute government; and
to reform, alter, or totally change the same, when their protection, safety, prosperity,
and happiness require it." [emphasis added]. It seems to me that his ideas give
us much to ponder in this era of contentious politics where ideological requirements
supersede the notion that to make society work - we all have to compromise for the
common good.

There are lots of theories about democracy and what it represents for a society.
Many theorists have noted that the democratic principle embraces the notion that
we can call into being something which did not exist before. In other words, new
ideas are generated, debated and either absorbed, modified or rejected. And, it
seems to me that the emphasis is on the last three words - absorbed, modified or
rejected. Democracy is also an aspiration, which is why the Arab Spring has caught
so much attention among most of us across the USA and other developed democracies.
Most of us do, indeed, hope that the aspirations of the people in Egypt, Tunisia,
Yemen, Syria and other places throughout the world will be freed from the constraints
of the authoritarian regimes which have dominated too many regions around the world
since the Second World War. But, aspirational freedom is not confined to "other"
places. Aspiration applies at home as much as it applies abroad.

We are a nation built on aspiration. As an example, all of the Fickenscher family
from prior generations emigrated here because of what our nation offers. I think
that pattern of growth for the United States will continue. We are the magnet for
those who adhere to the democratic philosophy by serving as "the beacon on the hill",
which President Reagan pointed out some three decades ago. However, despite that
position among the nations of the world, it seems that the United States is at
a critical juncture related to the directions of our society and the ongoing debate
of what our government should represent and how it should be accomplished. Why is
this happening?

I am not an economist, political theorist or other academic who holds special insight
into the state of government in the United States. I am simply an observer. It seems
to me that the crux of the matter in our nation's ongoing, acrimonious debates is
the increasing constraints we have on available resources. Following World War II,
the United States of America was the only economic game in town. Europe was in shambles.
Japan was decimated. The Middle East had not yet discovered it's oil reserves. And,
the rest of world was developing. As the economic leader, we held virtually unlimited
resources, including unlimited power. As a result, we did not have to make tough
decisions. When you're rich - either as a country or as an individual - decisions
on allocating resources are much easier. In many cases, there is not even a debate.
If you want it, you get it. If you need it, you buy it. If there is a problem with
having enough to pay for it, you move some resources around and solve the problem.
Resources are not the constraint and the internal debate is often much easier. If
this or that program needs a few more resources - so be it. Why argue? If you do
argue it's about personalities - not substance. Just as in families, it's not about
sufficiency as much as it is about the foibles of the individuals members. Such
was the state of the United States from the period following World War II through
the early part of this century. Then, suddenly, things changed...

The United States is no longer the only economic game in town. We not only have
competition from China and India but, Brazil, the Southeast Asian nations and other
regions are assuming major economic roles in the world. So, we can no longer make
unilateral decisions and expect the rest of the world to go along. And, more importantly
- for decisions made here at home - our economy is flattening out. It is no longer
growing in an unfettered fashion. We now have limits and constraints on how and
where to spend our increasingly limited resources. So, in many respects, it is not
unexpected that the acrimonious discussions would grow. But, acrimony does not solve
problems...

We have had other periods of divisiveness which handcuffed discussions in America.
Following the Civil War, a similar period of societal acrimony evolved - again,
because of limited resources. What took us out of that period - and, what will take
us out of the current environment is a recognition that problems are solved by listening
to one another. As a society, we need to create expectations for our politicians
that they need to solve problems rather than simply appeal to our prurient interests.

Which brings me to the point of this whole diatribe... We the People are still a
democracy. We the Disappointed are increasingly moving to our various corners to
advocate our respective positions but, We the Responsible have not stepped up! So,
who are the responsible? I could point to lots of sources but, I will restrict my
comments to the healthcare community. We are now consuming 20% of the nation's Gross
Domestic Product (GDP) - up from a mere 11 - 12% just over a decade ago. The resources
for healthcare - when allocated - come from someplace else. Education is a target.
Many states are doing away with second language programs. Infrastructure has lost
investment. Our nation's sewer and bridges are in deep trouble and need major upgrades.
And, the list goes on. It is time for We the Responsible to take up the baton and
provide leadership. For our part, the healthcare community knows how to reduce resource
consumption for care delivery. The healthcare community knows how to drive efficiency.
The healthcare community knows how to extract better quality - knowing that in the
end, we will do a better job for society.

So, the time has come. We the People...We the Disappointed need to become We the
Responsible. We need to stand up and inform our politicians that the current state
of affairs and debate is not acceptable. We need to insist on "listening" to one
another. We need to demand debating, modifying, and rejecting or accepting ideas
which are put forward to solve problems. Obstruction for the sake of obstruction
is unacceptable behavior - from either side. We must move the debate forward. The
United States has shown great fortitude in solving problems historically. Let's
live up to our legacy and again pick up the mantle of debate which listens carefully,
debates fairly and moves resolutely. This is the American way - not the current
state of affairs. We the People who project an image of We the Disappointed must
take up a stance of We the Responsible. Now is the time...

The Weekly Whisk

Musings from a foodie...

If you come to Washington, DC there's a place you've got to consider - but, only
if you're going to the National Zoo. The National Zoo is where the pandas lived
until they had to go home to China. Even though these icons have left for better
bamboo back home, the National Zoo remains one of the pre-eminent zoos in the world.
And, if you come to DC a lot you can become a member of FONZ - Friend of the National
Zoo [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108952418996&s=6409&e=001R2mcTyvI7kjUsTl6YjUD3l8YhdbO6cGazdZ1MABLL_8Xw0b-iDomrKWpdDV-k5Qxiu-e93iCrWenM8rQEaTDDOhSwJksPExzRw1G5lymmnlRU2__SZiaF2lVxa4E-ly6ojmLZlcsMVPvZjrMBbYkiUUP8180lrmm]
[JOIN today].They wear blue shirts and get you to the places you want to get to
at the National Zoo!! So, what's that got to do with food? Well, nothing but it's
an important set up for my dining place of the week.

Immediately across the street from the entrance to the National Zoo are several
food options. First, Starbuck's is right there. Yes, the ubiquitous Starbuck's is
at the National Zoo. Who could have imagined? Then, there's the 7-Eleven an equally
ubiquitous place where food is a non-sequitor. But, the alternative to these options
is the Zoo Bar [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108952418996&s=6409&e=001R2mcTyvI7khi7Oa7L3c9qtOS_qObTIc7hlgkZEchqF34W4D_0whuKZUCEkOnE5KpvLhQ-_Xn8Y0ncbDid4DZ778baFZI6O4F6wbcjagRsK8=]
(**). Now, the food is adequate but, more importantly from my perspective, it's
a fun place. First, there is Louie. He is the best bartender I've ever met!! In
the past year, he's become a connoisseur of fine cranberry juice - my potion of
the day. And, he can belt out the best of Frank Sinatra. Oh, what a voice!! But,
I digress...

It may surprise many of my readers but I don't always do lots-of-stars types of
restaurants. In fact, I'm actually more of a Zoo Bar, greasy spoon kind of guy!!
Now, for the food, I only rate it a double star because it's edible. Please note
that the food is passable but not world class or exceptional. It also solves the
pangs of hunger that frequent our lives on a regular basis. My favorite is the
Harley Burger which is a spiced hamburger with blue cheese topped with everything
(onions, tomato, lettuce, mayonnaise and pickles). So, if you're hungry after a
long day of visiting all of the animals at the zoo, The Zoo Bar is definitely a
consideration. They also have vegetarian options for those who are so inclined.

If you stop in, make sure you ask Louie to belt out a Sinatra tune. Also, if you
come in on Sunday evening, they have a Dixie Land Jazz band that plays live music
and is quite wonderful. But, don't let that distract you. The animals are across
the street and need your attention. You'll be amazed at what you can learn if you
visit the National Zoo. Go for it at The Zoo Bar - 3000 Connecticut Avenue, N.W.
- Washington D.C. 20008(Directly across from the main entrance to the Washington
National Zoo) - (202) 232-4225

The Good, The Bad, And The Ugly

The ongoing saga...

The Good - The US Labor Department announced that the American unemployment rate
unexpectedly dropped to 8.6% in November, which is the lowest level in two and
one-half years. 120,000 jobs were added in November so things may be looking up
a bit. Let's hope so...

The Absolutely Awesome - The only way to say it is "Green Bay Packers"

The Interesting - The times they are a changin' - 44% of children 6 to 12 years
of age want an iPad for Christmas. Second place? The iPod Touch at 30%. And, third?
The iPhone at 27%. It's a Steve Jobs legacy. He changed the world...

The Bad - The Paris-based Organization for Economic Cooperation and Development
(OECD), a group responsible for improving economic and social well-being among the
34 developed nations, issued a report noting that the disparity between the rich
and poor is the largest it has been in over 30 years. Topping the disparity list
were the United States, Turkey and Israel with a 14:1 ratio with Germany, Denmark
and Sweden at the bottom with a 6:1 ratio. Inequality in America has risen 25% since
1980 with the richest 1% making $1.3 million and the bottom 20%, $17,700.

The Ugly - The ongoing civil disruption in Syria. Why? President Bashar's attempt
to separate himself from the actions of the military in his recent interview with
Barbara Walters was disingenuous at best.
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