On the eve of a new decade. . .

Technically, the year 2010 belongs to the first decade of the 21st century, but we rarely talk about it that way. You remember all the Y2K hoopla we went through when, technically, the new century wouldn’t officially have begun until we FINISHED the 20th century (1901 -2000). Oh well, so much for technicalities.

So, giving in to popular convention, we sit at the dawn of our second decade of the 21st century and what do we know that we didn’t know ten years ago?

That a “failure of imagination” can kill you. That’s what the 9/11 Commission called our failure to foresee and prevent the attacks of September 11, 2001. While we acknowledge that hindsight is 20:20 and that most of us “Monday morning quarterbacks” think we know so much more than those in charge, it is hard to accept that we ought to be learning our next moves on the international chess board from the writers of science fiction and mystery. What is our next failure of imagination – only a look back at what we now call the future will tell.

That healthcare is a right, not merely a privilege. At least that’s what Bernie Sanders, Independent U.S. Senator from Vermont declared earlier this year.1 He goes on to remind us that “At the individual level, the average American spends about $7,900 per year on health care. Despite that huge outlay, a recent study found that medical problems contributed to 62 percent of all bankruptcies in 2007.” So, at the 11th hour, the American congressional leaders gave us a healthcare bill. Now we’ll see how long it takes for ordinary citizens to begin to feel the effects of such righteous medicine.

That we’re all getting older. No big secret here, but what I mean is we’ll all be paying the price for the birth of the Baby Boomers some 60+ years ago. We boomers were born between 1946 and 1964. Based on a July 2008 estimate there are 303,824,640 U.S. citizens and roughly 12.7% of us are 65 and over. The real sad truth is that most Americans live to be at least 75 years of age and some of us (at increasing rates) will become centanarians – about 214,000 by 2010 according to census bureau estimates.2 The trouble is not that we enjoy longevity, it is that the rest of the country will end up footing the bill for our long-term healthcare needs – a very costly enterprise.

Industry experts suggest that “By 2030 those needing LTC will skyrocket to 23+ million Americans, with projected, individual long term care costs reaching $300,000 annually per individual!”3 And we think health care is expensive now! When you consider who is and will be paying for Medicare and Social Security political pundits have warned, “Starting in 2008, 70 million baby boomers will begin retiring, and they will live longer than their parents did. That means that the number of workers paying for each beneficiary will drop to just over two by mid-century.”4 Two-to-one; dreadful odds, especially if you’re under 30.

For myself, I also know that:

• Being called grandmother trumps all the other titles I’ve had.
• I can live comfortably on less than I make.
• I don’t need any more jewelry.
• Life is a mystery – enjoy the ride!

1. Sanders, B. (2009). Health care is a right, not a privilege. The Huffington Post (December 28, 2009) accessed from http://www.huffingtonpost.com/rep-bernie-sanders/health-care-is-a-right-no_b_212770.html

2. Projected Number of Centenarians in the United States bySex, Race, and Hispanic Origin: 2000 to 2050. Current Population Reports, P25-1130, U.S. Government Printing Office, Washington, DC. Accessed from http://askville.amazon.com/centenarians-United-States-men-women/AnswerViewer.do?requestId=5959708

3. Long Term Care Insurance (2008). Long term Care Insurance National Advisory Center accessed from http://www.longtermcareinsurance.org/

4. Cannon, M.F., (2005). Medicare vs. social security: who’s on first? Nationalreview.com (April 14. 2005) accessed from http://www.cato.org/pub_display.php?pub_id=5357

Open letter to Charles Babington...

This is an open letter to Charles Babington, writer for the Associated Press, whose article in the Minneapolis Star Tribune on August 3rd made me wonder if he was interested in shedding light on the health care debate or merely adding to the heat. He asks that we check the facts, and then goes on to offer us his five insights on “the facts” as he sees them.

I offer a personal and a professional perspective as a nurse with 34+ years experience in the American health care system. I see our elected officials struggling to manage the macro-economics of health care yet failing to recognize, let alone understand, the micro-economics that confront each of us as citizens and consumers every day. I confess that my opinions are shaped by what I’ve seen over the years and read in documents like the Rand White Paper (1), Living Well at the End of Life, which lays out the costs of disproportionately using our resources to stave off death.

My bias is that our health care system is mostly an “illness care” system, prepared to tackle our health problems only after they have become huge obstacles in our lives. There is little about it that offers us wisdom on preserving health, managing minor illnesses well or making thoughtful decisions about the quality and length of our lives. The data, in some cases, are out there (smoking contributes to cancer and heart disease; exercise prevents many chronic illnesses) but our health care system is poorly set up to move the public health of our nation toward genuinely healthy decisions. Intervention comes a day late and a dollar short for most of our citizens. The rest of us just shake our heads and tolerate it. Oh, and by the way, we pay for it, too.

Mr. Babington hits on some important issues and offers us good arguments but no direction. Here are the five facts he points us toward:

1.THE FACTS: The House bill would require Medicare to pay for advance directive consultations with health care professionals. But it would not require anyone to use the benefit.

I agree with Mr. Babington, advance directives are intended to lay out a patient’s wishes for life-extending measures. Generally, these documents are constructed in consultation with health professionals, not government agents. Will Americans pursue with more vigor the construction of their own advance directives simply because a law permits payment for the consultation? Few people bother to write out their wishes now. Worse, even fewer emergency departments and first responders have access to these documents when important and immediate intervention decisions arise.

Jones (2 ) indicates that by 2007, only 41% of Americans had created living wills. However, for the advance directive to be an effective tool, far more of us need to subscribe to the premise that we want and need such a tool to live our lives thoughtfully and ethically, especially at the end of life.

Will paying for consultation lead people to take advantage of the opportunity to make their wishes known? I have my doubts. Perhaps instead, the law should require (at least for members of any “public plan”) that we must write out an advance directive. For me, I’ve done that, but in addition, I intend to have Do Not Resuscitate tattooed over my sternum, where hopefully, anyone attempting to save my life with CPR should find it.

2.THE FACTS: The proposed bills would not undo the Hyde Amendment, which bars paying for abortions through Medicaid, the government insurance program for the poor. But a health care overhaul could create a government-run insurance program, or insurance "exchanges," that would not involve Medicaid and whose abortion guidelines are not yet clear.

Since we don’t have any final language, I’d hate to see us dismiss the first serious U.S. health care reform in my adult lifetime on language we haven’t even read yet.

I’m a person of contradictions and paradoxes. I’m Catholic, so you know that my bias about abortion leans seriously against it. I’m also pro-choice, so while I admit I couldn’t choose to have an abortion, I am grateful that my government no longer criminalizes a woman’s choice to consider it. That said, if what we’re interested in is lowering the COST of healthcare, we have to think about the amount of futile care that goes on at the two ends of life – near birth and near death.

Our arguments about abortion get so loud that we forget to even discuss the topics that we should, like America’s infant mortality rates. If we want to talk about the wellbeing of babies, that’s the place to start. We forget all about PREVENTION and the modest expenditures required to bring most children into the world safely. Krisberg (3), writing for The Nation’s Health, alerts us to data “released in October 2008…the Centers for Disease Control and Prevention’s National Center for Health Statistics ranks the United States 29th globally in infant mortality in 2004.” It is a sad commentary on where our values lie.

In America, we rely on neonatal intensive care units (NICUs) to preserve the children who, with a little prenatal care, might have stayed safely in the womb until full term.

Lantos (4) reminds us, “Neonatal intensive care is one of the triumphs of modern medicine. Babies who inevitably would have died a few decades ago routinely survive today. But the success of NICUs should not lead us to see them as the only solution to infant mortality or as an adequate moral response to our children's health needs. We should constantly remind ourselves that the need for so much intensive care for so many babies is a sign of political, medical, and moral failure in developing ways to address the problems that sustain an epidemic of prematurity.”

That’s where our attention must be focused, on that epidemic of prematurity. Yet we insist on getting hung up on the abortion issue, and miss all the opportunities prevention could offer.

Then, when we do care for a child in NICU what criteria are we using for the treatment we insist on doing? It is usually not statistics (which can be grim). Hack (5) and colleagues remind us that the mild and moderate handicaps associated with preterm and low-birth-weight babies include asthma, attention-deficit disorder, visual problems, cerebral palsy, and the need for special education. These outcomes can drain a family financially, physically, emotionally, and spiritually. Clinicians, families and most in our society share a built-in bias to treat newborns aggressively.

But, we also owe it to these parents to help them become well informed of the potentially long-term struggles in raising a child with special needs. Health care providers should not tell them what to do, but counsel them fully so they are not surprised or saddened by the outcomes of their decisions.

3.THE FACTS: The proposed legislation would not require people to drop their doctor or insurer. But some tax provisions, depending on how they are written, might make it cheaper for some employers to pay a fee to end their health coverage. Their workers presumably would move to a public insurance plan that might not include their current doctors.

Wow – news alert, you may have to change providers! Every time your employer picks a new insurer you run that risk. If you lose your job you may lose your provider. And, if you have to change cities to get another job, you’ll probably have to find a new provider, too. This isn’t news. Primary care provider (the person you see for year-to-year preventive care) numbers are dwindling at break-neck pace, and they’re aging too. So, honestly, if you live a good long life, you’ll have to find a new provider from time to time.

Again, I agree with Mr. Babington when he offers his next set of facts.

4.THE FACTS: Millions of Americans already face rationing, as insurance companies rule on procedures they will cover.

And rationing goes even further into our healthcare choices and decisions:
•When healthcare facilities cut nursing staff, access to needed care goes down accordingly. The length of time from pressing the call bell to receiving a response, that’s an access issue too!
•When cities and towns cut back on first responders and ambulance crews, that’s an access issue as well.
•When drug costs soar out of the reach of common citizens, guess what? That’s an access issue.

Rationing happens! We just don’t want to admit that it does, and always will. Rationing isn’t wrong, but it shouldn’t be thoughtless or haphazard. We all ration, every time we examine our own personal budget. Personal rationing asks, how much will I spend on this or that? Will I make healthy choices for myself, or careless ones, hoping there’s enough money to pay for the damages they will cause?

The issue is WHO should be determining how public rationing occurs? In my opinion, it should be a layered discussion and decision. First, for simple things, the patient, family and provider should handle matters. After that, within a “public option” and for more complex issues, states should have an expert committee made up of healthcare professionals, community members, ethicists and clergy who help determine the tough issues.

There will always be rationing; our technological advances make it so. We’ll always have more tools available than we have time, people or financial resources to use them. And, just because we CAN provide a particular healthcare intervention, does not mean we should!

5.THE FACTS: Obama's pledge does not apply to proposed-spending of about $245 billion over the next decade to increase Medicare fees for doctors. The White House says the extra payment, designed to prevent a scheduled cut of about 21 percent in doctor fees, already was part of the administration's policy.

Mr. Babington tells us that the White House and Democratic lawmakers are talking about creating a powerful new board to root out waste in government health programs. He suggests that it's unclear how that would work.

Well, I have some ideas. The new American health care system should:

-- Require advance directives and the conversations they initiate. Write out your health care wishes, update them regularly, let family, friends and your physicians know about them and above all, be informed about what end-of-life care means. Be careful what you ask for!

-- Focus on prevention. Make preventative health care a RIGHT not a privilege so that we begin to level the playing field for all of our citizens. Immunizations cost less than the diseases they prevent; check-ups catch early signs of disease when it is more treatable; information about healthy choices offers us choice about our long-term health care goals.

-- Change providers thoughtfully. Consider a new provider when you’re approaching 65 especially if your physician is too! Consider a new provider when you’re not getting access to information about national guidelines designed to drive best health care practices. Consider a new provider when your provider fails to treat you as a partner in your own care!

-- Ration rationally. Think again about how we use our intensive care units and emergency services (of all sorts) so we’re not spending the bulk of our dollars on the final year of life, but on the early years when a healthy start can make a world of difference.

-- Help the government root out waste! Report fraud and certainly don’t engage in it (like lending your insurance card to an uninsured family member). Don’t steal – no, the towels, pillows, sheets, and extra supplies in your hospital room are NOT YOURS to take with you.

Don’t ignore the signs of illness and neglect to take appropriate action. The life you save may be your own!


References cited:

1. The Rand Health White Paper, WP-137, (2003). Living Well at the End of Life. Accessed August 3, 2009 from: http://www.medicaring.org/whitepaper/

2. Jones, C. (2007). With living wills gaining in popularity, push grows for more extensive directive, Crain's Cleveland Business, August 20, 2007. Accessed August 3, 2009 from: http://www.highbeam.com/doc/1G1-167959744.html

3. Krisberg, K. (2009). U.S. lagging behind many other nations on infant mortality rates: Healthy behavior, healthier babies. The Nation’s Health (February 2009). Accessed August 3, 2009 from: http://www.apha.org/publications/tnh/archives/2009/February09/Nation/BabiesNAT.htm

4. Lantos JD. (2001).Hooked on neonatology. Health Aff (Millwood). 2001;20(5):240.

5. Hack M, Taylor HG, Drotar D, et al. (2005). Chronic conditions, functional limitations, and special health care needs of school-aged children born with extremely low-birth-weight in the 1990s. JAMA. 2005;294(3):318-325.

School Daze II

School is starting this very week and I feel like a prisoner of my own choices. I’ve chosen to go back to school to pursue this post-master’s FNP certification. I’ve committed my time, my energy, my schedule and risked the significant relationships in my life toward the completion of this graduate work. Yet, right now, I feel as though I may very well have chosen poorly, and that is most discouraging. Some dreadful confusion has led to our not having an instructor in place for one of my courses. The tempus is fugit-ing and so far, all we (students) know is that the school is “working on the problem”.

This seems to be happening everywhere. Just last week I was trying to help another school sort out a similar faculty difficulty. That school was scheduled to bring 8 senior students (BSN program) to my workplace, and they found themselves at the 11th hour without a clinical instructor for the student group. I got pulled into the problem-solving because our Education Specialist was out on medical leave. In the end, the school found someone to teach the clinical section. Who knows what her credentials are, and whether she’s ever seen patients like those we serve every day. She’ll have no rapport with the staff here and no familiarity with the curriculum the students are studying. A lovely way to begin the semester!

In the long-run, this fall’s difficulty will disappear from my memory. I will accomplish my goal and like all unpleasant experiences, this one will dissipate and become a thing of the past. For me, this is merely annoying.

For my fellow students, and especially for those undergraduates who are set to begin their clinical instruction at my hospital next week, I find this situation reprehensible. My colleagues in graduate school are mostly young women (okay, there’s one guy). They either have jobs that function on shift-work or student loans that will bury them for years to come. They have young children and aging parents to care for, and spouses who probably have less tolerance for nursing graduate school than mine (with two PhDs) does.

We (hubby & I) were having a conversation just last evening reminiscing about our fond memories of graduate school. His experiences were in the 1950s and mine in the 1970s, which seems like eons ago. We remember faculty members who liked their work, faculty who liked students and were committed to our success. We remember faculty who mentored us, encouraged us and set each of us (twenty years apart) on paths that would launch us on meaningful careers of life-long learning. What are my school colleagues getting out of their graduate experience? And, perhaps even more importantly, what are today’s undergrads experiencing in their educational programs? Will they even WANT to consider going on for more schooling? If the undergraduate experience is discouraging, why would anyone sign up for more?

This is, I believe, the 21st century challenge in higher education: to recruit, hire, support and retain high-quality teachers. How do you do that, especially with a reward system so skewed, especially in the healthcare fields, toward being out in a practice setting, rather than in higher education? Out in the work-world of healthcare, the practitioner can earn at least half again as much each year as the professor who taught her. Its sad, but true.

That I am in nursing gives me only one perspective and limited insight, but I have to believe that the situation is similar in all the healthcare careers including medicine, the rehabilitation therapies, dentistry and social work, each of which are requiring increasing levels of graduate education for practice. As we continue to require more years of education, we tax the faculty we have and we probably dissuade the practitioner from teaching, given the financial burden he or she has accumulated during the preparatory educational process.

This time around, getting graduate education in the 21st century, I find myself discouraged. If asked by a colleague, “should I go back to graduate school?” my answer might not be the rapid and automatic “yes” that it would have been before my most recent experience. No one is, at this moment, mentoring me as a student. I have to wonder if my younger colleagues, who do not have the nostalgic memories of graduate school of long ago, are even more discouraged than I am.

What should graduate education be?
To my mind it should definitely be:
-- An exciting encounter in which the learner is stretched and challenged by the information, not by the logistics of learning.
-- A reinforcing, supportive place where the learner gains a new vision of his or her own professional possibilities, a time to imagine an ever-opening future.
-- An opportunity to hone those generalizable skills like reading comprehension, analysis, synthesis and problem-solving that will complement anyone’s lifetime of experience.
-- A place where learners meet faculty who are excited and positive about their work, connected to the current trends in their field, happy in the work that they’ve chosen, rewarded for their ability to teach well and impart wisdom as well as facts.
-- An environment where faculty are also supported, encouraged, mentored, enlarged and connected to each other and the practice world into which they are charged to launch the students.

Wishful thinking? Probably.
If only I could see my way clear to be part of the solution, instead of just a prophet in my own land.

Past, Present, Future!

Everyone talks about living in the moment and I do “get” the sentiment of that, being present, acknowledging what is right here, right now, and engaging that set of realities. But I also have to acknowledge why my mind wanders and why I find myself savoring the great moments of the past (and, if I’m truthful, embellishing on them) and projecting myself into some warm, imagined future where all the hassles of today are done and I am free to do all the things I’d rather do.

Foolishness, huh? I agree but it is where I tend to live my life – in the spaces surrounding the now – the past, carefully sorted out to diminish the unpleasant realities, and the future, carefully constructed to allow me to put one foot in front of the other an move forward believing that there is a hopeful finish to it all!

Is that a good way to live? Well, if I have to defend it, I’m going to say, “Hell, yes!” But, if I can step aside from the realization that it is ME I’m talking about, I have to admit that all of this is simply a rationalization, a ruse, to avoid the painfulness of the present I have constructed from myself.

The present (this summer, this time right here and now) is a most unpleasant place. I have been consumed for 10 weeks with one thing, completing the requirements of a 4-hour graduate course that should have been great fun, but wasn’t. Yes, there were moments of great fun (those brief events where living in that moment made the whole semester worthwhile) mainly because there were some delightful successes.

Now these are not the sort of successes most folks could recognize, but for a mid-life adventurer, moving through a world of new information that is confusing, contradicting and often complicating to the learning I’m engaged in, the successes were brief but beneficial. Things like palpating my first prostate gland (no, it wasn’t MY prostate gland, but it was the first one my finger had successfully felt, in a clinical way!). Or actually remembering the five essential health promotion questions to ask during a clinical breast exam (ask the questions when you’re palpating her breasts and she doesn’t have the concentration to lie about whether she wears seat-belts in the car of has guns in her house!).

Hopefully, I will be able to catalogue them among my “great moments of the past” and resurrect them when once again I find my present full of dismal realities. And it is not as though they are few or far between. They merely pale in the reality that the summer has been full of stress, clutter, delayed gratification, disappointments, settling for less, tolerating, putting-up with, doing-over and doing without.

There are two weeks between the end of this semester and the start of the next (yep, two weeks!) and I intend to “savor the moment” on each and every one of those 14 days that separate the summer from the fall in terms of the school calendar. I can’t possibly make up for all the deficits of the last 10 weeks but I can reach deeply into the fleeting pleasures of summer and drink up all I can in this end-of-the-season binge of relief. What will I binge on? Simple things to be sure. . .

• I want to clean my house, and finally put a load of laundry away, rather than just scattering it onto the guest-room bed so I can wear it again the following week.
• I want to invite friends over for a pot-luck and show off that great grill we bought at the end of last year’s season and have only had a few chances to use this year.
• I want to actually visit the gym near my house where I purchased a membership but rarely go because even though it is a 24/7 work-out place, I am only an 18/7 kind of person who needs at least 6 hours for sleeping on a regular basis to avoid automobile accidents. So, my presence ant the gym has been less than consistent to date.
• I want to swing a golf club (duffer that I am) and flail away at that annoying little pink sphere that seems to have a mind of it’s own as soon as it leaves the tee. Not because I’m any good at it or because the tendonitis in my shoulder is helped by the over-use I put it through just to complete nine holes. I do it because for the brief 90 minutes that I’m out there with the bugs and the sunscreen, I feel like a genuine person, with a life and maybe even a lifestyle (God forbid!).
  

So here I go, plunging into the sacred space between the summer and the fall, the moments I intend to savor over the next two weeks that will permit me to feel human again. And I will remind myself over and over again that there is a purpose for all that I have chosen to put myself through; there is a higher calling, a bright future, a light at the end of the tunnel that (hopefully) isn’t a train! Because fall will be upon me in a heartbeat and there will be new textbooks to buy (and read) new papers to write, new concepts to grasp and new relationships to forge.

But I can do this. I know I can. I have managed my way through so much “stuff” that surely I will have the strength to endure so that I can look back on all of this “schooling” and find amidst it a host of “wonderful memories” to place in my mental scrapbook of great moments of the past. And, remembering them, I will sigh and say, thankfully, “this too, has past!”

Reflections on Being Sick

I haven’t been sick in a while (lucky me) but this past week-end, I was really, really sick. Clearly it was a virus (self-diagnosed) and it ran its course in roughly 48 hours but during those two days, it certainly made me miserable!

It started with a headache. I don’t get headaches often, although, I’ve noticed that I get them certainly more frequently than in previous years. My head began to throb just above the right temple around 5 PM on Friday (just in time for a few days off, naturally!).

Hubby and I had an appointment that evening – not necessarily one we were looking forward to, but nonetheless, a commitment we felt we needed to honor. It was an evening that seemed endless and as it wore on, my headache crept from tinker’s hammer to carpenter’s hammer to sledge hammer in the course of about 3 hours. By the time we got home, I was eager to be horizontal and unconscious. Even food wasn’t high on my wish list but I had a peanut butter and jelly sandwich just before I crashed for the night.

Saturday was a complete bust. The headache was back. I managed to be up, out of bed, for roughly two hours during which time I ate a scrambled egg and some bread, drank some tea and watched the news. By 10 AM I was back in bed, mainly moaning about the headache again. Hubby brought me an ice pack which enabled me to get back to sleep. On and off, I slept, watched television, played with Nutmeg, the cat who kept vigil on the bed with me, and groaned (as if groaning would make me feel better!).

Around 5:30 PM I took an Alka-seltzer-like product (a no-name, generic product) and decided to see if a shower would help. I turned up the hot water in the shower, downed the bubbling cool liquid and stepped into the refreshing water in the hope of curing all my ills. Within three minutes, I threw-up everything I’d eaten all day. Then, shortly after the shower, the stomach cramps and diarrhea began. I was clearly in for a long night.

Up several times in the night, Saturday blurred into Sunday and I tried to rouse myself for the morning talk shows and newspaper – alas, no luck. I managed a cup of tea and went back to bed. The headache had returned. Hubby went to his work-out around 11 AM. I never missed him; I was dead to the world.

On Sunday afternoon, Hubby came back to the bedside (it must have been around 2 PM) and asked if I wanted anything. We’d just received a beautiful shipment of Florida oranges from a neighbor who snowbirds there. I asked him for some fresh-squeezed juice and, in his most loving manner, he made my wish, his command. Within minutes a fresh ice pack and 10 ounces of fresh Florida orange juice were brought to my room. The juice was amazing! The ice pack was even better. I fell back to sleep.

Sometime after 6 PM I awoke feeling strangely human. I got up. Hmmm…no headache, even vertical! I found my robe and wondered downstairs. Hubby was caught up in television news and gin on ice. I had some water. It felt good. I was hungry (and quite surprised to discover that) and so I contemplated what to eat. I figured it had to be bland. So, feeling quite domestic, I boiled some water and cooked some high-fiber pasta. This plus a teaspoon of butter would be my first experimental meal. If it stayed down, maybe the worst was over.

I managed to stay “up” until 8 PM but tired go the best of me, so I went back to bed. Hubby came to bed around 9:30 PM and neither of us felt the need to watch the late news so we drifted off to sleep. I awoke around 1 AM for a bathroom run. It was not as “urgent” as those of the previous night. I woke again at 3:30 AM with a strange feeling that something had changed. I sat up (displacing the cat who believes she has all rights reserved to the slice of bed between my body and the bed’s edge). Hmmm…no headache, that was nice! I ambled to the bathroom, this time just to pee. Then, back to bed, hopefully for a bit more sleep.

This morning at 7 AM the alarm went off and I sat up (no cat this time) to find myself essentially well. Amazing! Fortunately, I had the day off and could use my Monday to make up for a lot of lost time since Friday evening. A virus, no doubt! Well timed, I thought. Just long enough to rip off my week-end.

Oh well, the clear head and calm stomach felt so good, I went downstairs, made coffee, squeezed fresh juice (enough for hubby and myself) and reveled in the new-found health of the morning. It was raining outside. The television news was full of sad stories and unhappy circumstances across the world. I sat there sipping my juice and thought, “what a splendid day!”

An open letter to The Secretary of Health (whomever that turns out to be!!)

H -- Hurry, people are suffering needlessly!
E -- Everyone – not just a few people deserve core services
A -- Accountability – no more shrugging shoulders on the part of payers/providers
L -- Leadership – on behalf of the greater good, not individual money niches
T -- Together – stop deciding FOR people, begin working WITH them for health
H -- Healthcare Vs. Illness care – let’s not wait ’til it breaks & try to cure

R -- Reality – what real people face; not the wishes of the wealthy & well heeled
E -- Evaluated – follow the data, focus on achieving the best outcomes
F -- Fit – one size doesn’t fit all. Address special needs of high risk people
O -- Orchestrated – but not MANAGED – work together to serve patient Vs. payer
R -- Reach – out to find community leaders who can engage the people
M --Money – too much waste, too many hands in the till, too few resources aimed at making a significant difference in the lives of patients and families who get lost in the money shuffle



Dear Secretary of HHS–

Above you can see my thoughts on health reform. As a nurse, I come with a professional bias on how healthcare should be designed and delivered. Some of the things I believe in and will describe for you here would upset my own nursing colleagues because they have begun to prosper on the status quo. For instance, where have all the nurses gone – they’re working for insurance companies! Rather than taking care of patients, they are taking care of the assets of the payers who would rather not spend money on the “covered lives” they’ve accepted the responsibility to serve. I offer that perspective so that you don’t think I paint my own kind with a softer brush than I do others in this broken system. We’ve all got room to examine and change our practices.

When are we going to see dollars spent on wellness in America? Those of us with adequate insurance and at least some disposable income take part in such things as fitness clubs, diet plans, annual physicals, having our teeth cleaned, using community walking paths, nutritious eating, wellness counseling, and holistic alternative care options.

We’re clear on the problem. Here are a few facts I gleaned while watching public television:
5% of the people use 55% of the healthcare resources.
75-80% of hospitalizations are for chronic disease episodes – why? It is too little, too late.
Source: http://www.mnchannel.org/video_archive.php?video_id=22

But what does the typical American do?
He or she ends up in the hospital because no one teaches or supports him or her with the tools to manage life and health, to recognize early warnings, to take initiatives on his or her own behalf. Sometimes technology is all that is needed so that early intervention (short of coming to the Emergency Room) can be provided to prevent the crisis from occurring.

The average American can’t name his of her healthcare provider. (You’ll note, I didn’t say physician because I think if we limit our thinking to physicians, we lose sight of the wide range of care services people need – including the services of nurses at all levels). Sometimes that is because that American doesn’t have a primary care provider. Sometimes it is because there is no provider accessible. Frequently it is because the inattentive American doesn’t “get it” that healthcare is a daily activity we each engage in, not something we finally attend to when the pain or the problem is too hard to bear.

The reluctant Americans wait to access healthcare until the problems are beyond control. And, they know that there is no money, in their government plan, their minimally funded insurance plan or in their own pockets to address the difficulty before it becomes catastrophic. Why aren’t all our payer sources (from CMS to the VA to nationally recognized health plans) putting their money into prevention, rather than protecting themselves from “big costs” when it all begins to unravel? It is as though we have the motto: “Pay now; get sick later; I told you so!” It is a “gotcha” mentality rather than one that serves the need of people.

What needs to happen?
Dismantle health insurance as we know it – just look at the salaries we pay to people at the top of these enterprises and you can see why an honest person would hardly find him or herself in such a job (remember Bill McGuire, former CEO of United Health?). Obama is on to something when he wants to get rid of the Medicare “Advantage” programs – my husband is 78 and manages his statements from Medicare just fine. Let’s help people learn to manage rather than convince them to let us manage their money and healthcare decisions for them!

Build on best practices -- Take the best of what we’ve learned from Medicare, Medicaid and the VA system, mix in whatever Massachusetts is up to and help citizens see how to live healthier lives (yes, even with chronic illness! Look what happened in AIDS care in middle-America, where we treat it as a chronic disease, not a death sentence!).

Challenge the heart of Americans – I know that in the 1980s we declared that “Greed is Good!” but every time I hear statistics about poverty, prematurity, hunger or seniors aging alone, I am touched that the GREATER GOOD is what matters, not my “need” for Tuesday tennis shoes to match my grey work-out sweats. We all have to sacrifice a little to get the American healthcare system we want and can be proud of.

Stop paying for poor productivity – and yes, I mean everyone with their fingers in the healthcare till! What are we doing subsidizing vacations and cruises for prescribers, golf trips for healthcare executives, ginormous salaries for physicians who don’t see patients and nurses who don’t practice nursing care? (and don’t get me started on lobbyists!) Let’s pay for outcomes that improve patient’s lives, programs that change the health of whole communities, ideas that squeeze the nickel ’til the buffalo brays in an effort to get the most out of every dollar we spend on healthcare!

You, Ms. or Mr. Secretary, may be our last, best hope. Obama may build the only federal administration in my lifetime that could actually be responsive and accountable to the people rather than to special interests. Now is the time. Healthcare is the issue. Do not let this moment pass without enacting change.

Sincerely,


Paula S. Forté, PhD, RN

What does this inauguration mean to you?

I’m one of those middle-aged, American women who was hoping that in my lifetime, I would be able to celebrate the election of a woman with enough chutzpa to really do the job of president, not just declare candidacy. We got one hell of a contest but, in the end, something even more amazing unfolded, the election of our first Afro-American president who has the diversity of Kansas and Kenya all wrapped up in a Hawaiian mindset. Who could have ever imagined that?

This inauguration, this history-making, stereotype-busting, oh-m’God-can you-believe what-just-happened inauguration means to me a fresh appreciation for what liberty is all about. I am white, female, middle-class, middle-income, well-educated and boringly “ordinary” in the statistics of this amazing country of ours. I have enjoyed every freedom known to man in the latter half of the 20th century. But what this inauguration brings is the fresh, new opportunity to say out loud, in the hearing of politicians and policy-makers alike, the America I know and love, “has no clothes on!”

We, common, ordinary Americans now have a champion about to be sworn into office who doesn’t need to paint himself or his America as perfect. He admits he’ll make mistakes, even before he’s seated and given the chance. He’s seen America’s warts from the shenanigans of Washington to the mean streets of Chicago to the littered beaches of Honolulu. He knows what America is, where America’s been and (thank heaven) where he wants America to go. The liberty to speak the truth is an astounding thing. We finally will have an administration that isn’t all about saving face, but about naming the problems America is facing and getting them solved.

My career spans over 30 years in healthcare. I am full of opinions and ideas about what might make that one sector of America’s troubles better. To date, I have never been moved to speak any of these ideas to anyone in any political party. This reluctance is not born of fear, but of the confidence that no one in office really cared what I thought. Now, I do see myself writing to the former senator, Tom Daschle about what I think, what I know from inside the belly of the beast, and what I think we can do to make Americans safer, healthier and more engaged in protecting their own health. I do see myself standing up in community forums and speaking what is on my mind. I do see myself encouraging others, especially physicians and nurses, to say what we’ve seen and stop pretending we don’t know what’s wrong with the most expensive healthcare system in the world. We do. And now, in this administration, we can say it with confidence that something may be done about it.

After all, what is liberty if it is not the freedom of speech? But liberty with hope is a powerful thing and more Americans than ever before in my lifetime are eager to speak what they know, to speak truth to power and influence the re-emergence of the great American country by the people, for the people; the one we all grew up believing could prevail.