Thursday, October 1, 2009

Who Will Flash Mob the Public Option Like Whole Food Markets? Or How?

The Disease Management Care Blog watched the news about a pro-health reform ‘flash mob action’ that materialized on Sept 29 at the Oakland Whole Food Markets with considerable interest. Disgruntled over that company's CEO John Mackey’s August 11 editorial in the Wall Street Journal, members of the Northern California based and culturally ‘Left’ Brass Liberation Orchestra (BLO) wanted to noisily make known their disagreement. As their bullhorned leader exclaimed in the back aisle, health care is a right and Mr. Mackey is an extremist right-wing hypocrite.

The DMCB recalls reading that editorial. It wasn’t all THAT exciting. It was similar to many of the other just-say-no-to-government-involvement-in health-care opinion pieces that have been appearing almost daily in that newspaper over the last two months. Mr. Mackey, like many CEOs who want to cover health insurance for their employees, was in favor of a) promoting availability of high deductable plans as well as health savings accounts, b) allowing cross-State border health insurer competition, c) repealing benefit mandates that favor special interests, d) enacting tort reform, e) increasing cost transparency, f) reforming Medicare and (and this was a new one) g) using tax forms to enable voluntary donations to help persons without insurance.

What provoked the BLO’s ire was the legal and market basis of his arguments in a paragraph about halfway through. After a careful read of the Declaration of Independence and the U.S. Constutition, Mr. Mackey noted he was unable to find any mention of food and shelter as ‘rights.’ He interprets this to mean that Americans decided long ago that these are really needed ‘services’ that are ‘best provided through voluntary and mutually beneficial market exchanges.’ He argues the same logic applies to health care.

The BLO and its action allies obviously beg to differ. What’s more, they argued that Whole Foods Market’s high nutritional-value products, like good health care, are also being priced out of reach by the same cold market-based logic.

Well done, says the DMCB. What is America without the ability of the BLOs of this world to vex the powerful and make uncomfortable the rich? It’s quite cool that this was done with a horn section and without the kind of bile we witnessed at the infamous August Town Halls. In the end, shopper-bystanders were grinning. Point made.

More importantly, if government dominated health care ever does come to pass, the DMCB is confident that the BLOs of this world will be needed more than ever. Given Medicare’s track record, for example, of denying coverage for potential lifesaving services like virtual colonoscopies, not fully paying for wheelchairs and oxygen, or driving contracting entities into bankuptcy, there little reason to believe that the public option won’t be just as capricious.

But it won’t be so easy. As anyone who has visited the Hubert H. Humphrey Building in Washington DC or CMS’ Headquarters in Baltimore knows, there are security guards posted at all the doors with metal detectors. What’s more, in Baltimore, you need to be on a preapproved list and your car will be get-out, open the hood, open the trunk and open your luggage searched. Unlike just walking in the front door at Whole Foods for a flash mob with instruments in hand, it’ll be hard to get that tuba through, let alone explaining what you’re up to to a Federal Officer.

And don’t even THINK about pulling any stunts at the Jefferson Memorial.


Brady Augustine said...

Classic, thoughful, and entertaining as always Jaan. The best role of government is to set the 'what' and not the 'how.' The best way for them to do this is to set national goals and expectations and provide funding, information, and incentives to spur innovation that recognizes both the art and science of health care. Problem is, since outcomes measurement, public health objectives, and patient role are a daunting task necessitating a thoughtful long-term commitment, providers and CMS have both chosen to start small with a focus on what is relatively easy - process measures.

Let's not forget that there are thousands of smart and dedicated people that work at CMS headquarters and their regional offices. What we have is not a people problem, it is a system problem and that goes to leaderhip, which we should expect from DC, Wall Street, and boardrooms. CMS has role to play here as well but focusing on them misses the bigger picture.

Brady Augustine said...

Also, let me add that even though I described the "best" role for government in my previous comment, it assumes that the private sector works well. If it does not, as in the case of the elderly, infirmed, children, dialysis patients, veterans, etc., the public believes it should step in as a provider or payor of last resort.

Problem is, though this is well-intentioned and necessary, it increases the problems of the larger health system as I described in my post, The Pottery Barn Rule of Health Care ( ~BAA

Jaan Sidorov said...

Well said Brady.

On the other hand, and while I agree with you, CMS' actions, while aimed small, often turn out to be magnified thanks to a byzantine and opague process mixed in with a increasingly hidebound health care system. For example, minor wordings in the Medicare regulations involving prcoess can be interpreted by legions of lawyers and payers into millions of dollars.

Like you, I've met many of the good people at CMS. They are good people. But they are also accountable and from time to time are involved in bad decisions arising out of good intentions. They should be subject to the same noisy, uncomfortable, messy and ultimately democratic 'actions' that have helped make our country great. Right now, in the name of security, it's to easy to conclude they're hiding behind security guards, car searches, bag searches and metal detectors.

Brady Augustine said...

They don't hide physically by design, their HQ is a terrorist target and valuable piece of our nation's infrastructure.

That said, your points about the less obvious signs of evasiveness and opaqueness are real. My feeling while at CMS, was that if one is going to make tough calls, you have to get out in the community at all levels and make the case for change. A quick funny one conference where I was advocating for a change in payment policy, I got spit at by a "professional" attendee. The existing policy needed to change and in the ascence of a better community solution, CMS took a shot. It was not the ideal solution and it created some challenges for some doctors but it galzanized the community and we modified the solution to make it work. It was messy and took a commitment to working with others. That is what we need now. People who are willing to deal with difficult issues, build community consensus around solutions, and then get things done. But this necessitates a skill set not often found in Federal officials. This is the change we must expect from HHS and CMS.

CMS goes through these periods like a pendulum swing. It opens up and then closes again. It is our responsibility to push Congress, the WH, and HHS to empower thoughtful leaders in the health policy sphere.

Jaan Sidorov said...

I can sympathize with the folks as CMS who don't want to be vulnerable to personal or other types of attacks. On the other hand, there is is something to the notion of being accountable when it comes to using other people's money. In my past in the commercial insurance market, any doctor unhappy with our decision making could get a hold of me personally. The invective could be considerable, but as professionals, you learn to live with it. Sometimes you also learn you made a mistake.