Running for office? Audition on a cruise

If you’re thinking of running for public office, first book a week-long cruise. There is no better boot camp.

Politics and ocean cruising bring the promise of spectacle burdened by the weariness of process. It was never clearer than on our recent cruise through Alaska’s Inside Passage as to how voyaging has slipped into a scarcely muzzled dog fight mirroring American elections.

Cruises were once a petri dish for the refined. The slinkiness of Carole Lombard, the peregrinations of Agatha Christie, the skullduggery of Humphrey Bogart, the world reshaping of FDR and Churchill, all draped in waves of rhetorical or other inebriation.

The fancy people bathed in perfumes, Johnny Walker, winks, nods and Vaseline promises, and dirty deeds done (maybe not so) damn cheap.

On my first cruise, a 1972 honeymoon to Bermuda, the Holland America captain sat with us for dinner. Off the stern, you smacked golf balls into the Atlantic or shot-gunned clay pigeons. Earth Day had barely registered its arrival, and happy hour was a competitive sport.

Forty-five years, more voyages and uncounted elections later, cruises and politics are a fool’s gold of coarse ordinariness.

Cruise cities, as they are that, have become showcases of socioeconomic schmearing. Here, there is a forever high tide of pretension. Facts, like dollars, are shaken off like sudden salt spray. 

Here, you test regional humor -- “He stinks worse than a foggy outhouse.” Religion and sarcasm – “Bless her heart, she’d better save me than last slice of chocolate cake or there won’t be anything left to bless.”

Shipboard as in American politicking, what matters is Hot ‘n Now. You vie to become Buzz Lightyear -- first in line for infinity. Acquaintances are played like party balloons: extend, fill and release. Test every water, set it afire, walk on it, bottle same.

This is a vetting of your political platform. On a recent Princess cruise, chance encounters offered these supporting-cast opportunities:

• A meat market manager from southeast Wisconsin was just back from trophy hunting in Africa. His seatmate was a Californian extolling the spread of state-legal marijuana. Jaws tensed in the cliché. A middle ground was brokered: both reveled in the joys of morel hunting. New office-seeker, these could be your regional campaign managers.

• A former teacher from Arizona wore a saggy, anti-Trump T-shirt. She also voiced disdain for teachers, students, administrators and her onetime union. She sampled and dismissed every purple gourmet cookie at a British Columbia tourist spot.  Her selective candor was refreshing and off-putting. Found, a potential high court nominee.

• A disembarking tour was delayed by bum directions from a ship bureaucrat. Another official, a young woman from South Africa, took to the theater loudspeaker, deflecting a peppering of nasty shouts. “Ladies and gentlemen, I don’t know how these mistakes were made but I know how to control a crowd. I will get you off the ship in a timely way but only if you listen to me.” Mmm, a potential chief of staff.

Your teething political chops might observe how tired hucksters and adventurers dive for the wallets of the bored. I tinker with the actual themes, but hear now sound of their lures: Art auctioneers, “Four hundred years in 40 minutes.”  Outdoorsmen, “Solo kayaking the Passage with breaks for beer and ice cream (but no sex).” And bartenders, “Mimosas and margaritas at dawn as glaciers die before your eyes!”

This is a PG-13 Las Vegas, leagues away from a Madison Square Garden balloon drop. Cruising is political training wheels, a gateway to yelling “Mouse!” in a Michelin-rated eatery. Nowhere will you likely eat worse Baked Alaska than offered on an Alaskan cruise – how better to serve a stump speech?

At journey’s end, I joined most bestowed with coffee-break fantasies explaining belt-buckle spillover.

But someone aboard this odyssey of the ordinary may have gleaned a recipe for earning a campaign check and a check mark on an absentee ballot. If I could only persuade two such newly minted visionaries to climb aboard, we’d create a killer reality show.

(Also published as an op-ed in the August 25, 2017 edition of The Fresno Bee.)

John G. Taylor, a former Fresno Bee reporter and editor, is owner of JT Communications Company LLC. Write to him at jtcommunicates@comcast.net.

The charade of patient education

The healthcare system has saved my life but my only trust is in its dedication to delivering incomprehensible bills.

Promises of patient-friendly invoices quickened with the Affordable Care Act in 2010. But closed-door jawboning has resulted in what many view as the usual self-perpetuating flimflam.

To wit: “The government created the mess that we’re forced to use (hint: blame them). … If we become too public, our competitors will put us out of business. … The formula for what we charge is proprietary information (suspicion: there is no reward for clarity).”

Invoices are a Pandora’s Box of hieroglyphics and hierarchies culminating in “patient share … pay this amount.” There’s neither  education nor empowerment in the drumbeat toward collection agencies. Ghosts still run the machine, which seemingly flaunts examples of excess.

Take the NYC Health + Hospitals corporation. The public health system cut nearly 500 management positions this year, saying it would save $60 million in fiscal year 2018.

"Today we've implemented a difficult but necessary action to help build a stronger, more agile and more stable public healthcare delivery system," said Stanley Brezenoff, interim president and CEO, in Becker’s Hospital Review. "By restructuring and reducing unnecessary layers of management, we can better direct resources where we need them most — at the front line of patient care."

So, until now, the resources were being squandered by layers of bureaucracy putting care was risk? We all pay for this doublespeak.

Executives know the price of everything but the value of nothing – save grandstanding. Why else would Daniel Snyder, CEO of Shreveport, La.-based University Health System, try to one-up a Louisiana state senate hearing inquiring why his company hadn’t paid a $12 million debt for Louisiana State University physician services.

There’s not be enough documentation to support the request, said he before whipping out a $6.2 million check from his coat for said services. So there, enjoy the half a loaf I’ve been carrying for lunch.

"If this is how you conduct business, the future doesn't seem to be too bright," replied a stunned Finance Chairman Sen. Eric LaFleur in Becker’s Hospital CEO newsletter.

Patients are jittery as they enter the sprawling boxes of concrete with jail-like windows. How do I get to the head of the line and out of here quickest -- in good health?

We are compelled to present government identification, proof of insurance (sound like a traffic stop?), to sign and pre-pay (credit card would be ideal, I’m told, but is that a good idea?) and authorize things that supposedly shouldn’t occur but which I’ll never recall approving anyway.

I’m compelled to trust whatever caregiver is assigned to me -- who changes every eight to 12 hours -- that they will adhere to the same care plan and advocate for me as my condition changes. That’s a fragile, frightfully important task remanded to strangers when my physical and psychological faculties are unsteady.

Troubling, too, is how little caregivers know about the cost of services.  More than 60% of emergency medicine clinicians can’t accurately estimate the costs of care, according to a study in the Journal of the American Osteopathic Association.

That’s odd given that administrators expect doctors to stick to a formulary of medications and a defined storehouse of gear and tests that have been proven to cost-effectively get the job done.

Fiscally empowered doctors can involve patients in cost containment.  When told that as part of cataract surgery I could have lenses installed that would end reliance on eyeglasses – if I forked over an additional thousand dollars – I opted to keep my eyeglasses.

Given the punitive nature of billing, it’s no surprise that:

• A survey from Bankrate, a financial planning site, found that a quarter of 1,000 adults went without treatment because of cost.

• Nearly 70% of patients with hospital bills of $500 or less didn’t pay off their balance in 2016, up from 49% in 2014 (Healthcare Financial Management Association).

• Those who can fork out thousands a year can bypass insurance by buying concierge care – “me first” access to doctors and medical facilities.

Explaining a hospital bill ranks right up there with educating patients about lifestyle choices. They’ve been triaged out of the picture by politicians and providers as too costly, time consuming and raising more questions they don’t really want to answer.

(Also published as an op-ed in the July 8, 2017 edition of The Fresno Bee.)

John G. Taylor, a former Fresno Bee reporter and editor, is owner/operator of The JT Communications Company LLC. Write to him at jtcommunicates@comcast.net.

Feasting on people: A diner’s guide

The sylph-like hostess sashayed through the restaurant like a baguette looking to shed a cold pat of butter as her shawl slipped, again and again, from the twist of her neck. By mid-evening, artifacts from the menu were destined to be dipped, dusted and otherwise magnetized from the floor into every fabric fold.

When it comes to take-your-time dining, the ballet and missteps of this Morro Bay kitchen were as much a Rubik’s Cube to patrons as was the industrywide marketing rationale that inevitably wrapped at least four but never more than six shrimp in a $30-ish glaze.

The back shop is predestined to dwell in the Twilight Zone, Gordon Ramsay be damned. But the clientele and the front staff can be sifted, sampled and given a Michelin review, welcomed like the perfume of sautéed garlic shrimp or scorned like burned popcorn.

Where the restaurant bends from its entryway bottleneck to full flagon there sat this evening’s Judge, earning the label for overall imperiousness commencing with crook of his neck. This patron’s gaze rendered all as miscreants or worse – perhaps potential juror panelists -- as his wife, shoulders dappled by the Morro Rock sunset, regaled him with a Democrat-flavored judgment of congressional hearings for then-Supreme Court Justice nominee Neil Gorsuch.

What, what? You know I can’t hear whispers, said his voice, a megaphone that invoiced what he would or wouldn’t have with his salmon, and how – bring cruets and shakers -- he would zest it himself when it debuted. Water was his beverage, wincing as his wife reordered a lemonade.

We early diners were a weak tide in this California offseason, choked by rain and mudslides. A woman with a yellow rain smock cinched around her waist. A grandmother holstered in a polished walker, shepherded by a benign young man who wended her to a perch that espied the ocean while reviewing a menu both knew by heart and agreeing that selecting an inexpensive red wine would escape anyone’s aspersions.

The servers regarded the regulars as though resuming an interrupted diary with updates of a wallet lost, the results of cancer screenings (the type specified as “women’s”), how a co-worker’s pregnancy leave had left them short-handed and, only when asked, a reminder about the chef’s specials.

This confessional, mindless of us nearby as we dropped eaves, on no occasion led the servers to provide the irregulars with their first names or position themselves as inviting, knowledgeable resources about preferences on a blissfully limited menu that hasn’t needed more than a fresh varnishing of plastic over the decades.

No hard sell, no memorable menu to share with tourists many of whose car undercarriages suffered keel-hauling on humpback streets in arriving at this 75-year-old perch above the fuss of the embarcadero. This restaurant, whose name I spare, rests abundantly well, thank you, on the elbows of its reputation, no need for ruffles about dining experiences or special ministrations beyond adjusting shades to accommodate the sun’s death glare.

As this evening’s first tables were turned, the woman in the rain smock was surprised to find it diving to her feet, transfixing her like an anchor dropped and compelling her husband to drag a leg like a poorly trained skier to avoid a cavalcade of tumbling well-fed, poorly toned bodies.

Somehow, the Judge missed this side-chapel sketch as he slurped his salmon and moved on to finish every crust of bread while his wife elsewhere was possibly reallocating her lemonade.

His arms opened to assess the table’s remnants, unfurling a scowl. Well-seasoned or otherwise, morsels did not belong ensnared in his teeth. He grabbed a dinner fork and prosecuted them with four fine tines before handing a raft of cash to his server and softly parading to the door behind his wife.

A breeze had kicked the outdoor air cold. There was no jovial buzz, the kind spawned by the warm alcohol of summer. Off-season tips were less rich, more dear.  Maybe the hostess caught the drift. She plastered menus against her chest, clawing her shawl to her throat like a suddenly sacred scapula as though there were no etiquette for such things and certain no one would ever pay her any mind anyway.

(Also published as an op-ed in the April 29, 2017 edition of The Fresno Bee.)

John G. Taylor, a former Fresno Bee reporter and editor, is owner/operator of The JT Communications Company LLC. Write to him at jtcommunicates@comcast.net.

Mysteries surrounding 'Play Ball!'

Three hours evaporate too quickly in baseball, says me. If time inexplicably drags for you, consider mysteries of the game.

Umpire Dirt Devil: In a daily ritual, umpires or designees use mud harvested from a secret New Jersey bog to slap down the polished look of new baseballs, presumably helping pitchers’ grip. This isn’t illegal scuffing designed to baffle hitters, which pitchers and catchers execute surreptitiously. How do muddy middlemen eat up time, spritzing dozens of balls? Do they rub to the Ipod churn of Metallica (maybe Muddy Waters)? Scope out the Home Run Derby on ESPN Classic? For kicks, do they sneak in a still-polished orb to see if anyone notices?

Ground Rules or Grub Guide: What’s up with the pre-game huddle at home between umpires and managers, presumably to discuss individual ballpark oddities? What’s really discussed – stir fry and brew joints? How many times during a four-game series can you jawbone over what happens if a ball gets hung up in Wrigley Field ivy or underneath a tarp? It sure couldn’t have prepared for Yankees outfielder Dave Winfield being arrested in Toronto in 1983 when he accidentally killed a wayfaring seagull with a warmup throw.

Tarp Dancers: How often do groundskeepers practice the Tchaikovsky ballet of rolling out the tarp? Hire a Sikorsky chopper to create a headwind in preseason to prep for a summer thunderstorm?

Janitors in a Drum: The Oakland Coliseum innards stink like “Indiana Jones” catacombs. Snakes? You bet maintenance guys don’t venture far without those base-clearing clubhouse potty excavators. What ghoulish tales handymen could tell, if only the Centers for Disease Control dare ask?

Jocks-of-All-Trades: Sometimes a line drive will snap a glove’s webbing. A slide will tear a pants leg. A jock strap will go missing. A Nutshellz (aka family jewels’ shield) will crack. A collision will knock out a tooth or contact lens. Microphone batteries will fail for a slurpy-voiced anthem singer. Who are the sometimes game savers, lurking in the stadium bowels? Their packs of tricks including scissors, tongue depressors, ear irrigators, cold packs, duct tape, saline solution, location of emergency shutoff valve for sprinklers and an Uber hotline for the gold-toothed reliever whose car battery expired.

Mr. Nice Guy: What are the rules (does slipping cash help?) on who is bequeathed a foul retrieved by the ball boy?  Would love to see the liability policy preventing pitching the keepsakes to cheaper seats.

Evictor-in-Chief: A friend got mouthy with Jose Canseco back when he was half of the steroid-challenged Bash Brothers. He wanted the critic tossed. The Oakland security shirts ultimately ejected the wrong jouster. How does security decide when you’ve crossed the line? And what are their “judicial” options?

Sultan of Sales: There are other winners and losers in games. Hauling cases of soda when it’s 31 degrees at Milwaukee, when you need pliers to crack open peanuts? Selling beer in a section dominated by elementary kids? Some kind of pit boss makes assignments for what vendor hawks the top sellers and who waves cotton candy in the rain. What’s the racket?  And, painful reality, who decides the geographic borders so that I’m always outside bellowing distance of the churro dealer?

Odor Eaters: Lastly, for the hourly staff who churn volcanoes of garlic fries – What’s the trick? High pressure hoses filled with Febreze? -- so they can shed their Eureka! aroma and sleep regularly with the family.

I’ll snap out of such puzzling with opening day in April. Rebirth arrives when the first, fast, mud-speckled sphere challenges a hand-sanded, finely grained chisel of ash whipped by Buyanesque wrists soon to be tailored for All-Star sleeves.  

(Also published as an op-ed in the March 4, 2017 edition of The Fresno Bee.)

John G. Taylor, a former Fresno Bee reporter and editor, is owner/operator of The JT Communications Company LLC. Write to him at jtcommunicates@comcast.net.

Telling a doctor 'no' -- A healthy option

By John G. Taylor

No, you can’t autopsy my father. When I was 19, saying no to a physician was like cursing at a priest.

I mustered the answer because it carried certainty – funeral then burial then true mourning. Years later, I grasped deeper consequences – Dad becoming body, then cancer specimen, then data blocks and, overriding all, an autopsy delaying everyone getting on with their lives.

In medicine, saying no has muscle. Patient told there are no beds, no chances of survival and no water after midnight. Physicians told no end to paperwork (verifying, testifying, glazing over), no end to pushy hospital administration (earn your privileges) and no relief from second-guessing.

It takes courage for a patient to say “no” or “not yet” to a physician’s recommendations. It arises from conflict –  frustration, mistrust, fear.

For some, it launches dialogue –  persuade me how your therapy will benefit me now and 10 years from now. For the newly insured, it’s a blunt challenge to the white-smocked expert that he explains my care in simple doughnut-shop speak.

Why is such transliteration not built in? The jagged-glass payment system doesn’t reward education and lifestyle management.

No requires homework. The doc says you need a total knee replacement. After a lengthy wait for a second opinion, you opt for a simpler, outpatient meniscus repair. In between, you’d scoured the Web, talked to physical therapists and patients. Maybe you’ll need a new knee, but you weren’t sold now.

No – to hand reconstruction. That was a hand surgeon’s high-cost, long-recovery remedy for a recurring cyst.  You chose less radical but highly cringe-worthy draining by a primary care doc. Author-surgeon Dr. Atul Gawande said incremental care, providing a grocery store of services, never gets the credit it deserves. Skilled specialty surgeons draw research grants and myriad resources, while primary care docs are lucky to afford a nurse.

Biopsies, mammograms, colonoscopies – gray areas to patients. Physician-as-mentor won’t pillory you for wariness. There is time in a bottle – watchful waiting -- for lots of ailments and diagnostic tools. Even so, the patient should feel compelled to remind a physician about worsening aches or discolorations.

Physicians are rarely praised for their relentlessness, selflessness and frenzy. Neither are abusive physicians pursued for their self-lubricating criminalities with the zeal we accord terrorists.

Some patients need to be told no. Some milk the system to feed addictions (so much so that California enacted CURES, an electronic data base that tracks prescriptions for painkillers and other controlled substances). Some saturate emergency departments as though they were taking free carnival rides (Fresno County has taken steps to deter such “frequent fliers”). And some patients – and doctors – need to experience a hard stop when it comes to pumping kids with cough medicine and useless antibiotics for the convenience of pawning them off as healthy enough for day care.

Patients should weigh their words carefully. Unlike politics, good manners and civility count for something. A January 2016 study in Pediatrics found that nurses and doctors didn’t provide the same quality of care when they encountered rude behavior.

Navigating no is getting more complex. For one thing, the hands-on part of caregiving is diminishing. Your doctor visit doesn’t routinely include checking ears, throat and eyes unless they’re attached to your complaint.  Medical intermediaries abound – tasked with gauging your blood pressure and pulse, taking an X-ray. You’re supposed to know – instinctively? -- what not to ask them.

So, digging in your heels may get you the higher-up attention you want. Any doctor who doesn’t appreciate a patient’s commitment to his own well-being deserves a turnstile not a waiting room.

(Also published as an op-ed in the Jan. 28, 2017 edition of The Fresno Bee.)

John G. Taylor, a former Fresno Bee reporter and editor, is owner/operator of The JT Communications Company LLC. Write to him at jtcommunicates@comcast.net

Hunting for a new MD: Recurring nightmare

On a scale of dreadful things, searching for a new family physician ranks up there with hunting for a divorce attorney.  Unlike divorce, pursuit of a new doctor has become nearly an annual punishment.

What’s worse, the triggers for this torture are increasing.

• Elections: It was called the Patient Protection and Affordable Care Act when it became law in 2010. But political demonization quickly lopped off “patient protection.” It’s not hard to imagine that repealing/replacing Obamacare will hugely upset the patient-physician relationship.

• Networks: Insurers annually rejigger their accounting Rubik’s Cubes, and our favorite docs quietly disappear from “the network,” leaving us “physician du jour.” Patients lose in the caregiver numbers game. The California Health Care Foundation found 40% of California physicians provide 80% of Medi-Cal visits.

• Life cycle: Physicians die or open wineries in Paso Robles. The Physicians Foundation found that 46% of 17,000 doctors surveyed are accelerating their retirement, cutting back on patients or getting out of direct, hands-on care. For those who remain, morale is tanking.

• Bad habits: Injecting 20 million newly insured into a chaotic industry has encouraged the Dickensian viper pit behavior of the worst medical practices while leaving unmet the need to educate new patients.

Doctor shopping is the opposite of speed dating. Docs aren’t standing by the window with shades open. This is more a mandatory trial marriage or the luck of a mail-order spouse. It comes with a whole built-in family of doctor/insurer-preferred relationships – the preferred hospital, X-ray services and pharmaceuticals.

I’ve rarely seen it happen, but it would help if doctors and patients openly aligned their expectations from the start.

• Timeliness, courtesy, clarity and follow-up. Mistakes ought to be rare and acknowledged. Dishonesty and evasiveness, unacceptable.

• Bring a script or crib sheet reminding you why you’re seeking medical help. Also, bring a list of medications, surgeries. And take notes while the physician is assessing you. “Patients need to be more sophisticated and do more homework,” said Dr. Alan Kelton, a Fresno primary care physician and faculty member who specializes in internal medicine at the University of California, San Francisco Fresno medical education program.

• “There’s less touching than in the past, and fewer head-to-toe exams,” said Kelton. Patients need education on routinely self-monitoring chronic conditions such as high blood pressure and diabetes. More physicians are engaging in email follow-up with patients, although payment and liability concerns remain. A patient’s after-hours call needs a better mechanical engagement than “call 911.”

• The need and value of medical tests needs to be weighed, especially given disputes about mammograms, PSAs and others. What will insurance cover – and what may happen with the results? Still more tests, involving a specialist?

If there is truth to “patient-centered” care, then we must vaporize the dehumanizing institutional maze.

Patients are not “the 2:30 appointment.” Often under-dressed and sometimes dehydrated, they are cold-shouldered into an overly bright room encountering a man whom they see rarely and briefly but always in the most vulnerable times in their lives. The feel is like slipping into a crevasse.

Doctors are not typically coddled craftsmen who flash through patients like FBI mugshots while whining about burdensome paperwork that rewards them comparatively lavishly. In slivers of time, they must repeatedly sleuth a remedy based on what patients say, how they look and act and what new evidence can be uncovered. Success and satisfaction aren’t assured and rarely arrive in tandem.

For both parties, access remains the No. 1 issue. A backed-up waiting room may well signal a compassionate and involved physician – someone who has trouble turning away need. Physician and patient are wholly interdependent. Both need to get their acts together because every failed audition ultimately can turn tragic.

(Also published as an op-ed in the Dec. 10, 2016 edition of The Fresno Bee.)

John G. Taylor, a former Fresno Bee reporter and editor, is owner/operator of The JT Communications Company LLC. Write to him at jtcommunicates@comcast.net

Truth serum: Daily dose required

Just before bed, I reach for truth serum. It’s a gift of nothingness, no flashing images or pulsing sounds – save for a vibrating ceiling fan, an aching ankle and the outlines of a spider web at a joist.

I tune out so I can get attuned to how I responded to the day. Often, about the only control in our hands is how we react to choices, both incidental and impactful.

This daily meditation, if that’s what you call it, is not purgatory. It begins with sensory fasting. Heeding the Scriptural “still silent voice.” It’s clearing the decks, taking stock of experiences, setting the stage for the next act.

Surgical teams call a “time out” to ensure they and their tools are aligned before operating. Yes, music is frequently played during medical procedures – but it’s not competing with everyone knowing their role and clarity of purpose.

Most of us breeze past self-reckoning. As the gag line goes, we all speak at least three languages – English, sarcasm and profanity. Did we choose wisely? Do we wish we had a do-over? Do we ever question ourselves?

One pastor’s homily included this suggested daily critique: What have I done today for which God would have said, “thank you”?

Consider what we ask our children. What happened at school? How did you spend your time? What kept you busy? We attach neglect or blame to the usual response: “Nothing.”

As adults, our good-soldier answers might raise eyebrows. Especially replies like “Nothing special” and “I don’t know where the day went.”

If we invest in second guessing, we may arrive at: Where did I screw up? Why did I yell at the dog rather than pay attention? Where did I give honor when none was expected – a smile?

All experiences are not of equal value. Holding a door open only matters when your arms are crammed with groceries. Cutting someone off on a roadway matters more if you’re required to jam on your brakes – unless, at some part of the day, you own up to making that reckless turn.

Some people fear being alone with their thoughts. Some have the experience foisted upon them.

The late Fresno Bishop John Steinbock injured an eye during seminary, requiring prolonged periods of total darkness. He used the time to learn Spanish from recordings.

Retired Yankees superstar reliever Mariano Rivera has had 60,000 people hurrahing or jeering at him. He routinely tuned it out and delivered. And when a hitter won the day, he took it as a lesson learned rather than a beating absorbed. A casual mindset does not get you to that crossroads.

Focus. Fasting. Pain. Deprivation. Isolation. Attached are such names as Cesar Chavez, Mohandas Gandhi, Nelson Mandela, John McCain and Aung San Suu Kyi.

We covet busy-ness as a blessing, the heartbeat of being goal-driven. And “nothingness,” if not fertile grounds for deviltry, is allocated the disdain accorded sloth, a purposeful disabling of God-given talents.

Taken as a whole, we know the price of very many things, but not the value of nothing.

Sleep provides distillation, but is not an active recollection. Showers relax, but are more reminders of our desperate need for more out-of-the-ordinary time. Our day needs an exceptional bookmark.

So, before I surrender to night, I put aside my printed and digital stimuli. I dust off my memory and assess my soul. In my faulted scale of justice, have I left the world – my friends, the happenstance of those I’ve encountered – in a better or less kind condition than if I’d not drawn a single breath?

I’m often chagrined by my answers. Truth is a motivating mirror. But only when you pause to look.

(Also published as an op-ed in the Oct. 29, 2016 edition of The Fresno Bee.)

John G. Taylor, a former Fresno Bee reporter and editor, is owner/operator of The JT Communications Company LLC. Write to him at jtcommunicates@comcast.net

Hospital quality: Spinning the 'Wheel of Fortune"

What’s a good hospital? The one good enough in a life-or-death event – the nearest emergency department for a heart attack – may not best when you have time to plan for a heart bypass, knee replacement or hysterectomy.

Truth is, the wellspring of informed intelligence for patients on medical decision-making is murky and likely will take years to clarify.

Irrespective of the Affordable Care Act, reform was urgently needed for our episodically wonderful and nearly indecipherable health system.

But the critical conversion from volume-driven payment to pay-for-performance – quality outcomes borne of cost-effective, best practice medicine – hasn’t yet resulted in a universal, reliable value-driven scale. Sure, the jargon bandied about is sensible enough for Google News readers – centers of excellence, star ratings, the patients’ choice.

Consumers are being told what they want to hear and where they ought to seek care. But there’s no definition – among insurers, providers and regulators – on a single set of benchmarks to separate fair, good, excellent and execrable. No one has created a medical Federal Reserve Board to oversee and certify best practices and practitioners.

Yes, the Joint Commission, the premier hospital evaluating body, has certification programs. So do insurers and organizations like the National Cancer Institute. But it’s not clear if they share their criteria or evaluation methods.

Consumers are still tasked with substantial, Byzantine self-education. So, in a Yelp world, how about a star ratings system for hospitals? That major controversial step occurred last July.

The Centers for Medicare & Medicaid Services released its first star ratings for hospitals based on 64 quality measures ranging from patient satisfaction, to mortality, readmissions and safety and effectiveness of care.

Few hospitals earned five stars; some prestigious names earned one. The Central Valley had one five-star facility (Fresno Surgical Hospital) and one of the state’s and nation’s lowest (Tulare Regional Medical Center with one star). Even those who did well criticized the methodology.

Consider a few of the wild cards involved.

Take readmissions. Not every hospital operates an emergency department, and even fewer are teaching hospitals which educate future physicians.

Hospitals which have both, like Fresno’s Community Regional Medical Center, are likely to see more patients with multiple chronic illnesses that have sporadically, if ever, received medical attention. They arrive in bad shape, take longer to leave the hospital as an inpatient and are more difficult to place with follow-up continuing care. For socioeconomic reasons, their progress may be hard to track. As a result, many are readmitted within 30 days of discharge for their same problems.

The result: Such hospitals may be hit with federal financial penalties. And their star ratings suffer.

How about patient experience? One survey aspect involves querying how pain is being addressed. Pain management is a complex science that factors in a patient’s ailments, age, other medications – and whether substance abuse is an issue. Here again, safety-net hospitals get hit harder on ratings that those that don’t have emergency departments or take Medicaid patients.

“They liken or cheapen medicine to a 4-star hotel rating,” one longtime Valley physician told me.

Fact is, being held to a very public standard of accountability – however shaky it now is -- insults some, infuriates a few and encourages those who believe in a more holistic, transparent approach to well-being.

“Administrators know the lay person cannot ascertain truth concerning quality care nor can they define it,” my physician friend said.  “It is an experience!  And the image is part of the experience.”

Many folks don’t know anything about their caregivers – their training, what they do well and, more importantly, what they do rarely or poorly. Patients may not know an endoscope from an angiogram. They trust and do what they’re told.

They don’t research (asking Siri doesn’t count).

The myriad of ratings and possible excellence centers is, at best, a convoluted start for the clear, sustaining education that consumers – and caregivers – urgently need.

(Also published as an op-ed in the Sept. 24, 2016 edition of The Fresno Bee.)

Civility: What would George Carlin say?

When networks have to bleep a presidential candidate, we’ve surpassed the George Carlin benchmarks of what can’t be publicly said. That’s as opposed to what should be normal discourse and is increasingly being rendered archaic.

When I wrote a blog-- The Martial Arts of Common Courtesy -- detailing how the “please and thank you” standard of good manners has devolved into the spoken equivalent of shoulder shrugs, the Fresno Bee published it as an op-ed. And readers amplified.

“I am exasperated by people, mostly young, who say ‘no problem’ as if they were incapable of uttering ‘you're welcome.’

“I'm damn tired, too, of being told to ‘have a good one’ instead of being thanked.” – Don Slinkard

“I cracked up reading your article. My husband and I have been irritated with the ‘no problem’ response for years. So our comment back is ‘Was there going to be a problem?’ Employers should educate employees on manners.  Have a good day!” – Karen Miller

“I used to think I was perhaps the only who thought this was an issue for me.  Call me ‘old school,’ but I do believe the ‘art of civility.’  When I say ‘thank you’ to the clerk, cashier, waitress or the person who held a door for me, the response is always, ‘no problem.’  How I would love to hear a ‘you're welcome,’ once in a while.  Could this be generational? 

“Another generational phrase that has been shortened is, ‘I'm sorry.’  On campus, I constantly hear students respond, ‘sorry.’  That is just a word without identifying who is sorry!  I am teaching my grandchildren how important it is to have ownership, ‘I'm’ and for the issue, ‘I hurt your feelings; I hit you, etc.’

“As for your comments on customer service, I had an experience such as you described.  Can't a manager see there is an issue with a customer, and respond ‘I'm sorry for the misunderstanding, mix-up, etc.?’  Whatever happened to ‘customer service? ´

“Yes, all those wonderful responses I grew up with: ‘Please,’ ‘thank you,’ ‘you're welcome’ and ‘I'm sorry,’ do matter.  Perhaps with their return it might make our world kinder, gentler. -- Martha Magnia

“You are spot on: ‘No problem’ is definitely a problem. And so are some of the other absurdities that have sprung up recently, and which I staunchly condemn: ‘No problemo’ (a disgrace to Spanish and probably unique to California); ‘You guys’ (sad testimony to the lack of a second-person plural pronoun); ‘I’ve got your back’; and that terrible word ‘frigging.’

“The language is definitely under assault, and at extreme risk are the irregular preterits – to which scant attention is paid anymore. We are daily bombarded with such atrocities as “speeded, slayed, thrived, bidded, dived and pleaded” – all from sources who should know better. Where is Eric Partridge when we need him?

“Can we expect a future of, say, ‘eated, goed, flyed, thinked, sleeped’ and kindred horrors?

“Thank you for the response, Mr. Taylor. It’s a real pity that such a sorry fate has befallen so many verbs of long-standing and accepted irregularity. There is no end to which this theme could be enlarged.” -- Paul Watts

The martial arts of common courtesy

We continue to screw up two of our most powerful words: thank you.  Give a simple “thank you” to a cashier. If you get a response, it’s: “No problem … Sure ... Who’s next?”

The airing of “You’re welcome” makes you gasp. And “It’s been my pleasure” transports you to Downton Abbey.

We’re nearly as lousy with “I’m sorry.”

Apart from politics, we’ve fallen so far in the art of civility that it’s costing money and prompting action. Nearly every industry is attempting to hardwire customer service – aka, common courtesy -- into its employees.

Hospital attorneys are even coaxing some administrators and doctors into injecting “I’m sorry for our errors” into oral and written explanations to patients and their families irrespective of lawsuits that often attend medical mistakes.

Most of us are forgiving folks. Just don’t spit in our faces if you’ve accidentally jammed a door into us. “What can I do to make it right” goes a long way in affirming good will, especially if it can be made real – a complimentary meal, a write off of charges.

Doing the honorable thing has become such a surprise that I can easily recall three personal examples.

A jammed bathroom pocket door had trapped a granddaughter during a visit. She was in tears by the time we extricated her. We hired a carpenter and were satisfied with the outcome of his hours of work.  He shook his head. Don’t give me your money, he said. It doesn’t pass my muster.

Wow.

News reporters and editors often don’t see eye to eye. During my decades in the newspaper business, the office atmosphere was “condemn in public and praise in private.”

I once cautioned a Fresno Bee editor about a story I was covering on a Saturday night. Nation of Islam leader Louis Farrakhan was scheduled to speak.  He was regularly in the national spotlight, frequently criticized for anti-Semitic comments. He would talk for hours – loading his most contentious remarks in his final 90 minutes. I’d listened to numerous speeches and knew the arc of his oratory. This won’t work within regular deadlines, I said.

Deadlines are deadlines, the editor told me. We’ll publish what we can in the Sunday paper and trust that will be enough.

As usual, reality snickered at benchmarks.

Local television and radio had captured the midnight hour rhetoric, commanding the Sunday airwaves. Community leaders were outraged that their newspaper of record contained nary a word. And my byline was attached to a story that chronicled only the eloquent calm before the vitriolic storm.

The next day my editor sought me out. I blew it, he said. You were right and I should have figured something out. I’m sorry. Will you please write a follow-up story and make it right with the readers?

Wow. Never heard such self-effacing comments from an editor before or since.

Lastly, some expressions of honesty crack the mold. I was 30, living in Wisconsin when my mother died suddenly in the New York City area. During her wake, her physician – who’d taken care of me as a child back in the days when doctors made house calls – pulled me aside.

I’m shocked and sorry, he said. I should have better monitored the potassium levels for her heart. As I struggled to react, he shook his head and then my hand, and walked away. It was the last time I would ever see him.

As I near the age at which my mother died, I’m still astonished and refreshed by his “out of nowhere” candor and caring.

I’m a tad late. Thank you, doctor.

(Also published as an op-ed in the Aug. 27, 2016 edition of The Fresno Bee)

Elie Wiesel: No safety on the sidelines

Elie Wiesel lived in a world, the one here still, where gray ruled over black and white. And it was the gray that he fought relentlessly.

His spoken and written words were shorn of adjectives. Evil and good were nouns and verbs, his weapons. They needed no embellishment. He stood as exclamation point. Read “Night,” his riveting recollection of his existence in Nazi death camps. Listen to his presentations, interact with him as I did as a Fresno Bee reporter during his May 1990 visit to Fresno.

What he experienced in surviving the Holocaust suspended his belief in God and the value of memorializing his existence. Fortunately, he reawakened and never ceased shining a spotlight on the authenticity and invasiveness of evil until his death July 2 at age 87.

It is in the gray areas of our lives – the formative, the evolving, the dissolute – that good and evil forever vie. We take a turn. We shrug a shoulder. We respond to a message. A primal urge takes the lead. Instinct squares off with intellect – and the devil takes the hindmost.

The gray that leans toward evil is too easily excused by hormonal powers, bowing to rather than questioning illicit authority and the contrivance of waiting for evanescent better times to stand one’s moral ground.

The gray that bends toward good paradoxically has some of the same mettle as evil. Goodness requires the churning and fertilization that Wiesel wielded. He knew that it is in the gray that the good fight must be fought and won, and won again as though for an eternity of first times.

“We must always take sides,” he told the world in his 1986 Nobel Prize acceptance speech. “Neutrality helps the oppressor, never the victim. Silence encourages the tormentor, never the tormented. Sometimes we must interfere.”

He spoke before a crowd of 2,000 at a Fresno State lecture – “Building a Moral Society.” The world of 1990 is alien to many in the black, white and gray bubbles of today.

Iraq invaded Kuwait, setting the stage for the first US Persian Gulf War. Nelson Mandela was released from prison in South Africa. East and West Germany had reunified. The World Wide Web had been born, and the Hubble Space Telescope launched. The Exxon Valdez tainted Alaska with its oil. The Baltic states declared independence from the Soviet Union amidst the era of “perestroika” or “openness” of Mikhail Gorbachev’s rule. And tens of thousands of Soviet Jews were allowed to emigrate to Israel, while some who remained were targeted by an anti-Semitic pogrom. The Soviet Union was a year away from collapse.

Wiesel saw the contradiction between the sudden freedom of Soviet Jews and the unvarnished remaining hatred.

“Does it mean that liberty, in a paradoxical way, could bequeath hatred? If so, what is the meaning of liberty?”

He had little stomach for religious fundamentalism of any stripe. “It is dangerous because fanatics believe that they possess the holy truth, that they possess God. They keep God prisoner. And I believe it is our duty and our privilege to free God from their prison.”

He joined scores of Nobel laureates in calling for an end to the political sidestepping and affirming that a genocide had indeed occurred to millions of Armenians at the turn of the 20th Century. Referring to Serbian leader Radovan Karadzic who oversaw the slaughter of Bosnian Muslims, Wiesel said, “How can you ever adequately punish a man who is guilty of ordering the assassination of 8,000 human beings [in Srebrenica]?” Only last March was the longtime fugitive Karadzic sentenced to 40 years for the genocide that occurred in the early 1990s.

Freeing prisoners of conscience. Challenging “it’s not my fight” placidity.  Examining the word “tolerance” –  and finding in it a dangerous permissiveness, something that can be bestowed or revoked.

What would be his greatest fear on his deathbed, I asked. Society’s forgetfulness, he said. That all his efforts to bear witness had changed nothing.

That’s no less our fear now, lacking as we do the presence of this moral lightning rod.

Killing off, adding hospital beds --- Why?

Hospitals nationwide appear to be seesawing over the fate of hundreds of inpatient beds and, with them, the future of thousands of jobs, entire communities and how patients will get care. The add-them, subtract-them decision isn’t so much a show of uneasiness as it is the result of hard realities, often unique to a hospital’s geography, as well as redesign born of healthcare reform.

In California, billions are being spent on retrofitting or new construction to ensure that hospitals meet earthquake standards that take effect in 2030. The deadly 1994 Northridge quake resulted in a legislative mandate that has caused some hospitals to close, downsize or sell to others who envision something other than intensive care beds on hospitals’ pricey, seismically rocky coastal real estate.

Whether the end result will provide sufficient beds to handle California’s growth and aging Baby Boomers depends on where in the state you live. In a 2015 report, the California Health Care Foundation said the San Joaquin Valley and the Inland Empire may be hard pressed to meet demand by 2040.

Different factors play out in rural areas, especially in southern states. Changing reimbursements have inhibited the ability of smaller hospitals to weather financial challenges, to satisfy requirements for installing electronic records and to lure and retain physicians, especially specialists. Some may call them “mom and pop” hospitals, but many smaller hospitals are critical “way stations” for healthcare emergencies, tending to patients until they’re transported to higher-acuity locales.

With fewer than 100 beds – many of them unoccupied – these hospitals are closing or becoming freestanding emergency departments where state laws permit.

Sometimes a single decision can push a once-successful small hospital to the edge. That’s occurring in Coalinga, Calif., where the district hospital took a huge fiscal hit when California shifted care of nearby state inmates to distant, newly created prison hospitals.

In New York City, the problem has been a chronic oversupply of beds coupled with costly, politically charged labor agreements.  Sometimes that has meant paying sizable staff and operational costs when there were few or no patients to oversee.

Nearly 20 city hospitals have closed since 2000, and Mount Sinai Beth Israel has been facing a fiscal crisis threatening its existence. It’s opted to try something radically different. Over the next four years, it will replace its existing 856-bed hospital with a 70-bed hospital with an ED as part of a massive expansion of outpatient care services.

The scale of transformation at Mount Sinai is astounding. Some of the 4,000 unionized workers will need to be retrained or laid off.  Perhaps $700 million in hospital real estate will be sold. The institution’s goal is focused on outreach and public education, to avoid or remediate medical issues before they necessitate costly inpatient care.

The seesaw effect of the Affordable Care Act of 2010 is nowhere close to flattening. The U.S. Centers for Disease Control said the nation’s uninsured rate in 2015 fell to 9.1%, the lowest on record. It was 16% when the law was signed, 14.4% in 2013 before its major provisions kicked in, and 11.5% in 2014.

The newly insured continue to seek treatment for ailments they habitually ignored, some of which have become chronic and irreversible. Many will need highly specialized care, complex surgeries and other sustained interventions and costly hospitalizations. Hospitals in regions of historically high unemployment and shortages of medical access can expect high rates of inpatient utilization to endure for years.

The reward for doing what matters – cradle-to-grave education and prevention, and doing it very well – will be empty hospital beds. That still sounds like a “pay me later” experiment, where later means future generations while today we’re addicted to “Hot ‘n Now” results. Ultimately, for hospitals, it forms the only solid ground when choosing to add or subtract inpatient beds, or just flat out go out of business.

(Also published as an op-ed in the July 30, 2016 edition of The Fresno Bee)

Pharmacists: the National Guard in lean times

The front line of healthcare is crammed between the linguica and callus removers. Yet we breeze past pharmacists as though they were dried prunes.

It’s time to break that habit. Pharmacists and a handful of others – including nurse practitioners and midwives -- are part of a growing, important corps of service providers called “physician extenders.” Although that makes them sound like a variety of Hamburger Helper, they are bridging the very real gap between the doctor supply and the unmet demands of newly insured patients.

They’re becoming advocates, educators, psychologists, lifestyle translators, life-saving human data bases, and red, green or yellow flags to our habits. They’ve come a long way from the tart British description of pharmacist as “chemist.” Fact is, you can almost always find a pharmacist. How quickly can you see your doctor? And, behind-the-scenes, pharmacists are playing increasingly important roles at patient bedsides.

Legislation has placed both retail and clinical pharmacists at the nexus of ethically complex encounters that can include providing medications for patient-assisted suicide (or not), over-the-counter contraceptives (once the prescription-only province of physicians) and involvement with medical marijuana.

While still answering “do I feed a cold and starve a fever” queries, they also now translate the arcane world of formularies. That includes sometimes determining whether a pricey brand name drug prescribed by a physician –unaffordable for some patients and therefore unused – can through science and diplomacy be changed to a cheaper generic acceptable to everyone including insurers.

“The needs of people go beyond their medication needs,” said Will Ofstad, Pharm.D., BCPS, CDE, assistant dean for education at California Health Sciences University (CHSU), which opened in Clovis in 2012. “A big part is education. Another big part is motivation.”

Ten years ago, pharmacists handled medication dosing and didn’t spend time outside the four walls of their offices, said Bruce A. Lepley, RPh, director of pharmacy at Fresno’s Community Regional Medical Center.

They’re now part of a daily caravan of stethoscopes and smocks, visiting hospitalized patients, working with other professionals on treatment plans and medication selections.

“We try to get to know you better than your family physician does,” said Lepley, who has been part of the profession’s metamorphosis for nearly 40 years. In the next 10 years, pharmacists will likely become more involved – and get more cooperation from physicians some of whom initially rebuffed interactions with harsh words and an occasional tossed scalpel.

“Including a pharmacist in a care team leads to significant savings -- $10 for each dollar invested – and reduces medical errors,” said Ofstad. “It improves access to high-quality, patient-centered care, particularly in underserved communities.”

Ofstad, a certified diabetes educator, said benefits can be keenly felt in that disease which hits hard in the Central Valley and costs California $24 billion annually. Diabetes hospitalization accounts for half that spending.

As the region’s safety net, Community Regional and its pharmacists try to alter that trajectory. “Can we convince patients to get well in the time we have them? Then we can make a difference,” said Lepley.

Discharge planning – where to guide patients for continuing care when they’re healthy enough to leave the hospital -- can reduce costly hospital readmissions. “The more we can do before discharge the more effective we are,” he said. Once out the door, do they keep taking their medications? That follow-up’s tricky when patients have no permanent address or phone number.

Building a new sustainable dietary way of life for a diabetic is far preferable to helping them adjust to a prosthetic leg from an avoidable amputation. Yet some insurers won’t pay for diabetes education.

Pharmacy education goals are changing. At CHSU in Clovis, the published targets include civic engagement and “a high degree of innovation, divergent thinking and risk taking.” The future mandates such adjustments, says the American Association of Colleges of Pharmacy:

* We’re living longer and, consequently, getting more chronic diseases;

* We’re presented with medications and devices in increasing numbers and complexity;

* More physicians are retiring and fewer are specializing in primary care (let alone gerontology);

* We’re trying to control costs and ensure quality, and

* We’re relying more on preventive, home and long-term care.

The number of pharmacy schools and colleges in the United States has exploded – from about 80 in 2000 to about 135 now.

There were more than 297,000 pharmacists in 2014, earning about $121,500 annually, according to the U.S. Bureau of Labor Statistics. Most than 50% work in pharmacy, grocery or department stores, and about 20% in hospitals.

However, there are kinks in the hose.

Researchers warn of a pharmacist glut. The labor bureau estimates job growth at 3%, slower than the average of other occupations. And the market is shifting.

Hiring is slowing in retail – where pharmacists were once lured from hospitals by better pay, bonuses and shorter hours. Corporate mergers and online and mail-order pharmacies are eroding that face-to-face market.

Demand is tilting toward direct patient care. But there are problems.

Hospitals need a reimbursement formula that pays fairly for pharmacists as the delivery system shifts from volume to value based. Medications can be ordered from many specialists, but pharmacists are expected to assess them and prevent screw-ups. Who has a rewards category for errors avoided? Another hang-up: Less than half of pharmacy colleges and schools offer patient physical assessment courses. Those courses are required by California’s SB 493 which created the hands-on category of Advanced Practice Pharmacists in 2014.

So, sit and wait as your prescription is filled at a Walgreens or CVS. You may overhear personal talk of great complexity with little filtering.

Will this drug make my wife’s constipation worse? I know it makes you sick so I’m trying to get your doctor’s permission to switch to another medication, and his staff is slow about returning calls. I know it’s a hassle, but the law requires written prescriptions each time you get pain medication to limit abuse. Yes, we can provide bottle labels in Spanish.

Throw in a flu shot. Guidance on using the free blood-pressure tester. And help in purchasing a cane. These investments of time and skill aren’t usually built into a physician’s workday.

Give the future a whirl. Spend less time selecting salsa and a few minutes asking for a pharmacist consultation.

(Also published as an op-ed in the June 23, 2016 edition of The Fresno Bee)

Hospital billing, exec comp: These fixes are bogus

When last I gleefully waved my paycheck in anyone’s face I was earning my first dollar an hour. But as wages and responsibilities grew, they became my private business.

So, I understand why titans of industry get ticked when their salaries are paraded for public pillorying. But my nerves get rattled when my telephone bill arrives with minutiae that totals up to more than my first teen-age work week. And when nobody at the utility can simply explain how my phone bill was concocted, I become more inclined to question why the digital big cheese merits his millions.

The same holds true in spades when it comes to healthcare. Nothing about medical costs, and very little about the care processes, can be translated into seventh-grade text, which was long the benchmark educational standard for writing and editing daily newspapers (where I worked for 30 years). And when I worked as a government advocate for a nonprofit hospital system, I saw the same bewilderment among the very industry fiscal experts and government regulators who built and papered over for decades the acronym soup that drains checkbooks and fattens frustrations.

Those twin thorns of healthcare costs and executive compensation are again being furiously wiggled in Sacramento by lawmakers, community activists and labor organizers using legislation and ballot initiatives.
It’s the usual carrot and stick.  Labor leaders usually want access to additional hospital members and their dues. Pouncing on hospital complexity is a reliable weapon.

When it comes to finances, critics reach deep into the murk of charity care, community benefits, bad debt, profit margin and costs vs. charges to dig a labyrinthine trench that only CPAs and $500-an-hour lawyers can assess. The critics don’t help the Twitter universe define what constitutes charity care even as they parse it in more puzzling ways to dramatize their case.

They don’t clarify evolutions underway in the post-Affordable Care Act world in which more people are granted coverage but not pathways to access it – in part because the payment methodologies don’t encourage broad physician participation.

When it comes to compensation, critics are now stretching their reach beyond the top tier of nonprofit leadership – who are already required to publicly report their compensation on the federal 990 forms – and invading layers of health professionals whose salaries, bonuses, overtime, pension and other compensation may total $250,000 annually. That’s potentially a heckuva lot of people – if the clear purpose is outrage, what is the good end?

Fact is, the sizable salaries of numerous elected and professional California employees – from mayors to police and sanitation workers – are accessible on many public websites including the libraries of large daily newspapers.  Yet the same labor leaders who levy multipliers of how hospital executives are paid hourly compared to rank and file staff have themselves mustered legislative and legal challenges – up to the Supreme Court – to quash or limit how easily fellow union members can determine how their dues are spent and where they’re given a voice.

Hospital CEO salaries are not a significant factor in health costs – the big money goes to total employee wages and benefits, and pharmaceuticals and new technologies.  The California Hospital Association estimates that average total compensation for a hospital CEO is less than one-tenth of one percent of a hospital’s budget.

Both the finance and compensation chokepoints are usually carefully targeted so as to affect nonprofit hospitals that are not already solidly in the hold of organized labor.

The ballot tactics require tens of millions of dollars to execute – and millions more by their targets to defend. So many ballot initiatives were floated this year that it’s been reported that California petition workers were paid $5 for each valid signature gathered.

These so-called fair billing and equitable compensation campaigns inject neither illumination nor innovation where the public needs it. They are retributive -- not remedial -- efforts.

In reality, various hospital systems are implementing bare-bones billing policies. Their true value ultimately will be reliably equating them with quality outcomes. Some chargemaster policies no longer bill patients for items – such as ibuprofen or antacid – if they’re available over the retail counter at places like a hospital’s outpatient pharmacy. That’s a good first step to eliminate the $15 aspirin headline.

And hospitals – the ones that will survive, anyway – are fast moving away from keeping every bed filled and every practice specialty flooded with patients and switching to benchmarking success by years of quality, productive living returned to patients in cost-effective manners. That’s a longer haul.

On compensation, California healthcare is a unique beast in job complexity, especially in the nonprofit world. The California state Legislative Analyst’s Office says that 70% of the state’s hospitals are nonprofit, most of them providing the state’s largest share of care to the neediest of patients. Volunteer boards of trustees usually oversee how nonprofit execs are paid and vet their strategies. Board members usually live where the hospitals conduct business, and often go there for medical care. They don’t live over my back fence but they’re way more reachable than Wall Street.

The recurring political targeting of hospital pricing and executive comp doesn’t address what’s ailing us.  It’s diversionary.  Its only transparency is its own self-serving nature.

(Also published as an op-ed in the May 21, 2016 edition of The Fresno Bee)

Hospitals: Taking it to the streets

Catering to and fostering people who want to be healthy. That’s the healthcare environment we’re evolving toward. That’s not yet the propelling force behind many hospitals.

Once you’re in the hospital door, you’re often regarded – from security screening, to triage station to patient financial services -- as another clot in an already sclerotic system.

You encounter warnings and scrutiny -- not hospitality, education and encouragement. Leave your valuables at home. Prepare to provide a co-pay on admission. Bring a designated care advocate – with legally binding permissions – to stand up for your rights.

There may be valet parking and a colorful folder explaining confidentiality, billing and patient care services, but there’s signage suggesting perdition -- “perfusion lab … densitometry scans… interventional radiology.”

When fiscal or physical dilemmas arise, you are pointed where the nomenclature turns dark. Charge nurse. Case manager. Ombudsman. Administrator on duty.

You hear that sizable staff are assigned to quality/infection control, risk management -- suggesting variability abounds and unpleasant experiences lurk. If you’re looking for the forward-thinking positivism of a chief imagination officer, try the Sundance Film Festival.

Patients receive arcane brands. “Non-compliant” means not following instructions (though if a caregiver can’t speak the patient’s language, that tag can be mistakenly applied). “Frequent flier” – that will get you bonus airline points but in hospitals it’s attached to those who frequently and often needlessly use emergency services (often for lack of public social services like behavioral counseling). “LWBS” – left without being seen, as hours turn to days of waiting for non-emergent care.

Fortunately, the inherent cultural infirmities of hospitals are changing. More patients with insurance mean heightened demands as well as expectations. Government reimbursement hinged on paying for quality and penalizing for lapses – faulty as it is, particularly for safety-net hospitals serving disproportionate numbers of chronically ill patients – is hastening improvements as well as sometimes-warranted closures. Retirements and shortages of physicians and nurses will translate into extending scopes of practices for other providers, and a rocky hand-off that will be.

Most hospitals were not founded with the mandate of putting more feet on the street – sending out multilingual social workers and educators, creating transitional housing for the homeless, lobbying governments to increase green grocers and green space, safely accessible to the public. That was the presumed province of government agencies and community organizations.

But better care at lower costs means systemic re-invention.

Ultimately, more empty hospital beds are part of the success story. That was no more the benchmark college curriculum for most of today’s healthcare execs than experiencing rigorous interrogation by patients of treatment options was for physicians educated a decade ago.

The innovations and experiments needed for that re-invention are evident.

• The Mayo Clinic has created a staff burnout task force, recognizing that rested and rejuvenated caregivers provide better patient service.

• The University of Illinois is funding apartments for as many as 20 chronically homeless Chicagoans for a year, easing emergency department usage.

• Kaiser Permanente is testing patient “health hubs” in Southern California, described as a kind of “public square” where care mingles with yoga classes, cooking demonstrations and educational classes.

• And in Fresno, Community Conversations -- a collaborative of health providers, community, government and other activists -- has not only revived a county mental health system eviscerated by funding cuts but also established a one-stop entry point to a usually Byzantine network of behavioral, substance abuse and homeless resources in the region.

Ultimately, the hospitals that flourish will increasingly empower those they serve. And they certainly will be more hospitable.

(Also published as an op-ed in the April 23, 2016 edition of The Fresno Bee)

A cancer ‘moonshot’ – making rhetoric real

Hyperbole is anesthetic of choice in political warfare. It feeds the craving for finality -- carpet bomb, build a wall, love it or leave it.   

But President Obama surprised me by what he tucked into his final “State of the Union” address this year -- exhorting that a cure for cancer be this generation’s “moonshot.” 

This was a reach. It was safe. But, as one of the countless millions touched by cancer, I also took it as a dare. 

It was a reach because many who heard Obama weren’t around to recall the nation’s rallying of resources and spirit that led to our initial manned landing on the Moon in 1969 – and, not inconveniently, abating massive political leveraging by the Soviet Union of its earlier successful space forays. It’s also a reach because it’s not a current campaign issue. And because some believe it’s impossible. 

It was safe because he assigned the task of champion to Vice President Joe Biden, a skilled political navigator still fresh from the loss of his son Beau to the disease. Though the opportunity for something politically meaningful to occur in Obama’s remaining months is slim, Biden needn’t be shy. 

But I also took it as a challenge to rewrite the narrative of how cancer will be fought. Curing cancer is a universal want. It is that implacable beast, actually hundreds of beasts, for whom a single defining moment has proven unreachable. Presidents of both parties have dangled it in their crosshairs over the decades. Biden would do well to craft a game plan where accomplishments and obstacles are identified and measureable benchmarks established. And where moonshot is not the buzzword. 

There are few moments of magnificence in life, author-evangelist Chuck Swindoll told this year’s Fresno/Clovis Prayer Breakfast. Much of life is maintenance. Doing the same thing and striving to do it well. We need to recognize the power of incrementalism – as with fighting cancer, I would say -- and remove needless ankle weights. 

We have cancer successes. For the last two decades, the nation’s lung cancer death rate has steadily declined. Fewer people smoke, thanks to education, science and a soaring product price point. The American Cancer Society reports declines in the rates of colon and prostate cancer as well.  

The strides are not evenly distributed among various ethnic and socioeconomic groups. Other cancers are on the rise. Poverty and gaps in education and access to care also are factors in why cancer remains the leading killer of Americans. 

We have impediments. Key among them: 

• The chaotic and fragile healthcare system. We pay too much for care inconsistent in quality and availability and superabundant in complexity. 

• Costly government regulations that restrict data sharing, delay testing, waste resources and dissuade both investors and scientists. Science is inherently trial and error, returning scant spendable headline-making capital. 

• Education and advocacy on prevention of illness, the maintenance of healthy lifestyles, the value of hospice and palliative care.  They require a daily grind – school nurse, telemedicine, home health at the door -- to become hard wired. They are costly in the short run and the antithesis of a sexy stump speech. 

Many cancer-fighting groups use tiered strategies – what we hope to do by when. Biden might consider a multiplier, a Marshall Plan. Quick refresher: With Western Europe in ruins following World War II, the United States invested billions to rebuild roads, bridges and infrastructure across international boundaries between 1948 and 1952. The Marshall Plan brought about the fastest period of growth in European history.  

Money and moonshot proclamations may not lead where you need to go. In 2003, the head of the National Cancer Institute was quoted in the New York Times as saying his group’s goal was to end suffering and death caused by cancer by 2015. Sen. Arlen Specter asked Dr. Andrew von Eschenbach if a budget of $600 million a year would advance that date to 2010. His reply was yes. Not sure if he got his funding, but, in 2012, Specter died of cancer. 

I’m reminded of a challenge that then-Fresno Bee Editor George Gruner posed to his editors in the 1980s: Produce a daily front-page “reason to live” story detailing a person’s success in a tough life situation. He didn’t view this as an ultimate immunization against cancer or any darkness. Just an encouraging snapshot of how people deal with what life presents. 

We have an inventory of the benefits of painful relentlessness in remedying cancer. We need a coherent national Marshall Plan – a scorecard of strengths, weaknesses and opportunities – if a cancer “moonshot” is to go beyond rhetorical artifact.

(Also published as an op-ed in the March 19, 2016 edition of The Fresno Bee)

Death, deliverance, dollars

"Please submit death certificate."  That was my “good morning” email from a legit insurance company. When I called, they couldn’t find me in their database. Clearly, as I get ready to retire from a 15-year career in healthcare, I’ve not done enough to register as energetically living.

Fact is, I think the “state of healthcare” is more robust when I first signed on to communicate and advocate on medical issues. That’s largely thanks to the 2010 Affordable Care Act. Still, the nation’s so-called system is also a heavy breather on life supports. To me, healthcare expectations generally fall under “delivery, deliverance and dollars.”

Delivery: Since 2010, we’ve added 17 million Americans to the rolls of newly uninsured. Every business says customer satisfaction is Job One. So, those 17 million are a lot of new Job One’s. We didn’t conjure up additional doctors or, in most states including California, allow other medical professionals to perform services historically done by physicians. How long you wait for treatment often depends on where you live and if you need specialized care. The California HealthCare Foundation found that only 52% of Valley primary care physicians were accepting new Medi- Cal patients. In part, that’s because reimbursement doesn’t cover their costs. So, after 15 years, the outlook for delivery/access to care is -- short of hospital emergency departments -- chancy.

Deliverance: Call this surviving vs. thriving. The roadmap would drive Siri nuts. First, the array of healthcare scorecards and “best practices” is confusing, contradictory and stitched with self-interest. Atop scorecards, the US just rolled out this ICD-10 creature -- the 10th revision of the International Statistical Classification of Diseases and Related Health Problems. It adds 125,000 diagnostic and procedural codes to your hospital visit (insect bite, left nostril, second time; arm injury, flying saucer). It may explain why more people work in billing than in hands-on patient care. Lastly, the growth of electronic medical records will be more of a lifesaver once differing computer systems can chat, staffers don’t leave unencrypted flash drives at Starbucks and physicians remember than looking at, listening to and touching patients are at least as critical as the mandated punching and poking at computer workstations.

Dollars: Along with flying a kite with Mary Poppins, our hearts expect when a medical bill arrives, it will be “one and done.” We daydream that the invoice won’t have children and will be only slightly more difficult to swallow than peanut brittle. We should be stunned then, when in a rare moment of bipartisanship, both hospitals and Congress concur that prices and billing practices virtually violate the “first, do no harm” oath. To be fair, providers adapted to poorly crafted rules written 40 years ago that are now being rewritten daily. Payment for each service rendered is being replaced by pay for positive outcomes (and penalties for most anything else). Pharmaceutical profiteers are scalping where they can. And, retirements, mergers and closures have skewed the marketplace to where patients feel like they’ve parachuted at night into a minefield.

Somewhere along this path, we will recognize that getting and staying healthy takes work. And as the patient increasingly becomes the CEO, the levels of expectation and the need for education for said CEO will rise. Be interesting to check back in 15 years to see just how many hospital beds are empty, how many schools have full-time nurses and whether urgent care clinics replace Big Gulp fountains at 7-Eleven’s. Maybe if I dodge another email request for a death notice...

(This blog originally appeared at www.communitymedical.org)

(Also published as an op-ed in the Jan. 17, 2016 edition of The Fresno Bee)

Wonderfully (Dys)functional California!

Mandatory condoms in porn movies. Legalized marijuana. Electronic cigarettes, taxed. Plastics carryout bags at convenience stores, protected by law. Same kind of disposable bags, prohibited by law, except if you pay a 10-cent usage tax. Ah, another election year approaches in the fully functional/dysfunctional citizens’ democracy of California.

More than a hundred potential ballot initiatives have been filed so far with the California Attorney General’s Office for the 2016 ballot. It only costs $200 to file each of them. Proponents must gather signatures equal to 5% of votes cast for Office of Governor in the last election. And, because so few eligible voters among California’s estimated 38 million residents bother to vote anymore, that means only 365,880 valid signatures are needed to qualify for the ballot. Maybe 15 to 20 will get on the ballot. Still, a ton of work and expenses for signature gatherers, state fiscal analysts, rule writers and polling workers.

And a bonanza for professional fund raisers. They will feed marketing campaigns and ad purchasers – especially on the still-somewhat-limited space called commercial radio and television. Beware the geyser of online popups!

Woven into this richness of general bizarre theater is some context – a cause and effect. Californians elect 80 folks for the state Assembly and 40 for the Senate. And in their two-year legislative session, they cumulatively introduce roughly 3,000 bills. They’ll beget, maybe, a thousand new laws annually.

Clearly, many believe the elected legislature doesn’t do enough ofthe people’s work, hence the endless tide of ballot initiatives – designed to reward or punish, diminish or enlarge government, correct, negate or exaggerate existing laws. One of the sacred hallmarks of government by ballot, the property-tax limiting Prop. 13, became a constitutional amendment nearly 40 years ago – a virtual artifact, unknown to many homebuyers who benefit from it but who are oblivious as to what California looked like pre-1978.

Important initiatives – to support hospitals, to create revenue for innovations in mental healthcare – can easily be buried by competing ballots, bonehead stuff and jargon-laden doubletalk. When a voter encounters streams of briny prose separated only by a string of numbers, the easiest option is to skip it or tread heavily down the “no” boxes.

Sadly, as a writer in the Economist magazine noted in 2011, the direct-democracy tool of ballot initiatives has gone from being a safety valve to being an engine of policy making. And another California "Twilight Zone" episode.

(This blog originally appeared at www.communitymedical.org)