The following is a dialogue between an avid supporter of Hillary Clinton and me, who avidly opposes Mrs. Clinton's election.

This is an illustration, I think of the possibility of friendship, dialogue and colaboration between different political perspectives.

From:

RE: Page 7ff rights responsibilities realities year 2000 -- Larry - I have been rereading this evolutionary description of your practice--awesome , by the way--and one question keeps surfacing with me: If we want maximum personal responsibility to occur on the part of the patient/ consumer--rather than "paternalism" ---how can our language and framing be designed to accomplish this.  Observation: It is not apparent to me in this paper.  Thanks for dialoging with me on this!! I am including  on this email. She will start as a full time employee June 1. She will be a policy analyst for THI on this area.

Dr. Holly’s initial short comment:  Genuine caring, compassion, respect and admiration of those who are living simple, significant and important lives  Read the following:

• http://www.jameslhollymd.com/Your-Life-Your-Health/The-Healing-Touch.  
• http://www.jameslhollymd.com/Your-Life-Your-Health/What-makes-You-a-Human-Being
• http://www.jameslhollymd.com/Your-Life-Your-Health/Reach-Out-and-Touch-Someone-this-Season

   e:  this is a link to the piece to which you refer above: http://www.jameslhollymd.com/Your-Life-Your-Health/pdfs/setx-healthcare-issues-facing-southeast-texas.pdf.  The following is a copy of the relevant section:

“Constable or Counselor?

“Healthcare providers must never lose sight of the fact that they are providing care for people, who are unique individuals.  These individuals deserve our respect and our best.  Healthcare providers must also know that the model of healthcare delivery, where the provider was the constable attempting to impose health upon an unwilling subject, has changed.  Healthcare providers progressively are becoming counselors to their patients, empowering the patient to achieve the health the patient has determined to have.  This is the healthcare model for the 21st Century and the computerized patient record is the tool, which makes that model possible.

“Providers and patients being collaborative in the patient’s health initiatives is a data driven dynamic and it requires the sharing of that data between patient and provider.

“Managed Care:  Realities, Rights & Responsibilities

“Managed Care focuses attention on the three categories related to each party in the healthcare delivery equation.  They are ‘realities,’ ‘right’ and ‘responsibilities.’  Managed Care is the free-market’s response to the realities of the healthcare industry.  

“Three Fundamental Questions Which Face All OF Healthcare

“The first reality is that there is no possibility of healthcare financing and management ever returning to the laizze faire style practiced up until twenty years ago.  Someone is going to control and manage healthcare.  The only real question is, ‘Who?’  

1. “The financing of healthcare will never return to a system where the medical decision making process takes place in isolation and independent from the question of ‘Who is going to pay for the services?’

The second reality is that because of the expense of technology and because of increasing access to healthcare by a larger population, it is possible for healthcare alone to bankrupt the United States government.  Unchecked, the cost of healthcare delivery can prevent the balancing of the Federal budget.  

2. “The financing of healthcare will never return to a system where the medical decision making process takes place in isolation and independent from the questions of, ‘How much is a service worth and how much is society willing to pay for it?’

“This expense produces the third reality, which is that there are limited resources to continue to provide the excellent healthcare, which the citizens of this country presently receive.  Someone has to allocate those resources.  The question is ‘Who?’  

3. “The financing of healthcare will never return to a system where the medical decision making process takes place in isolation and independent from the question of, ‘What is society’s responsibility to its most vulnerable citizens as far as access to affordable healthcare is concerned?’

“The fourth reality is that the government has assumed, by law, the responsibility of providing healthcare to a certain segment of our population, and the government is not going to surrender that responsibility.  The facts of this reality are explained by the AAPCC – the Actual Average Per Capita Cost.  This is a calculated figure based on HCFA (Health Care Finance Administration) payments for healthcare in the United States.  It is calculated on a county-by-county basis for every county in America.   The AAPCC is higher in Southeast Texas, which means that the cost of healthcare per capita is higher here than in most places in America.

“In the private sector, the principle is the same.  While there is no Trust Fund, private companies have budgets and must meet them.  Managed care allows industry to budget its healthcare costs by transferring the ‘risk’ to another company.  In order to remain competitive, private industry must control healthcare ‘risk.’

“The second relevant issue is ‘responsibility.’

“Each ‘player’ in healthcare delivery today is in an unspoken partnership, which has actual and implied responsibilities.

• Payers (managed-care companies),
• Providers (physicians and other deliverers of health services)  
• Patients (insured).

“Each ‘player’ has its peculiar responsibilities.  The payers, of course, have responsibility for operating within the ‘realities’ of the AAPCC and/or contract, and for making sure that access to healthcare is maintained.  Balancing these responsibilities is a function of the core values and integrity of the managed-care company and of HCFA regulations.  Providers are responsible for providing outstanding care.  In managed care, healthcare is more directed toward preventative healthcare than to treating a problem, which has already developed.  Physician must be aware of the differences in cost for care.  The reality is that care obtained at one place, which is equal to the quality of care obtained at another, can be three times as expensive.  To conserve the healthcare resources for the benefit of everyone, the physician’s responsibility is now, not only to assure quality, but to consider cost-effectiveness as well.

“The patient has responsibilities in the managed-care system as well.  In order to get the expanded benefits and cost decrease of managed-care, the patient is responsible for utilizing physicians who have contracted with the managed-care company and who are committed to complying with utilization management guidelines, pre-certification of procedures and review of care.  The patient also has a responsibility to avoid habits, which cause increased health problems when and where possible, and to cooperate in obtaining preventive care, which can decrease the cost of maintaining health before serious and costly problems develop.

The Third Relevant Issue is Rights:

“Within these ‘realities’ and ‘responsibilities,’ what are the patients’ and providers’ rights?  The patient has the ‘right’ to excellent healthcare and to access to needed care.  However, the rights of the patient must be balanced with the rights of the managed-care company and with the rights of the healthcare providers who provide care.  Likewise, the rights of these latter two groups must be balanced against and with the rights of the patient.  The patient has the ‘right’ to choose any PCP (Primary Care Provider) who is in the contracted network of the managed-care company and/or for the IPA (Independent Physician Association).  And, the patient has the right to go to any specialist who has agreed to cooperate with the managed-care company.

“But, the patient’s right to choose his physician cannot interfere with the right of the managed-care company to manage the ‘risk,’ which it has assumed.  The patient has the right to request that their favorite physician contract with the managed-care company.  But, the physician has the right to refuse.  And, the managed-care company has the right to expect the patients and providers to comply with the utilization management guidelines and standards required to manage effectively the ‘risk’ the company has assumed.

“Providers have rights also.  Most physicians have resorted to demanding their right to lead health care management.  The new realities result in that demand being rejected.  If providers wish to exert influence over the delivery of healthcare, they will have to accept their responsibilities and collaborate with payers and patients.”

        , your question repeated from above was:  “If we want maximum personal responsibility to occur on the part of the patient/ consumer--rather than "paternalism" ---how can our language and framing be designed to accomplish this.  Observation: It is not apparent to me in this paper.”  Remember, this paper was presented to the Beaumont Chamber of Commerce, August 24, 2000.  It was presented to a quarterly luncheon of a large number of the Chamber’s members.  Needless to say, I did not get through all of this material but it has served as a platform for discussion, unsuccessfully, I am sad to say, over the past sixteen years.  This paper was presented to non-healthcare professionals.

Language and Framing

1. Patient-Centered Communication -- The following is from an August 20, 2013, SETMA monthly training session entitled, “What is patient-centered communication? Have you really addressed your patient’s concerns?”  It can be reviewed at:  http://www.jameslhollymd.com/Presentations/What-is-patient-centered-communication.  The paper which is the foundation of this session was written by Carlos Jaen, MD, the holder of the Dr. and Mrs. James L. Holly Patient-Centered Medical Home Distinguished Chair at the University of Texas Health Science Center, San Antonio.  I have to admit until I read and taught this paper, the concept of a “patient-centric conversation was a mystery to me.  After reading and practicing it, it became clearer.  

2. The Conversation Project – This is the link to our October 17, 2013  study of this concept.  It is the brainchild of Maureen Bisognano at Institute of Healthcare Improvement (IHI) http://www.jameslhollymd.com/Your-Life-Your-Health/the-conversation-project.  

Maureen Bisognano, CEO of the Institute for Healthcare Improvement (IHJI) and a recognized international expert on improving healthcare systems, has taught us to ask a much more profound question and that is, “What do you want?” The elimination of the word “done,” changes the healthcare conversation from one of procedures, tests, services, etc., to one of outcomes, goals and desires.  It changes the conversation from science to humanity:  http://www.jameslhollymd.com/In-The-News/popup-the-conversation-project.   The is a link to SETMA’s Provider Training for October, 2013 which includes a study of The Conversation Project:  http://www.jameslhollymd.com/Presentations/SETMAs-Provider-Training-for-October-2013.  

The following material is from the article on the Conversation Project:
“One of Maureen’s most significant contributions to healthcare improvement -- The Conversation Project -- resulted from her  personal experience. The Project; is IHI’s program to make certain that healthcare providers, healthcare recipients and the healthcare system know how to talk about end-of-life issues.  The key is to ask the question, “What do you want?”  

“Maureen’s personal and poignant story was about her brother who died when he was 21 and Maureen was 23.  She shared their story:
“When my brother Johnny was 17 years old, he was diagnosed with Hodgkin’s disease. It progressed quickly, and he was in and out of hospitals regularly over the next several years. When Johnny was 20, he came to my apartment and told me, ‘I’m not gonna make it.’ He was ready to face death, but I wasn’t. I didn’t know what to say or do. All I could think of was to offer encouragement and try to give him hope. But Johnny stopped me and asked me, ‘Can I tell you what I want?’ ‘What do you want? I asked him. ‘I want to turn 21,’ he said.

“Johnny did turn 21 and died just a few days after that birthday. Throughout that last year of his life, I still didn’t grasp the power of that simple question that Johnny was asking me to ask: ’What do you want?’ Looking back, I wonder what might have come from asking that question. I wonder about the people Johnny would’ve wanted to meet and see. I wonder about the conversations they might have had. And I wonder about the functionality he could have had, to the extent he could, out of the hospital. But instead of Johnny realizing his wishes for his last year, he spent it mostly in the hospital. I finally learned the power of the question from a radiation oncologist. While Johnny was in the hospital during that last year of his life, doctors would come and go from his room. They’d speak over him, and about him, but almost never to him. Finally, this radiation oncologist went into my brother’s room and asked him, ‘Johnny. what do you want?’  ‘I want to go home,’ Johnny answered.

“The doctor then took off his jacket, put it on Johnny, picked him up from his hospital bed, and carried him to my car. Johnny came home, and spent his final days surrounded by the friends and family that loved him. That one interaction between Johnny and the radiation oncologist taught me not to rely on just providing encouragement and hope. These things are important, but more important, almost always, is having the conversation with a loved one about what they want. Find out what they want, then act on it, and carry it through. Trust me, you’ll be forever grateful you asked, ‘What do you want?’  I wept as I read this story for the first time.

“Patient-Centered Medical Home (PC-MH)

“As Southeast Texas Medical Associates has spent the last five years becoming a PC-MH, we have developed technologies to do ‘things’ and to perform ‘actions’ and to fulfill  ‘metrics,’ but we have only recently begun to understand the power of ‘patient centric conversations,’ ‘patient activation,’ patient engagement,” and ‘shared decision making.’  We have begun to understand that each of these categories is more than a once-and-for-all act.  They are a dynamic which are more accurately addressed in the continuing tense of the verb.  We have begun to understand that patient-centric requires continuous re-engagement more than just engagement, continuous re-activation more than just activation, and patient-centric conversions are not a single conversation but  is an on-going dialogue which takes place at many venues, at many times and with many different contents.  We have begun to understand that patient-centric is more completely defined by the profound question, ‘What do you want?’ than it is by the powerful electronic capabilities we have created.

“IHI’s ‘the Conversation Project’

“SETMA’s end-of-life conversation, which we perform with every patient and which we document as part of the structure of our medical home, is always begun by ‘What do you want us to do?’  What we should be asking is, ‘What do you want?’  My life stories reinforce what Maureen has taught us.

“As a sophomore in high school, I learned a lesson which has enabled me to carry out the most difficult personal and professional tasks.  One day, my friend’s father died suddenly.  That evening, I went his home.  I remember feeling very awkward.  I knew that I should be there, but at fifteen, I didn’t have the foggiest idea what to do, or what to say.

“Only one other friend came.  We made small talk and tried to forget the great loss.  At one point, we were talking about our families.  I said, ‘If my father ever did that, I’d kill him.’  If spoken words have a life beyond the hearing and memory of those present, these words seemed to have ;eternal life.  They hung in the air like a Damocles sword waiting to fall on my head.  If I did not know what to say, I surely knew what not to say and I had just said it.  Kindly, my friend glossed over my blunder.  The evening ended with goodbyes and expressions of sorrow.  

“The next day, after his father’s memorial service, my friend was sitting in the family car.  I walked over and said, ‘Louis, I don’t know what to say.’  Wiser than I at fifteen, he said, ‘You don’t have to say anything, you were there.’   To that point in my life, I had never heard kinder words.  They echoed in my mind louder than what I had blurted out the night before.  I turned them over and over in my mind, again and again.  My friend and I never spoke about this, but fifty-five years later, I have never forgotten those words.

Twenty years ago, I had a 24-year-old patient who declared that she had a dread disease but no diagnosis could be made.  A year later, during a pregnancy, we found the malignancy which was incurable.  She was from the Pacific Northwest and returned there. Three months later, she called me and said, ‘Can I come home?’  As she was with her parents, I thought she was.  She added, ‘No one will talk to me; they pretend that everything is OK,’  They had the same problem I had when I was fifteen.  She concluded,  ‘I want to come home so that I can talk about what is happening to me.’

She returned to Southeast Texas and for the next six months, we visited and talked often.  We prayed and planned for her son’s life.  My wife and family were involved with her.  Never once did we talk about medicine, surgery, pills or treatment. She did not want that; she wanted to come home.  She wanted to talk about the future and her life, not her death.  We never talked about healthcare; we talked about what she wanted.”

The following is Ms. Bisognano’s  response to SETMA’s work (this is posted with her permission):

“Larry, Can I tell you that you are my hero? You are such an amazing visionary, an articulate spokesperson for change, and an advocate for patients and families. I am honored that you would share my brother’s story. It’s in my heart (one of many)  and I so appreciate you sharing it. But everything you write moves me. Thanks for being you, the whole country benefits from your leadership. Hope to have coffee with you some day!   Warm thanks for all,  Maureen”  Maureen Bisognano, President and CEO, Institute for Healthcare
Improvement, 20 University Rd. Cambridge, MA 02138.”

3. On October 1, 1999, five months after SETMA had defined the structure of the medical home, SETMA published a booklet about EMR entitled, More Than a Transcription Service: Revolutionizing the Practice of Medicine And Meeting the Challenge of Managed Care With Electronic Medical Records (EMR) which Evolves into Electronic Patient Management  (the booklet can be read at http://www.jameslhollymd.com/your-life-your-health/medical-records-more-than-a-transcription-service.  In that booklet, SETMA said:

“Doctors need to learn new technological ways of organizing and conducting the business of medicine. They need to allow the power of information systems to change the way they approach healthcare. They need to maintain personal contact; patients are people first and last, but doctors need to see EMR as a powerful tool and not simply as a new and expensive toy. If they do, they will begin the 21st Century with an ability to impact the delivery of healthcare in America.
“Healthcare providers must never lose sight of the fact that they are providing care for people who are unique individuals. These individuals deserve our respect and our best. Healthcare providers must also know that the model of healthcare delivery, where the provider was the constable attempting to impose health upon an unwilling subject, has changed. Healthcare providers progressively are becoming counselors to their patients, empowering the patient to achieve the health the patient has determined to have. This is the healthcare model for the 21st Century and the computerized patient record is the tool, which makes that model possible.”

The key to “language and framing” is a mutual respect between providers and patients.  Respect is easy to have when healthcare providers realize how courageous many people are who are living with devastating health conditions which, whether their fault of not, make them all heroes that they live with them successfully.  When our genuine and sincere response to people is respect, admiration and compassion, patients are more likely to become:  activated and engaged and to participate in a share-decision making process which is the heart and soul of patient-centric care:  see http://www.jameslhollymd.com/Medical-Home/patient-centric-care.

4.  High Impact Leadership --
http://www.jameslhollymd.com/Presentations/ihi-high-impact-leadership -- SETMA Training from February, 2014, preparing providers to know how the language and framing of transformation.  

I will continue to think about this and send an additional response later.