A time of tremendous change in health care

James MandellI have used print, email, video and in-person communication to provide information about the strategic goals, operations, challenges and accomplishments of Children’s Hospital Boston and its faculty and staff. However, this is my first foray into the blogosphere. I hope it allows me a new opportunity to personally discuss our most important mission, simply stated: “We are here for the kids.”

Over the upcoming weeks and months, I will try to cover some of the most critically important (and I hope interesting) aspects of our world of pediatric care, research and education. I hope you will respond with comments, new ideas and ask questions about these and other topics.

For me, medicine is both a personal and professional calling. I am a practicing surgeon and the CEO of Children’s, but I’m also the parent of a child who at one point was critically ill and injured and the grandparent of six beautiful children. So I know first-hand what it’s like to deal with the stress, hopes and disappointments of raising a child – especially when that child has health problems. As a parent, you know that no one else understands your child as well as you. You must remain a fierce advocate for him or her, while shouldering the responsibility and heartache of having a sick child.

Our roles as caregivers and advocates for children are made only more difficult during this time of tremendous change in health care. I’m seeing turmoil at the local, state, regional and national levels about “health care reform” and all of its implications. And wearing all three of my hats – CEO, physician and father/grandfather – my worry is that issues such as access to preventive and acute care services for children will be dwarfed in the larger conflicts over the more costly coverage and payment for adults.

What concerns do you have about health reform? How can our health care system be improved without forgetting about its youngest consumers? What challenges do you face when accessing care for your child? Send your thoughts and questions and I’ll do my best to respond.

12 thoughts on “A time of tremendous change in health care

  1. I’m a senior fellow at the Center for American Progress, a think tank in Washington DC. Though health care is not my speciality, it’s an issue that touches all of our lives.

    My biggest concern about health care reform is that it won’t happen – that we’ll have a repeat of the 1990s again. I think it’s shameful that we have 46 million or so Americans uninsured – about 15 percent of our population. We as a country can do better.

    My three main questions – first, what are you planning to do to shape the debate at the local, state, regional, and national levels?

    Second, and this is not my area of expertise, but what do you think about this recent New Yorker magazine article about health care. Here is the link – http://www.newyorker.com/reporting/2009/01/26/090126fa_fact_gawande?printable=true

    Toward the end of the article there are some reference to the health care reform efforts in Massachusetts – the first state to adopt universal health coverage for its residents. As a resident and a leader in health care in that state, what are your views on those efforts? What are the pros and cons?

    Lastly, in a second more recent article found here:
    http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?currentPage=all

    the same author analyzes a town in Texas that is one of the most expensive health care markets in the country and finds that a major problem are the incentive structures for medical professionals, particularly in physician-owned hospitals. Again, this is not my area of expertise (I do foreign policy), but this passage seemed important to me.

    Do you agree or disagree with the conclusions of this article?

    “Somewhere in the United States at this moment, a patient with chest pain, or a tumor, or a cough is seeing a doctor. And the damning question we have to ask is whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue.

    “There is no insurance system that will make the two aims match perfectly. But having a system that does so much to misalign them has proved disastrous. As economists have often pointed out, we pay doctors for quantity, not quality. As they point out less often, we also pay them as individuals, rather than as members of a team working together for their patients. Both practices have made for serious problems.

    “Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coördination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? Getting the country’s best electrician on the job (he trained at Harvard, somebody tells you) isn’t going to solve this problem. Nor will changing the person who writes him the check.

    “This last point is vital. Activists and policymakers spend an inordinate amount of time arguing about whether the solution to high medical costs is to have government or private insurance companies write the checks. Here’s how this whole debate goes. Advocates of a public option say government financing would save the most money by having leaner administrative costs and forcing doctors and hospitals to take lower payments than they get from private insurance. Opponents say doctors would skimp, quit, or game the system, and make us wait in line for our care; they maintain that private insurers are better at policing doctors. No, the skeptics say: all insurance companies do is reject applicants who need health care and stall on paying their bills. Then we have the economists who say that the people who should pay the doctors are the ones who use them. Have consumers pay with their own dollars, make sure that they have some “skin in the game,” and then they’ll get the care they deserve. These arguments miss the main issue. When it comes to making care better and cheaper, changing who pays the doctor will make no more difference than changing who pays the electrician. The lesson of the high-quality, low-cost communities is that someone has to be accountable for the totality of care. Otherwise, you get a system that has no brakes.”

    1. Brian,
      All of us have a stake in health care reform. The question is not whether, but how. By focusing on the quality of care provided as well as cost efficiency, we are more likely to achieve the improvements in health care outcomes we deserve.

      Dr. Gawande, who is clearly one of the thought leaders in this field, has continued to raise important issues about access to care, quality of outcomes and variation in practice and cost. I couldn’t agree more.

      One of the interesting aspects of pediatric care is that the network of health care providers is very differently organized in terms of primary care, specialists and facilities. Most of the care is increasingly becoming regionalized. For example, in Massachusetts, half of the hospitals don’t even have pediatric beds. I mention this to suggest that additional thought will need to be given to the care of children in light of the overall reform process.

      Completely nationalized health care systems have many of their own drawbacks, so working to improve our current system I believe is the best approach.

      Massachusetts has made great strides in providing better coverage for our residents. Our current system is however a work in progress and all of us have a stake in continuing to reduce our cost structures without stifling the innovation and cutting edge improvements in outcomes embedded in our health care industry culture.

      Thanks very much for your comment.
      – Dr. Jim Mandell

  2. Terrific first post. I love your voice, your authenticity. The blog looks great, too, and the title couldn’t be better.

    You might add an email subscription feed (FeedBurner is my favorite) for those who prefer it.

    Keep it real. Very strong start!

  3. Dr. Mandell–

    Thank you for articulating your concerns about the “short-term political rhetoric” that dominates today’s health care reform debate. Many of us share your views, especially as they relate to how undervalued and underfunded pediatric services are (oral health to mental health). The reauthorization of the Children’s Health Insurance Program (CHIP) in early 2009 did not seem to have sweeping impact. On behalf of the millions of kids who remain uninsured, keep wearing those three hats.

  4. Dr Mandell, Thank you for adding your perspective from a variety of vantage points. As a parent of a son with both medical and mental health issues, I know that advocating for the best medical care has been my job for over a decade. I have also spent several years traveling to Washington to express concerns about access to care in our own state. We have had to leave our state for my son to get appropriate care for both his medical and mental health needs. The concern I have with National care is the Congress trying to implement plans that may overlook specific chronic complex health conditions. We already have had to fight for our son’s care in an ongoing basis. Finding ways to provide fiscally sound means is prefectly logical. These means should not be at the cost of people with chronic health conditions.

    IN my state there are people who are turned away from the only care center for epilepsy. These people have nowhere to turn if they have state insurance. We were fortunate to be able to have insurance that allowed us to come to Children’s of Boston when we had nowhere else to turn in our state.

    Advocating for care of my son has beeen a full time endeavor. My concern is, the complexity of the task before the Congress is extremely large. If solving the Social Security crisis has been beyond previous members, perhaps universal health care is as well.

  5. Ginny,
    First, let me thank you for your courage and determination to not only fight for your own child’s health, but your advocacy on behalf of all children. The fact that families must cross state lines to get adequate care for their children with chronic conditions makes an already difficult situation even harder for parents. We are pushing hard to make sure that state to state, coverage and access to health care for children meets reasonable minimum standards.
    Keep advocating and we will also continue to add our voices so our kid’s needs don’t get lost in the larger debate about health care reform.

    – Jim

    1. So wonderful to hear from you Cara – it was great to meet you and Nate at the Walk. Nate’s been incredibly generous in sharing his personal story to encourage other kids to get involved in Generation Cures, and the support of families like yours is absolutely invaluable in helping others understand what we do here at Children’s and why their support is so important. Thank you.

      For those who aren’t familiar with Generation Cures, it’s an online community that tries to help 8-to-12-year-olds and their families learn about science, medicine and how they can help sick kids.

      Thanks to parents like Cara and kids like Nate, we think Generation Cures is inspiring children across the U.S. to make a difference. We welcome everyone’s involvement, so please consider teaming up with the kids in your life to become a part of the Generation Cures community today.

      – Jim

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