Like many Americans, I was first stunned and then unsettled by the shootings that took place last week in Tucson. Since then, we’ve heard lots of debate about Jared Lee Loughner's motivations. Partisan media hyperbole? Targets on an election map?

Most recently, there has been a chorus of pundits singing about the ills of the mental health system. Michael J. Fitzpatrick, Executive Director of the National Alliance on Mental Illness, said, “The plain truth is that America's mental healthcare system is horribly broken and horribly underfunded. And across the nation, budget cuts continue to eviscerate community mental health programs that reach out to vulnerable individuals and put them on a path to recovery.”

But more surprisingly, have been the statements of key Republicans:

• Republican advisor Mike Murphy said on the Bill Mahar Show on January 14, 2011, "I'd like to see a better linkage between the gun control stuff we have now and the crazy-filter. Because if you look at Virginia Tech and you look at this guy, it is too easy for mentally ill people to get guns; because there’s no mental screening anymore."
  
• Virginia Republican Senate candidate Jamie Radtke (and head of the Richmond Tea Party) told ABC’s Top Line that "instead of it being about the political part, it’s really about needing to get our arms around our health care, the mental health policy here."
  
• Representative Mike Rogers (R-MI) said, "What we have to do is intervene earlier in that cycle of violence when they have this kind of disability. . ."
  
• Newly-elected Representative Allen West (R-FL) said, "The shooter was a very disturbed individual and it appears there were so many warning signs that he was going to do something horrible.  We should be focusing on the mental health crisis in our country, not politics."

Well, I have a simple piece of advice: if we want to stop tragedies like this from happening again, we should not repeal health care reform. Two years ago, national legislation passed that (finally) guaranteed that most individuals with insurance will have coverage for assessment and treatment of mental illness. The health care reform legislation builds on that non-discrimination parity legislation and assures that most Americans will have some form of health coverage that includes coverage of mental health conditions.

Earmarked funding for community mental health services will not solve the problem. We need to end fundamental discrimination against people with mental illnesses, and ensure that they have consistent access to the health care services that they need.

Americans are not of one mind about health care reform— a recent Gallup survey showed that 46% were in favor of repeal and 40% wanted to move forward with the law being enacted. (Interestingly, there were great differences in support of the law based on age – with the under 30 crowd clearly in support and the 50+ crowd favoring repeal.)

I can understand having qualms about some provisions of the health care reform law. If I were queen, I would have done things slightly differently. But, I am absolutely opposed to repeal. And what I don't see coming from the repeal advocates is a plan—for anything.

Our health care status quo isn't working for anyone—not for consumers, employers, governments, or anyone else. Last Thursday, the Congressional Budget Office concluded that between 2012 and 2021, repealing the law would increase the national debt by approximately $230 billion (more on that in a future blog post…). And so when I talk to the folks looking for repeal, my question for them is always: what's your plan?

Like many of you, on Monday I saw the news that a federal district judge in Virginia ruled that the insurance mandate in the health care reform bill exceeds the authority granted to congress under the Commerce Clause of the Constitution. (It apparently is Constitutional to mandate that employers provide health insurance, but not individuals – a distinction I don't quite get.)

But that is not the purpose of this missive. To all of my colleagues who are applauding the death of the individual mandate, I would like to give a quick remedial course in health care financing. In order for our health system to eliminate preexisting condition clauses and exclusionary enrollment in health plans, the current mandate for individuals to buy health insurance is a necessity. It is financially impossible to have one without the other; if there were no mandate, everyone would simply wait until they were ill to get health insurance – something akin to allowing an individual to buy homeowners insurance the day after they have a fire.

So what is the answer?
 

#1. Fight the Virginia Court decision to the Supreme Court (likely), and restore the individual health insurance purchase mandate within health care reform.

#2. Accept the Virginia Court decision and allow the return of preexisting condition clauses and exclusionary enrollment in health plans. I think this is poor (and penny-wise, pound-foolish) policy choice. We have many Americans who forced into bankruptcy paying for treatment for devastating acute and chronic health conditions.

#3.  Accept the Virginia Court decision and have the federal government provide health insurance for all uninsured persons, which would keep the ban on preexisting condition exclusions in health plans.

For those of us trying to find the “middle ground” in health care reform, I'd like to point out that ruling that individual purchase mandates are unconstitutional is likely to spur an increase in federally-financed coverage.  I'm not sure this is the outcome that many of those organizations financing the anti-health care reform lawsuits will want.  But, as they say, be careful what you ask for. . .

I just read a great piece in Becker's Hospital Review, “10 Key Trends for Hospitals in 2011,” which focused on hospital subject matter experts’ predictions for the new year. Their observations are relevant not only if you’re in the acute care sector of the field, but also serve as useful guideposts for any organization in the health care field.  

The ‘top ten’ trends this group is expecting include:

1. Lower reimbursements
2. Recovery audit contractors (RACs) gather momentum
3. More uncompensated care
4. Political gridlock
5. Uncertain fate of healthcare reform
6. Anticipated ACO rules may open the floodgates
7. Greater focus on experimentation
8. States will further cut Medicaid spending
9. Healthcare IT payments start
10. More hospital consolidation likely

I think these will prove to be trends that all management teams will need to factor into their planning scenarios. So make sure that your team – and your plan – is ready for the new year.

I’ve written in the past about the need for specialist health care organizations (such as behavioral health organizations) to reposition themselves in an era of changing technology, science, and financing. There are many possible directions for repositioning – from primary care for individuals with chronic conditions; focused disease management programs for consumers with multiple chronic diseases and complex social support needs; and program to address unnecessary use of high-cost acute care interventions.

Now comes yet another study on the cost savings opportunities of prevention efforts in two areas – high blood pressure and diabetes. The study authors concluded that reducing the prevalence of diabetes and high blood pressure by five percent would save the nation about $9 billion a year in the short term. In addition, conditions related to those health problems would also be reduced, which would increase the savings to about $24.7 billion a year in the medium term.

The study was conducted using 2003-2005 data from the Medical Expenditure Panel Survey.   Study results were released on-line on November 18, and are scheduled to be published in the January print issue of the American Journal of Public Health.

This is data that can be the foundation for designing (and marketing) prevention programs.   For more on the evolving wellness and prevention market, check out these recent articles by our team:

• Market Opportunity in Prevention Programs: Reform Creates New Market Niche for Prevention (available to premium OPEN MINDS Circle members)
• New Science Changing The 'Perceived Value' of Prevention & Early Intervention  (available to all OPEN MINDS Circle members)
• Mental Illness & Addiction Prevention & Treatment Critical to U.S. Health Reform (available to premium OPEN MINDS Circle members)
• UnitedHealth Group Launches Diabetes Prevention & Control Alliance With Partners Walgreens & YMCA of the USA (available to premium OPEN MINDS Circle members)
• J&J to Grow New Wellness & Prevention Business as Part of Consumer Division (available to premium OPEN MINDS Circle members)

On October 11th, John Boehner (R-Ohio), the current House Minority Leader—and the presumptive Speaker of the House in the 112th Congress—warned that we should not expect funding to implement health care reform if the Republicans become the majority in Congress – “They’re going to need money from us to hire those 22,000 federal employees we think it’s going to take to run this monstrosity. And I’ll just tell you, they’re not going to get a dime from us.” 

Representative Boehner went on to acknowledge that an all out repeal of the health care law is unlikely, as President Obama will still hold veto power from the White House. But even if an outright repeal isn’t possible, Republicans will still have the ability to hold up funding for many aspects of the reform legislation through the annual budget process. If Republicans take control of the House (as most polls indicate is a very likely scenario), Boehner stated that it will be the Republicans “job to do everything we can to keep it from being implemented, to keep it from moving ahead.”

So, as I see it, the choice in this election regarding health care is a clear one.  Flawed or not, do you want health care reform?  The bill has many great features—elimination of preexisting conditions clauses and recission, access to minimum coverage for the poorest Americans, etc. But, I think we all recognize that it also comes with a range of problems to be fixed.

Which leaves one question to think about: If the Republicans are in the majority, what is their alternative proposal?

I’ve been keeping up with the exciting new neuroscience developments on the cause (and hopefully treatment) of Alzheimer’s disease. One of the articles that I recently read was from CNET, “The Red Pill of Alzheimer's: Would You Take It?”  The most recent development is that scientists are now able to go beyond your genetic biomarkers for the genetic risks associated with developing Alzheimer's disease – they can now identify whether you will have a slow progression of the disease or a disease that will “spread like wildfire.” The scientific discussion in the article is interesting, but the part that I found most fascinating was the question that this research poses: If this genetic test was available, would you take it?  Would you take the “red pill” and see how far the rabbit hole goes?

If the “red pill” analogy is lost on you, a quick refresher: The red pill/blue pill concept was popularized in the 1999 movie The Matrix. The movie’s premise is that an artificial reality is advanced enough that it is indistinguishable from reality. And in the movie’s beginning, the protagonist (the always-contemplative Keanu Reeves) is presented with a choice—take the red pill, which will free him from “the matrix” and bring him into the real world, or the blue pill, which will allow him to stay contentedly unaware in the artificially constructed reality.  Borrowing from the movie, the terms “blue pill” and “red pill” have become a metaphor for the choice between facing the world’s difficult realities and maintain the blissful ignorance of illusion. 

So, back to Alzheimer’s disease; the real issue is whether or not consumers will avail themselves of these genetic tests. Alzheimer’s disease is really only the beginning—I’m sure that more advanced testing with genetic markers will soon be available for other conditions as well. The ramifications of these tests will take us far beyond medical decisions and treatment options; it is the individual psychological and larger societal implications that will have a monumental impact. Will consumers yearn to know so that they can better manipulate the outcome, choosing to live with the knowledge of their future demise? Or, will they trade in the time that they could gain to prepare for their fate for the bliss of temporary ignorance? 

I think the answer to that question lies in American’s unique “where there’s a will, there’s a way” attitude.  Consumers maintain a belief that, if they have early knowledge and they have access, there will be some treatment, some technology, some breakthrough that will enable them to change the outcome of the disease. And then the problem will become how consumers deal with the outcome once they have chosen to take the “red pill.”

In a recent speech, Kentucky Republican Senate Candidate Rand Paul said that Medicaid is “intergenerational welfare.” His stated rationale was that coverage has spread beyond those “truly in need” and citing the fact that 800,000 people out of Kentucky’s approximately 4.314 million citizens (18.5%) were on Medicaid. Given Kentucky’s Medicaid eligibility requirement—$13,671 in annual household income for family of 4 (62% of the federal poverty level)—I would say that has more to do with the income distribution in Kentucky.

I find Dr. Rand’s comments a bit hypocritical. This is coming from a candidate who is an ophthalmologist (an ophthalmologist who invented his own board certification, no less) and has 50% of his income coming from Medicaid and Medicare. This is the candidate who said in an interview on October 3, 2010 that he would cut Medicare benefits and raise the retirement age for Social Security in order to keep the full Bush-era tax cuts. So while depending on your perspective, I suppose you could consider this to be intergenerational welfare; I would maintain that it is, in fact, intergenerational war.

I’ve been a bit perplexed by this election season. I’ve decided we’re stuck in a real-life version of the 1989 film classic, Indiana Jones and the Last Crusade. You remember the one—the globe-trotting, action-packed search for the Holy Grail. I’m reminded of those prophetic words near the end of the film, “...choose wisely, for while the true Grail will bring you life, the false Grail will take it from you...”

These would be good words for voters to heed on November 2nd. Unfortunately, we’re caught between a false set of choices due to the political messaging that we’re bombarded with via every type of media on a 24-hour basis.

The Republican messaging, with its recent “Tea Party” flavor, is generally “All government is bad.”
The Holy Grail – Eliminate government and let the free market rein. 

The Democratic messaging, with its recent panic attack at the loss of the public popularity contest, is “Save government. It’s best for the little guy.”
The Holy Grail – Let’s keep our government operations on track.

I think the Republican Party is at its most disingenuous these days when compared to the past two decades, using those poor “Tea Party” chumps (most of whom are on Social Security and Medicare) to try to prevent government from curbing the worst of the free market abuses (I’m a free market person – and I can tell you that the ethical among us want protection from all of the unethical business entities).

I think the Democratic Party seems to be populated by fearful sycophants. They’re afraid to be the party of ‘good government’ (which is what we need) because introducing a accountability and good business practices would cause consternation among their traditional supporters.

My advice to voters: Choose wisely. Look for candidates who believe in good government – government that provides reasonable protections (regarding health, land use, safety, economics, etc.) to us all – government that is willing to apply standards, accountability, and good business practices. The candidates are out there in both parties, Republican and Democrat.  But we need to turn off the campaign advertising and look beyond the party-line messaging. If you take the time to explore each candidate’s positions and background, you should be able to choose wisely.

I've had a hard time putting the current unemployment data into context based on my own experiences – at OPEN MINDS, we've been on a hiring frenzy…and having trouble getting responses to our ads. Then, one Sunday morning a couple months ago I was watching Laura Tyson in an interview on ABC's This Week with Christiane Amanpour, and I had a flash of revelation. Ms. Tyson, former Chair of the President's Council of Economic Advisers during the Clinton Administration, said that "unemployment for those with college educations is now 4.5 percent." She went on to cite Bureau of Labor Statistics data that for those with less than a high school diploma, the seasonally adjusted unemployment rate was 13.8 percent during July. For those with a high school diploma but no college, the rate was 10.1 percent.

After thinking about that data, I have a new take on the unemployment situation. We have a structural unemployment problem, which is how labor economists refer to a mismatch between the skills of the people who of are out of work and the skills needed for the jobs that are available. And what this really boils down to is an education problem. A fundamental part of the long-term solution to our high unemployment rates is to improve our education system at every level – not only improving the graduation rates from high school and college, but also increasing the academic rigor of those programs. While it is certainly a valid point that "not everyone should go to college," given this employment situation, we also need to think of improvements to non-college technical/vocational training programs. Those training programs need to be relevant in the current context of a global economy and focused on areas with growth-potential that can provide a continuous living wage.

Diving deeper into the nationwide unemployment statistics and the prominence of the education attainment-aspect of the numbers led me to wonder what the implications of this situation would be for individuals with cognitive and mental disabilities. While assistive technologies are increasingly available to facilitate completion of advanced degrees by individuals with physical disabilities, disabilities that interfere with the thought processes are more punitive. In an economic environment where advanced degrees and related skill sets directly correlate to economic well being, the challenge of independently maintaining economic viability is becoming more and more insurmountable for these individuals.

I thought the best summary of the situation was in an article by Steven Pearlstein, The Bleak Truth About Unemployment. Mr. Pearlstein notes: "Somewhere between the rantings of the Republican right, which is peddling the nonsense that excessive government spending is to blame for high unemployment, and the Democratic left, which clings to the false hope that another helping of fiscal stimulus is all that is needed to get millions of Americans permanently back to work, is this stubborn reality: The loss of 8 million jobs reflects problems that are largely structural, not cyclical, which means they won't be brought back by fiddling with a magic dial in Washington that controls how much the government spends."

As Americans are pushed to develop a better-trained and more highly-educated workforce, the employment space for individuals with cognitive and mental disabilities will get smaller and smaller – leaving a population that will struggle to find a viable place in the fast-paced global market economy that we are heading towards.

One of my greatest personal and professional peeves is the “constant critics.”  These are the folks who constantly complain and critique what you do – but have no proposed solutions and rarely get things done themselves.  My experience as the founder and executive of a small business is that while it is easy to play the role of critic, it is quite difficult to develop and implement real, workable solutions.
 
These days, I consider the Republican Party to be playing the role of the “constant critic” when it comes to health care.  They had eight years when they controlled all branches of government, and did nothing.  And now that someone else has taken a swing, all they have managed to do is complain.  This “constant critic” position was perfectly captured in a piece by Grace-Marie Turner, “Putting the Brakes on Obamacare: How a Republican Congress Could Begin the Process of Repealing This Unpopular Law,” in the August 25, 2010 edition of The Wall Street Journal.  Ms. Turner outlines “the six key strategies that a Republican Congress could employ to put on the brakes.”  Her plans for health care reform? – Defund it, dismantle it, delay it, disapprove regulations, direct oversight and investigation, or delegate to the states.
 
Clever alliteration, but did you notice any solutions listed among those Republican “key strategies?”  

One of the big ‘war of words’ in health care is the issue of Medicare managed care – namely the Medicare Advantage program. President Obama and many Democrats want to scuttle the program because the cost of the managed care version of the Medicare program is purportedly 13% above the costs of the same beneficiaries in the fee-for-service version. Many consumers, and many Republicans, like the features and benefits and the voucher-like market orientation (respectively) of these plans.

The basic objections are captured quite succinctly by Ezra Klein in a piece in the The Washington Post, A private Medicare System Would be a Costlier Medicare System. He states, “They save money by limiting the generosity of the vouchers. Because the dirty little secret is that turning Medicare into a voucher program would actually make it cost much, much more. How do we know? Well, putting aside the fact that Medicare currently costs much less than private insurance, we actually have a private voucher program in Medicare as we speak. [...] But today, the market-based arm of the program costs more, not less, per beneficiary. Those fixed monthly payments to Advantage plans are, on average, 13 percent above fee-for-service Medicare costs.”

I think Medicare Advantage plans are an inevitable solution for the Medicare plan. The current fee-for-service system is an ungainly muddle of rules, with only the reduction in benefits (not politically feasible) and reduction in provider fees as its cost containment mechanisms. Even the health care reform initiative recognizes this through the creation of “accountable care organizations,” which are essentially provider-owned managed care plans. (And, it won’t take long for those provider-owned plans to “buy” managed care infrastructure from the current managed care programs.) Only this change in financing, moving us away from fee-for-service, permits the health care system to move beyond the current silos of reimbursement and allows for the rationing of services, which is an inevitability with, or without, health care reform.

That said, the failure that we currently have in the excessive rates mentioned by Mr. Klein is not a failure in program design, but rather a failure in contract negotiations and management. Medicare Advantage plans should not cost 13% more (or any more) than their fee-for-service alternatives. And, the medical loss ratio reporting requirements absolutely must be applied to Medicare Advantage plans to permit true transparency for consumers and a contract management tool for Medicare.

Remember the story of the blind men and the elephant? In varying versions of the story, a group of blind men/men in the dark touch an elephant in an attempt to determine what it is; however, each one feels only one part of the creature, such as the tail or the leg. The men then compare notes and learn that all disagree on what they felt—the man who felt the tail thinks it is a rope, while the man who felt the leg believes it to be a pillar.  The story originated in India and is used to demonstrate the relativity of truth.

Well, such is the reporting on the fate of one insurer, Assurant Health, in an era of health care reform.  And, I’m certain that similar reports of facts, resulting distinctly different perspectives, will become more common as health care reform is implemented.

The facts: Assurant Health, a Milwaukee-based health insurance company, announced last month that it was laying off 130 employees in Milwaukee and Minneapolis.

The first perspective comes from “ObamaCare Has Failed,” an article by Grace-Marie Turner, Chief Executive Officer of the Galen Institute.  Ms. Turner writes:

“The wheels are coming off ObamaCare even sooner than most had predicted. The American people are not being fooled by the sugar-coated sales campaign, jobs are being lost, health costs are rising, and the first program to be launched is a dud […] 

Do liberals really believe that people aren't going to pay attention to double-digit premium increases that are coming, $575 billion coming out of Medicare to pay for massive new entitlement programs, the $500 billion in new taxes that are driving up health costs, the barrage of new regulations putting employers and the health sector in a straightjacket, and the despised individual mandate that will force Americans to purchase expensive, government-dictated health insurance?

Today’s news has direct evidence of jobs being lost as a result of ObamaCare. Assurant Health, a health insurer based in Milwaukee that specializes in individual and small group policies, announced that it is laying off 130 workers as of October 1. Assurant is a terrific company that was the first to sell a Health Savings Account policy and has continued to be responsive with innovative products to serve customer needs.

But new one-size-fits-all regulatory requirements are forcing insurers to slash personnel to meet new ‘administrative’ tests, rules that present real challenges to a company that focuses on direct customer service rather than selling policies thousands at a time. Assurant is highly adaptable and will survive, but many capable employees and their families can thank ObamaCare for losing their jobs.”

The second perspective comes from “As Reform Improves The Overall Market, Inefficient Insurers Could Take Hits,” by Jonathan Cohn, Senior Editor of The New Republic.  Mr. Cohn writes: 

“When Assurant Health, a Milwaukee-based health insurance company, announced this month it was laying off 130 employees in Milwaukee and Minneapolis, it blamed the health care overhaul for its struggles […].  The carrier is Assurant, which specializes in selling policies in the individual and small business markets […] – the place you find carriers that aggressively avoid people at risk of getting sick […]

The health law forces insurers to cover basic benefits […] And it limits the money they can spend on administrative overhead or broker commissions. Once fully implemented, reform will also prevent these carriers from avoiding people with pre-existing conditions. Make no mistake: These are all good things. They mean insurance is becoming more accessible, more comprehensive and more efficient.

Alas, that may […] be bad news for Assurant. If the company's name sounds familiar, that's because it was in the news early this year when a Colorado jury slapped it with a $37 million judgment for wrongly refusing to pay the bills of a woman in a car accident. (The company claimed the woman had hidden evidence of a pre-existing condition. The jury, obviously, disagreed.) And when the layoffs were announced, an article from the Milwaukee Journal-Sentinel noted that reform would ‘undercut one of Assurant's strengths – determining which customers are the best risks.’ I have no idea whether Assurant can find other ways to survive as a business. But, if it can't, then we're better off relying on competitors that can.”

I was struck by the difference in “perspective” on the facts...and would welcome your own unique perspectives.    

What a difference two years makes.   Two years ago, the Federal deficit never popped up as a topic of interest in press or policy.   Today, both the popular press and voter polls report on the Federal debt as the cause of angst for average Americans. 

First, a few Federal deficit facts:  When George W. Bush took office, the debt was ~$5 trillion — when he left office, it was ~$10.5 trillion.  According to the U.S. Department of the Treasury, the Federal deficit currently sits at $13.4 trillion according to the Monthly Treasury Statement.

The single largest category of Federal spending is the annual military budget at $700 billion, as stated in “Defense Officials Anticipate Drop In Military Spending.” This is important to point out, since there seems to be some allusions in press coverage that the Federal deficit is largely due to the Stimulus bill and health care reform legislation.  In fact, most of the current deficit and most future spending is related to our military entanglements across the world.  Since 2004 until the present, the U.S. spends more on military spending per year than the rest of the world combined (World Wide Military Expenditures). 

And, while Dr. Robert M. Gates, the Secretary of Defense, has been warning the Defense industries to be prepared for reductions in spending, as stated in the NPR story. I was bemused to hear (later in the same interview) that this warning is only that annual increases will narrow, not that there will be an actual cut in the military  budget.

Why should we be concerned about the discussion of the Federal deficit?   Of course, there is always the angst about being a debtor nation, possible increases in personal and business taxes, and American competitiveness – certainly key economic worries.   But, our debts to Gross Domestic Product (GDP) numbers are comparable (a shade higher) to other nations.  

To me, the bigger issue is one of priorities.  In the future, what are we  making strategic resource decisions?   To paraphrase a recent Thomas Friedman’s article, “OP-Ed Columnist: What’s Our Sputnik?,” we need to be investing in those specific area that will produce a strong and competitive country in the future.  I think that there is overall agreement that those areas include education of our populace, advancing scientific understanding, and developing new technologies (biomedical, clean energy, environmental controls, communications, and such).  I think there is also agreement about the need to invest in human and physical infrastructure – health promotion and rational health security, train and road systems, energy capacity, telecommunications, etc.  

The question is whether our current national politics (and national mood) will  allow military spending to crowd out our more strategic investments.   I’m not opposed to military spending as part of our investment strategy – certainly national security is a key element in national prosperity.  But I do think the current levels of military spending are unsustainable and they cannot be maintained at the expense of our future prosperity.

I had to laugh when I read The Washington Post piece, "Language lessons for Democrats, from the political brain of Drew Westen." Dr. Westen is the psychologist and neuroscientist at Emory University who wrote the 2007 book, "The Political Brain." His advice to Democrats is to quit using the terms "the environment," "the unemployed" or "the uninsured." I love his comment, "There are a few things if you know about the brain, they change the way you think about politics... If you understand we evolved the capacity to feel long before we evolved the capacity to think, instead of barraging people with facts (the standard Democratic way of talking to voters), you speak to people's core values and concerns. His basic advice is to quit communicating with "reason and facts" since people respond more to "emotional appeals."

I guess this is consistent with some of the new writing about change and leadership. I am particularly taken with the metaphor of the rider and the elephant by UVA psychologist Jonathan Haidt in his book The Happiness Hypothesis. Dr. Haidt's premise is that our emotional side of change is the Elephant, while our rational side is the Rider. Perched atop the Elephant, the Rider often seems to be the leader that holds the reins – but the Rider’s hold is precarious because it’s so much smaller than the Elephant. Any time the Rider and Elephant come to blows about which direction to go, the Elephant (our emotions) wins.

 All that said, it's a sad reflection on the state of advice for politicians or managers. I'm reminded of the words of Justice Felix Frankfurter, "Fragile as reason is and limited as law is as the institutionalized medium of reason, that's all we have standing between us and the tyranny of mere will and the cruelty of unbridled, undisciplined feeling…"

Just in case you've missed it, there is a bill wending its way through Congress to extend the HIT/EHR incentives that are available to all other health care provider organizations through the Stimulus (ARRA) funds to behavioral health. On April 15, 2010, Congressman Patrick J. Kennedy (D-RI) and Congressman Tim Murphy (R-PA) introduced the Health Information Technology Extension for Behavioral Health Services Act of 2010 (HR 5040). The bill adds mental health and substance abuse professionals, psychiatric hospitals, substance abuse treatment facilities, community mental health centers, psychologists and clinical social workers to those eligible for electronic health record incentive payments established under the American Recovery and Reinvestment Act of 2009 (ARRA). Psychiatrists and psychiatric nurse practitioners are already eligible for this program under existing law.

You can learn about the bill at http://patrickkennedy.house.gov/PRArticle.aspx?NewsID=1770. We'll keep you posted on the status of the bill in our coverage of breaking developments in the field.

"Medical applications are technically medical devices and therefore subject to federal regulation... There currently are no clear federal measures in place, however, to guarantee their quality and accuracy."

These lines, from the article "iRegulate: Should Medical Apps Face Government Oversight?" in Scientific American, got me thinking about the smartphone as 'medical device'. In February, Jeff Shuren, director of the FDA's Center for Devices and Radiological Health, testified before an FDA committee on health technology. He said: "With the rapid integration of apps into routine healthcare, however, time seems be of the essence. And as many physicians already use apps to check and update patient status, concern about logging crucial data incorrectly is not unfounded... Adverse events resulting from medical apps and other health information technology errors have already been reported to the FDA."

Certainly as we see more 'expert decision support systems' built into smartphone devices, there use in the health care field will expand - and will draw increasing attention from regulators.

Were you as surprised by that question as me? In his piece, The Right Man for the Job - Why Mitt Romney should run Obamacare, Daniel Gross made the case for Mr. Romeny. My initial reaction was skeptical.

But, Mr. Gross outlines his view of the three principal requirements for the job. The first is experience in management, business, and organization. The second is the ability and capacity to commit and to act. The third is relevant experience in implementing a large-scale health-care reform program. Seems like a job just made for Mr. Romney. I am sorry I hadn’t thought about it before...

I just read Gardiner Morse's great piece in Harvard Business Review, Ten Innovations That Will Transform Medicine. One of the ten – behavioral economics – reinforced my thinking that care management services for consumers with chronic physical health conditions is a great new market opportunity for behavioral health organizations. "If we all acted rationally, we'd eat right, floss, and take our pills as directed. But of course we can be pretty disobedient about doctors' orders, which not only is bad for our health but costs hundreds of billions of dollars a year. Behavioral economics tools — gentle prods that nudge us to behave in desired ways — may be more effective than any amount of browbeating by doctors... reminders, social pressure, default options, rewards, and other behavioral tricks can be used to improve compliance in stroke and diabetes patients... " I think that aggressive innovation organizations that are currently managing care (longitudinally) for consumers with a mental illness or addiction can be the ones to own the future chronic disease space (and, I think Alzheimer's disease, other dementias, diabetes, and strokes are great areas to start...)

P.S. The ten innovations that will transform medicine (according to Mr. Morse) are:

1. Checklists
2. Behavioral economics
3. Patient portals
4. Payment innovations
5. Evidence-based decisionmaking
6. Accountable care organizations
7. Virtual visits
8. Regenerative medicine
9. Surgical robots
10. Genetic medicine 

You may remember one of the few moments of levity in the incredibly complex and partisan discussions of health care reform came from Rush Limbaugh (surprisingly). In January, Mr. Limbaugh ended up in a Hawaiian hospital with chest pains. At a press conference after his recovery, he said, "Based on what happened here to me, I don’t think there’s one thing wrong with the American health care system. It is working just fine, just dandy.” What Mr. Limbaugh apparently didn’t know is that since 1974, Hawaii has had a statewide employer mandate for health insurance and near universal coverage for health care—a key provision of the now-signed health care reform bills. It was irony worth a chuckle.

Roll forward a month, and Mr. Limbaugh added another moment to remember when answering a caller's question on his radio show. The caller asked what he would when the health care reform bill passed. He responded, "I don’t know. I’ll just tell you this, if this passes and it’s five years from now and all that stuff gets implemented — I am leaving the country. I’ll go to Costa Rica." The irony is that Costa Rica has universal, publicly-financed health care—and one of the highest life expectancies on the globe (78.8 year). The very 'socialized' medicine that Mr. Limbaugh has long opposed. It was a great bit of humor in a very intense public discourse.

But, now the day has come. March 23, 2010, the health care reform bill was signed by President Obama. We have the countdown to March 23, 2015 to look forward to.