A Preventive Medicine Initiative, Stalled by Political Issues

        

   The rising costs of health care have alarmed the nation.  Measures to control excessive costs are warranted. That prevention is worth a pound of cure is a hackneyed phrase but does contain some truth and might define a path to cost containment.  However, solutions will not be easy since the problems are entangled with a variety of unanticipated costs.

   Preventive measures may lead to added costs attendant to testing procedures and for treating newly uncovered conditions, which in and of themselves may not require treatment.  Such eventualities might stymie preventive measures. Alternatively, the success of a preventive strategy may depend more on the astute handling of political forces, since it is these forces, which may present obstacles to health care reform.  The role of government in disentangling these issues is discussed in detail in The Perspective Section of the New England Journal of Medicine, 2016: 375: 1710-1712. In this article, the evolution of ideas leading to health care reform, with a strong component of prevention is discussed.

   The issue of preventive medicine has been a contentious issue for many years. The fact that it is has been difficult to document the success of disease prevention has inhibited physicians from a full-fledged endorsement of preventive strategies.  In an effort to prove beyond doubt the efficacy of disease prevention, the government established the US Preventive Services Taskforce in 1984. The agency was tasked with analyzing the data in a scientific fashion, free of cost concerns and political influence. This panel was proposed to serve as a consultant to practicing clinicians. In 2000, the Institute of Medicine suggested that congress should delegate Medicare preventive Services to the USPST, thus establishing a governmental agency, targeted with determining value of prevented medicine. Wary that the USPSTF’s credibility as an impartial determinant of efficacy might be undermined by political and cost considerations, a former task chief suggested that Medicare be allowed to govern insurance particulars. In 2008, it was suggested that the Secretary of Health and Human Services be empowered to add preventive measures if it was felt by the USPSTF that the benefit was substantial.   In 2009, a draft of the Affordable Care Act contained provisions that the USPSTF stipulate which preventive measures be covered.  However, this effort was felt to saddle the USPSTF with political and cost befit considerations, which was contrary to the original intention that this agency be free of such restrictions.  It called to attention the uproar in Congress when the USPTF suggested that mammography not be recommended for women under age 40, and later denigrated the value of PSA testing. At present, there is considerable controversy as to the role of the USPSTF in stipulating which services are to be covered.

   The effective implementation of preventive medicine measures holds promise for better patient outcomes with reduced cost. However, the solutions are not easy since the problems are entangled in cost issues, reimbursement for physician work, and political issues related to stakeholder expectations.  Medicare officials and those implementing the ACA subserve all these considerations under the sobriquet of public policy. The goals of the new administration muddy the waters a bit and an effective outcome is not yet evident.

Posted by Arthur Banner

Beyond the Cherry Tree

   After a recent meeting of the Wise Guys, Jim Hodges handed me a book he had written  entitled Beyond the Cherry Tree. The Leadership Wisdom of George Washington.. The cover consisted of a glorious painting of George Washington set against a pretty blue background.  The author’s wife Bonnie provided this illustration, as well as those throughout the book.

   My initial reaction was that this was a children’s book meant for our 7-year-old grandchild.  However, on more careful inspection, I realized that I was mistaken. The book represents an insightful analysis of what is meant by leadership. It is a multilayered examination of the moral and ethical values of George Washington, modern leaders of business and ultimately those of Mr. Hodges himself. It consists of multiple simultaneous narratives addressing each of these perspectives.

  

  This book was apparently a response to catastrophic business failures, in particular the debacle at Enron. The author attributes these failures to poor leadership, due mainly to ethical failings. The author chooses to center his analysis around George Washington since Washington was noted for his leadership, and moral principles, and qualities, which must resonate with the author’s own values. As the author points out, Washington’s leadership extended to business, agriculture and scientific farming. That he was ethically pristine is suggested by the story of the cherry tree, wherein Washington confessed to his father that he could not lie; it was he who cut down the cherry tree. The author realizes that the story is probably apocryphal and wishes to go” beyond the cherry tree" in his analysis of Washington’s ethical bonafides. The book is ostensibly a guidebook on how to conduct business based on ethical principles. In so doing, Hodges suggests that ethical behavior leads to improved profitability as well as improved human relationships.

   The book consists of 5 chapters each of which deals with a different aspect of leadership. The general strategy is to report the author’s ideas of leadership, intermixed with those of Washington and other individuals, generally representing CEO’s. . The ultimate conclusion is that those who follow ethical principles stand the best chance of success. The first chapter deals with leadership in general and highlights and embraces the views of Washington.  It begins with an actual letter of Washington, written at the beginning of the Revolutionary War to a Colonel   William Woodard, who solicited the General’s advice about how to lead men. In this first person letter he stresses the mechanics of good leadership. In other examples, Washington’s views are reported from secondary sources wherein he stresses the ideas of ethics, compassion and trust.

   The remaining chapters deal with character building, calculating risk, engendering loyalty, and planning for succession. In all cases, the views are essentially those of Mr. Hodges, but resonate with those of Washington. Frequently, the author describes those individuals who did not follow Washington’s leads, and were thus set on a course of failure and national derision.

    Contrary to initial impressions, the book is not really about George Washington but is actually about Jim Hodges and his notions concerning our national collective leadership.  That he chose to center the book on George Washington reflects his bond to the American leader.  He seems to favor male bonding as reflected in his participation in Jollies and the Wise Guys, where he is a valued member.

   As a conclusion, Mr. Hodges explains that his own leadership qualities were achieved by standing on the shoulders of a great mentor. This statement requires some thoughtful analysis. When one stands on the shoulders of others, he sees further than they did. Hodges never claims that his ethical principles were superior to those of Washington.  Rather what the statement does imply is that by standing on the General’s shoulders he was able to apply these principles to a modern world. It is these principles that enlarge one’s vision of leadership in a world crying out for guidance in matters of business, lest we go the way of Enron, and other failed companies consequent to failed leadership.

                                                             

Post by Arthur Banner

                                                                                 

The Wise Guys Creed

The Wise Guys consist of a group of highly accomplished men and women.  All are aware that with age comes the potential of declining vigor and all are aware that death awaits.  None are spared. Nevertheless they have chosen to remain relevant by engaging in the concerns of  responsible citizens, i.e. public affairs and public policy.    The manner by which one should  respond to aging is dealt with beautifully in a poem by Dylan Thomas which serves as the Wise Guys Creed.

The poet wrote his poem Do Not Go Gentle Into That Good  Night in response to his father's blindness. The metaphor of the dying of the light, originally used to describe the process of going blind, was then applied metaphorically to death. The Wise Guys rage against the close of day by active participation during the daylight.

Post by Arthur Banner