Receive, Give Thanks, Give…

Thanksgiving is a holiday that is celebrated around the world, in places as diverse as Canada, the Caribbean, and Liberia. As a national holiday in the United States, it is celebrated annually on the fourth Thursday of November.

The historical origins of this holiday involve "giving thanks" to the Divine for a bountiful harvest and the blessings of the year that is ending. The holiday’s origins also include English traditions dating back to the Protestant Reformation that emerged as a reaction to the large number of religious holidays in the Catholic calendar.

In the United States, the Thanksgiving tradition dates back to 1621, to Plymouth in today’s state of Massachusetts, where members of the Wampanoag tribe helped 102 pilgrim colonists by giving them seeds and teaching them how to fish. Over time, this celebration has become one of our most anticipated and joyous holidays.

Historical evidence suggests that, in other present-day American places like Texas, Virginia, and Florida, similar ceremonies of "thanksgiving" were celebrated, some by Spanish explorers, even before that first Thanksgiving in Plymouth in 1621.

The common thread, of course, is gratitude – the emotion that is aroused when we recognize and appreciate in everything that is, in everything we have, and in everything that surrounds us, the goodness of life. Gratitude is the recognition and appreciation of all that is given by and received from a loving and transcendent presence that we call God, or from those who are dearest and closest to us, or from so many who anonymously contribute to the greater good.

For this reason, we can say that gratitude is an essential, original, and spontaneous emotion, corresponding to the grace and benevolence of God and of life; it is gratitude that encourages and gives us strength to continue living, trusting, loving, and sharing.

Gratitude is an emotion inherent in human nature that produces in us the joy of living, waiting, and sharing "without cost, what we have received without cost" (Mt 10:7-15).

THANKSGIVING DAY is, therefore, a deeply human celebration that gives us the opportunity – together with those most beloved to us – to acknowledge how much we have to be thankful for and how much we can give on a personal, family, social, and national level.

The historical achievements of this Nation, earned through the labor and perseverance of its inhabitants, have made the United States the most prosperous country on earth. Today, we enjoy a very good quality of life compared to many other countries. This opportunity for prosperity has made the United States a safe haven, a beacon of light or land of promise to which so many men and women came and continue to arrive in search of a better life and who, with their cultural wealth and labor, enhance the present and future of this Nation.

The greatness of this Nation depends on, and will always depend on, our common purpose to care for and give thanks for the inheritance that we received from those who preceded us on this soil; while we must work to create the legacy we will leave to future generations, hoping that those who are born here and those who come here will continue to find reasons to give thanks, to love, to share, and to wait... Our greatness today compels us to care for our values, nature, institutions, and the current social infrastructure so that future generations may also experience gratitude.

Recognizing that we have so much to give thanks for, we are compelled - at the same time - to give, to share, to serve, to be supportive so that those most in need in our society and in the world have the opportunity to give thanks. Thus, gratitude becomes a permanent celebration and, above all, an everyday, common, and national attitude.

HAPPY THANKSGIVING!

How to fix Obamacare

HEALTHCARE advocates for the poor let out a collective sigh of relief when attempts to repeal the Affordable Care Act (ACA) went down in flames. But the story is far from told. Legislators on both sides of the aisle agree that Obamacare, as the ACA is better known, needs significant re-engineering to become economically sustainable.

Criticism, particularly on the part of conservative legislators, is focused on the cost of the plan’s expanded Medicaid provisions. The critics have a point. The established administration of Medicaid-funded healthcare is inefficient. By some estimates, waste and corruption cost U.S. taxpayers close to $140 billion a year, some 12 percent of the program’s total budget.

Lawmakers eager for a solution need look no further than a revolutionary Medicaid reform program in New York State, designed by state Medicaid Director Jason Helgerson and championed by Gov. Andrew Cuomo, who secured $7 billion for the five-year initiative. It’s called the Delivery System Reform Incentive Payment (DSRIP) program. 

This jargon-laden moniker obscures a highly innovate formula for healthcare reform. Gone is the traditional fee-for-service Medicaid model that compensates the health care provider for tests, office visits, and procedures. In sharp contrast, DSRIP shifts to a value-based payment (VBP) model in which the doctor or healthcare system is paid according to the long(er) term health outcome for individual patients.

It makes sense! Health care providers are rewarded for keeping patients healthy. This means the provider—in keeping with the medical calling, it should be added—invests time and energy in comprehensive, holistic, preventive care – ensuring patients follow medical directives, take their medicines, keep their appointments. Suddenly, the patient is at the center of the equation.

At the end of its five-year run, in 2020, DSRIP is on target to reduce unnecessary hospitalizations by 25 percent, which will represent a savings to New York State taxpayers of $12 billion. Reducing avoidable emergency room visits and hospital stays is precisely the fruit of comprehensive, holistic care. Today, it is all too common for Medicaid patients to fall through the cracks and wind up in the ER at great cost to the system not to mention the patient. Let us not forget that we are talking about real people, human beings whose illness and suffering carries its own, often-overlooked cost.

At this writing, the DSRIP program—after 30 months of laying the foundation of a complex infrastructure of clinical care models and performance measuring tools—has entered the second half of its five-year mandate. Since April 1, all 25 so-called Performing Provider Systems (PPSs) are being measured by the state according to performance targets and clinical outcomes. Encouragingly, in the first two years of the program, PPSs earned 95.78% ($2.53 billion of a possible $2.64 billion) of all funds.

It is important to note that NYS Medicaid Director Helgerson’s vision goes beyond the strictly medical and behavioral health factors that determine the well-being of a Medicaid recipient. His goal for healthcare transformation is to also address the social determinants of health. He asserts that successful, long-term reform of the Medicaid system means that, as he put it, the “healthcare sector must embrace a broader role in the communities in which we serve.” 

Research has amply shown that non-medical factors have a significant impact on a person’s health. For the bulk of vulnerable and poor Medicaid recipients living in urban settings, social or environmental conditions have a huge effect on physical and mental health: poor living conditions, pollution, crime, unemployment, lack of access to healthy foods. The list goes on.

The U.S. lags significantly on this front—even though it is very clear that neglecting social determinants of health is costing the country billions of dollars a year. In Helgerson’s vision, the primary care physician, the neighborhood doctor of old, is at the center of a coalition of service providers with expertise to address the gamut of a patient’s needs, medical and otherwise.

One notable stumbling block is the relative shortage of primary care physicians, particularly in lower-income areas. Across the board, less than 30 percent of U.S. physicians provide primary care, compared to well beyond or close to 50 percent in Canada, France, and Germany. Millions of Americans lack access to a primary care doctor, the very person who could play a central, comprehensive role in their health and well-being.

On this score, Advocate Community Providers (ACP) stands out as the only physician-led PPS in New York State. ACP’s vast network of 3,500 providers includes 1,400 Primary Care Physicians and 1,700 specialists who practice in the Bronx, Brooklyn, Manhattan, and Queens. What’s more, many live and work in the same neighborhoods as their patients—patients with whom, in many cases, they share the same ethnic background. Cultural competence is strongly emphasized by the DSRIP protocol and strongly embraced by ACP.

These neighborhood doctors know their patients intimately and understand the social and environmental factors that impact the household. They are committed to the comprehensive well-being of their patients, their families, and the communities at large. This rehabilitation of the role of the family doctor is driven and encouraged by the Value-Based Payment model, as it promotes a holistic approach to healthcare reform.

Such could be the next chapter for America’s healthcare reform, with individual states or the federal government adopting a Value-Based Payment formula to improve the quality of Medicaid care, even as it reduces waste and fraud. Making the considerable investment in a nationwide DSRIP program has the potential of truly enormous savings down the road—savings that in turn could keep Obamacare premiums for non-Medicaid insureds in check. Such radical reform should be able to garner bipartisan support.

Finally, to dream even bigger, why couldn’t the for-profit insurance companies who are part of the Affordable Care Act work with their providers and also introduce—not to say enforce—a Pay-for-Performance formula? Monies spent in the best possible way and savings achieved will benefit all parties—patients, first and foremost, but also providers, insurance companies, and the government. For the business-minded party in charge of the Administration and Congress, truly smart reform of Obamacare at all levels should be a no-brainer.

Comprehensive, holistic care will keep Medicaid patients healthier

It is the story of summer 2017 and a nation’s differences are laid bare as Congress struggles to formulate an acceptable law to replace the Affordable Care Act. Are the proposed replacements “mean,” or do they not go far enough? How do leaders reconcile the practical drive to slash the nation’s public health care budget with the repugnant (and politically unattractive) prospect of leaving at least 22 million fewer Americans without health insurance coverage?

How do legislators come to terms with proposed Medicaid cuts that would jeopardize health care for more than 70 million people—among them children, the elderly, people with disabilities and pregnant women—by 2026?

There is no doubt that health care expenditures in the United States need to be curbed; compared with other industrialized nations, we spend the most per capita but deliver inferior care. Medicaid as we know it has been prone to waste and fraud. However, simply cutting the health care budget will only worsen the situation for those at the lower rungs of society. These are the men, women and children our government is dutybound to provide for, and to do it well.

True reform—a goal apparently lost in the partisan bickering—would be to get smarter about exactly how health care dollars are spent, so that costs can decrease even as the quality of care improves.

A revolutionary experiment underway in a handful of states is aiming to do just that. California, Kansas, Massachusetts, New Jersey, New York, Oregon and Texas have authorized versions of the Delivery System Reform Incentive Payment program. At its heart is the value-based payment formula, which stipulates that health care providers are compensated based on their patients’ longer-term health outcomes rather than the volume of services provided (that is, transactions such as office visits and tests).

The D.S.R.I.P. model—executed in New York State by 25 performing provider systems (also known as P.P.S.’s)—incentivizes health care providers to keep a close eye on their patients’ progress, monitor adherence to medical directives, assess mental health factors and empower patients to self-manage chronic conditions. The objective is to prevent 25 percent of unnecessary hospitalizations, which, at the end of the program’s five-year mandate, is projected to save New York taxpayers $12 billion.

Imagine such a strategy implemented in all 50 states; the Affordable Care Act’s drive to cut Medicaid spending could be achieved even as the quality of care improves. This is truly the best of both worlds, satisfying both patient advocates and budget hawks.

The visionary behind D.S.R.I.P. is Jason Helgerson, the Medicaid director of New York’s Department of Health, who passionately argues that we must take into account the social determinants of health as well as a patient’s medical condition. On this score, the United States lags behind other developed nations that recognize the significance of these factors in providing health care to the poorest citizens.

Social determinants include patients’ housing situations as well as their economic, employment and educational status. In many cases, they are also affected by the criminal justice system. These nonclinical issues directly impact physical as well as mental health, and they should be taken into consideration as part comprehensive health care designed to produce lasting results.

Case in point: A recent briefing for P.P.S.’s by the New York State Department of Health on housing issues reported that indigent households often choose to pay rent over buying food; this is a practical decision but one with serious health implications, particularly for young children. Rent and housing instability is shown to put mothers at a 200 percent higher risk of depression. There is also the impact of mold, lead paint and pest infestations. As a recent study by New York University’s Furman Center showed, an increase in “poverty concentration—the extent to which poor New Yorkers are living in neighborhoods with other poor New Yorkers” compounds the impact of a troubled housing situation as a social determinant of health.

In the vision of Helgerson—who likens the D.S.R.I.P. model to a start-up driven by venture capital—the neighborhood-based primary care physician becomes a true community leader who engages local leaders and activists in the areas of housing, employment and education to form community action teams. Their mandate is to make comprehensive resources—both medical and nonmedical—readily available to the poorest Medicaid patients in order to ensure their long-term flourishing.

Comprehensive, holistic care is the solution to keeping Medicaid patients healthier, taking control of chronic illnesses and avoiding expensive emergency room visits and hospitalizations. Such comprehensive care is commensurate with respect for the human dignity of each and every human being. Our nation’s political leaders should commission research into the social determinants of health and refocus their attention on health care reform that provides states with incentives to being truly smart and innovative in how public health care funding is spent. Billions of dollars can be saved while millions of lives are lastingly improved.