Health-care reform & the lost art of healing

In 1996, the renown Dr. Bernard Lown—emeritus professor of cardiology at Harvard and founder of the Lown Cardiovascular Group, among other distinctions—published “The Lost Art of Healing.” The book may be more than 20 years-old, but its message is as timely as ever, and arguably more urgent today then in 1996. The New York Times put the spotlight on Dr. Lown’s message when it recently ran an Op-Ed by an intern at Brigham and Women’s hospital in Boston who encountered the venerable physician when Dr. Lown was in that hospital being treated for pneumonia.

In “The Lost Art of Healing,” Dr. Lown charged that “doctors no longer minister to a distinctive person but concern themselves with fragmented, malfunctioning” parts of the body. The doctor-patient relationship, the author lamented then, and still laments today, has become impersonal, mechanical, remote and cold. In “The Lost Art of Healing” he called for the revival of the “3,000-year tradition, which bonded doctor and patient in a special affinity of trust.”

As resident physician Rich Joseph wrote in his column, Dr. Lown has called for “a return to the fundamentals of doctoring—listening to know the patient behind the symptoms; carefully touching the patient during the physical exam to communicate caring; using words that affirm the patient’s vitality; and attending to the stresses and situations of his life circumstances.” 

At 96, Dr. Lown made it clear that he was not pleased with the state of affairs he had warned about all those years ago, and which today he describes as the “industrialization of the medical profession.”

The Times piece is worth quoting at length because it so pointedly and accurately describes the state of contemporary health-care in the US, both in its for-profit and publicly-funded forms. The case is worse for the latter, with traditional Medicaid being particularly prone to impersonal medical care and an emphasis on transactional treatment in the form of tests and perfunctory office visits; a formula that is prone to waste and fraud, and that provides very little if any opportunity for the establishment of a bond between patient and doctor.

Enter the Delivery System Reform Incentive Payment (DSRIP) Program, a pioneering approach to Medicaid ushered in by the New York State Department of Health that has just begun the fourth year of its five-year mandate. Its goal: the reduction by 25 percent of avoidable hospital use at the end of five years, which would amount to a savings of more than $12B for New York State taxpayers. 

These are impressive facts and figures; important as they are for the bottom line, they are secondary. At the heart of DSRIP is superior, holistic care for Medicaid patients who are treated as human persons, not as cost centers or bundles of various medical ailments—care precisely of the kind Dr. Lown insists has gone missing.

SOMOS Community Care is one of 25 so-called Performing Provider Systems (PPS) in New York State, which are funded by DSRIP. To qualify for maximum funding, each PPS is held to strict deadlines, delivering certain levels of care and meeting crucial milestones all, ultimately, leading to those dramatic reductions in hospitalizations. DSRIP is driven by the Value-Based Payment (VBP) or Pay-for-Performance formula. That means that physicians and other providers are not paid according to tests administered or office visits logged, but based on the longer-term health outcomes of their patients. If their patients stay healthy, their doctors earn more. It’s that simple.

VBP, however, is a tool, not an end in itself. Value-based care means that doctors are rewarded, are recognized, for paying closer attention to their patients. Better care, to cite Dr. Lown once again, depends on the development of that “affinity of trust” between doctor and patient. Such an authentic bond requires that doctors make a genuine effort to get to know their patients, which takes time, energy and resources.

Providing truly superior care means that doctors and their staff must go the extra mile not only to comprehensively assess a patient’s physical, as well as mental health; it also means getting to know the patient’s family, the family’s living conditions, and to develop an awareness of the environmental and social factors that affect the home life—the so-called social determinants of health, which Dr. Lown succinctly describes as the “stresses and situations of [the patient’s] life circumstances.” Only in this labor-intensive, patient, persistent and demanding fashion can doctors once again become genuine healers, patients’ confidants, who are trusted and admired leaders of their communities. 

SOMOS Community Care is unique among the 25 PPSs in New York State in that it provides services to the poorest residents of New York City through a network of independent physicians. The other PPSs are hospital-based, mostly massive corporate systems, for which the genuinely and indispensable personal touch is much harder to achieve. SOMOS supports its physicians with a team of Community Health Workers, which train the staff of physician’s practices in digital record-keeping—freeing up the doctor to give his or her full attention to the patient—and which make home visits as needed, making sure medical appointments and regiments are kept, and giving the doctors vital feedback on patients’ home circumstances.

SOMOS, in sum, is making for the contemporary reiteration of the family doctor of old, making him or her again a familiar and relied upon neighborhood figure. In many cases, our doctors live and work in the same communities as their patients, often sharing their ethnic background. Cultural sensitivity and competence, in fact, are a hallmark of the DSRIP VBP formula.

It must be stressed that our more than 2,000 doctors, most of them members of Independent Practice Associations, have gone out on a limb in signing up with DSRIP. The old Medicaid formula stood for a predictable, reliable level of income. The Pay-for-Performance model, by contrast, means that doctors have to work harder, and provide superior health-care, in order to qualify for higher compensation. As independent small business people, our doctors are really taking a chance and deserve a great deal of credit for thus boldly embracing their professional calling in a way that is by no means risk-free.

Value-based care is the new wave of health-care reform; it will deliver superior care, thanks, in part, to a strong emphasis on preventive care. This, in turn, translates into reduced health-care costs by keeping people healthier and out of hospitals, etc. It would make a lot of sense for policy-makers to begin paying closer attention to value-based care—and to consider funding the efforts of Independent Practice Associations. This would enable the independent doctor as entrepreneur to succeed under the VBP regime by providing truly personalized health care, whose quality hinges on that “affinity of trust” between doctor and patient. This would be a much-needed complement to the massive funding of inevitably more impersonal hospital-based systems that currently dominate the publicly-funded health-care arena.

As for SOMOS, we are laying the groundwork for life beyond the DSRIP mandate, which concludes on March 31, 2020. SOMOS Community Care will continue operations as a for-profit entity. Experience to-date has given us confidence in the VBP formula and we are prepared to, literally and figuratively, bank our future on it!

Standing up for immigrants worldwide!

The phenomenon of human migration is among the most complex and massive global crises of our time; it is the greatest cause of human suffering and the tragedies humanity is experiencing in our day. 

It is a very complex phenomenon because it forces to the surface all the unresolved challenges faced by humanity in making this world more humane and just; it brings to the fore the urgency of creating genuine solidarity among all the countries and peoples worldwide. There is administrative and outright governmental corruption in various countries; social inequality; social injustice, plus a thousand forms of violence and death, epidemics, famine, intolerance, racism, and various other forms of discrimination, etc.

The number of people involved, the sheer size of the worldwide migration phenomenon, already transcends all borders, races, creeds, cultures, and ideologies. The migration and refugee crisis has become a part of daily life, creating the Dantesque dimensions of a living hell on earth. The crisis is subhuman and apocalyptic in the suffering it inflicts upon men, women, children, young people and the elderly, all of whom, for the greatest variety of reasons, were forced to leave their homelands to look for a better future abroad—to try to begin new lives in strange and foreign lands, many of which are nakedly hostile to the newcomers.

This phenomenon of mass migration affects all of us. All humanity is united in the good as well as implicated in the evil inherent in how the world responds to the crisis. Sadly, the search for and implementation of fundamental solutions to the crisis are postponed indefinitely: everyone, leaders and citizens alike, are wholly lethargic in their response to the worldwide tragedy—all of us simply prefer to avoid dealing with the problem.

Those who are the primary victims of this migration phenomenon are—for the most part—men and women on the fringes of society, suffering the shame of their position of being people who are unwanted. They are the products, the victims of what Pope Francis calls "the culture of discarding;” the throw-away culture; they are what he labeled "the disposable." They are men and women who have become impoverished because they are being denied all access to social services and social opportunities; they are simply "discarded" because they aren’t important players in the hyper-productive economic machinery that drives this globalized world.

The causes of this painful and massive migration phenomenon are many; they range from people’s desperate search for better economic conditions, to displacements under duress due to political or religious persecution, as well as other forms of violence which make remaining in their homeland impossible.

Examples of this phenomenon today are the huge masses of migrant and refugee populations that are making their way—often at the cost of risking their lives—from Africa to Europe; from Syria and Iraq to Europe, for example; and then there are people from around the entire world, including Latin America, trying to make it to the United States.

This complex, massive worldwide problem calls upon all of us to find solutions of equal magnitude and complexity: the crisis, first of all, calls for solutions in the countries of origin; and then for a strategic response to ameliorate the double suffering of those who have been uprooted from their countries of origin and then meet with hostility in new lands where they are decidedly unwelcome, even as they try to rebuild their broken lives. The countries that take in the greatest number of migrants must be able to call on the rest of the world for vital help in finding ways for the newcomers to integrate in their new homelands and build a new, dignified way of life. 

Until today, this phenomenon—which is so dramatic, so tragic, so visible, causing so much pain and bringing about so much social upheaval and individual suffering—this phenomenon which calls for such an urgent response, has been met with lack of action, with indifference, with governments badly failing to coherently and dynamically making a response to the crisis a priority.

The primary causes of the crisis are neglected or ignored: bureaucratic inefficiency and administrative corruption; social injustice; inequality in the distribution of resources, goods, services and social opportunities. What’s more, the very factors that force so many millions to emigrate also turn destination countries into hubs of misery, even as they continue to regularly attract thousands upon thousands from all corners of the earth, each and every day.

Neither the current politicians in each country of departure of these large migratory masses—who are, so often, victims of massive corruption—nor the governments of the country where the migrants seek to make their new home, nor the international agencies and entities charged with care of the most vulnerable—such as the European Union, the United Nations, the World Health Organization, the International Monetary Fund and the World Bank—are succeeding in resolving the current migration phenomenon through adequate humanitarian means. Instead, war-mongering and the show of military might are on display.

It is urgent, therefore, that we find ways to restore to all those affected their dignity as people—not with welfare programs, but through solutions that promote and sustain human development.

It is also urgent that faith-based institutions representing the gamut of creeds and religions contribute to comforting the suffering migrants; let their service and prophetic mission set the tone for secular governments. Religious leaders must fearlessly and consistently denounce all the aspects of the migration crisis that undermine human dignity, that impede the ability of all men, women and children affected by the crisis to lead dignified lives, as individuals and communities. Sad to say, the opposite is true today, with so many religious leaders having become co-conspirators of silence, demonstrating a glaring indifference to the migrants and refugees. 

We must create a world that serves as a great table of plenty at which all people have a seat, and where all are in solidarity, partaking in equal shares of the abundant life. This vital task should bring all of us together in unison and harmony. The failure to build a more humane global community, marked by solidarity, is a grave moral defeat, which should fill us with shame. So far, governments and civil society have done precious little—there is so much, so much more that we must do to bring comfort and healing to our migrant brothers and sisters from all around the world.

Easter: New and Abundant Life for All

DURING this time of year, the Catholic world prepares for the celebration of the most important holy day of the liturgical year: Easter—the Resurrection of Jesus Christ.

This essay will explore two aspects of this feast, two very important meanings that this holy day has for all of humanity, for the Christian world, and for our North American society.

First, the confession of faith in the Resurrection of Christ has a historical basis or reflection in the transformation of life experienced by the first Christians; these men and women recognized and proclaimed to each other and to non-Christians that they had become new men and women, with a transformed mentality. They were now able to understand the whole life project of Jesus of Nazareth; and now they could live out its principles and put them into practice, fueled by a new vision of God, of the world, and of the “other,” their neighbor.

Some of the disciples who had accompanied Jesus in his travels and ministry—his first witnesses, his intimates, but who clumsily did not understand him, and instead denied and abandoned him—now were sent into the world. Two thousand years ago they began their mission proclaiming that Christ was alive, that he lived in them because he had radically changed, renewed, and transformed their lives. Now they were living out, in its fullness, the commandment to love; they recognized that all men are brothers, children of the same Father in heaven—just as Jesus had taught and shown them.

How much we all need this each and every day: this personal renewal and this transformation in order to become better human beings, to transform ourselves—to move forward. This is precisely what the word Easter means in Hebrew: "to step," to step over and let go of resentments, fears, small and big hatreds, this focus on differences, intolerance, discrimination, quarrels, divisions, and all forms of violence and death. We all need to move forward toward new ways of understanding and living life--new, renewed and transformed ways of relating to each other. This makes coexistence possible, a coexistence that, even if it is not always fraternal, is at least humane and civilized!

For all of us, the first meaning of the Christian Easter is new life. And how much does this message of Easter not apply, with so much urgency and necessity, to our American society, in the here and now?

We are surrounded and distressed by a thousand forms of violence and death in our homes, our streets and our schools. We are overwhelmed by unemployment and dread of the future, fear of diseases and political uncertainty; then there is the use of drugs by so many people, especially the young, and the destruction addiction wreaks in so many families; plus, there is the loss or distortion of traditional values because of the primacy of having over being, the pursuit of pleasure and power at all costs—regardless of the means—as the ultimate goal of human existence, etc. 

This reality threatens to suffocate the potential of human life and harms and hardens the coexistence of all of us in contemporary society. The situation clamors—with great urgency—for a transformation, a change, a metanoia, a new life. It clamors for people whose lives are transformed as well as the reconstruction and renewal of institutions so that they become more just, more supportive, and more humane.

Second—and inseparable from the power of Easter to transform lives—the confession of the Resurrection of Jesus signifies a triumph of life over death, a step away from failure and toward victory. Thus, Easter also stands for an "abundance of life" as the ultimate destiny of human kind, of every man and woman who comes into the world.

Today’s many ills, as mentioned, that afflict and distress individuals and society at large, call us to a daily task; we have a calling to progress from the bad to the good, from the inhuman to the human and humane, from the mediocre to our best selves, from lies and errors to the truth and honesty, from the twisted and confused to a clear conscience. We can make such progress through our words and in our actions, building up—through that step forward, that transformation, that novelty in our lives—the room for abundant life.

Let us embrace abundant life, so that, in our nation, it can manifest itself in the realms of law and politics, in economics, and in the quality of inter-communal and interpersonal relations, in the world of art and sciences, in the exercise of our professions and in all our daily tasks, and so too in the world of entertainment, recreation and sports, in our religious practice, etc.

Our society—proud of and enriched by so many material achievements—is the stage for so many accomplishments and the reason for so much hope for so many who have come here or dream of doing so. Yet, at the same time, within and without or borders, there are so many who are suffering the pain of unfulfilled dreams, unfulfilled longings, and dashed hopes; the pain of a thousand injuries inflicted by unjust and inhuman ways of life. All of this demands from us that we embrace a new life—and invite others to do the same—to embrace Easter’s promise of an abundant life, the prosperous, full and happy life for which we all yearn.

Let it be Easter then every day. Let all our days witness our passage from the old to the new, and from scarcity, and petty and precarious ways of life, to a truly abundant life!