Giddy-up Dallas - Yee Haw! 2

The Gossips

Breakfast began at 0630. My dietary preferences were requested upon registration. My preference? Low salt, vegetarian. The menu for the conference was provided at check-in. “We want to make sure you have what you need.” I was bowled over by their service and thanked them profusely and thoroughly.

The meals were buffet-style with a plethora of vegan / vegetarian choices: several salads, hot and cold vegetables, whole grain and pasta entrees. It was by far the most truly, healthy buffet I’d seen outside a specialty establishment.

Breakfast backslid and contained all the usual suspects: scrambled eggs and bacon, oatmeal, fresh fruit, yogurt, pastries, bagels, and granola. I served up a plate of fresh fruit and coffee and longed, not for the first time, for bacon. I miss eating bacon, its scent is irresistible - still. AUGH!

As an interesting aside, our badges were bar-coded. Entrance into all conference events, including meals, were scanned. That’s a first.

I found Linda in the crowd of 300 - whew! The opening presentation covered the state of healthcare in the US. 

“Eight thousand dollars per person per year. Did you get that kind of value? We have the most expensive care, not the best care. Could we do better by the money we spend? It will take a shift from pay-for-performance (pay for procedures) to pay-for-results.” To that end, the remaining lecture addressed population management - moving the nation’s population toward health. How do we do that?

“For starters, one must understand the scope of the problem.” 

Visit: http://www.countyhealthrankings.org/ to view health outcomes by US county. This site provides the state of the state as measured by adult smoking, adult obesity, physical inactivity, excessive drinking, premature death, and death by motor vehicle crash.

Here’s an interesting statistic against which you can measure yourself: what percentage of Americans exercise 20-minutes three times per week, do not smoke, eat five servings of fruits and vegetables each day, wear seat belts, and have a normal BMI (body mass index = a ratio of body muscle:fat = gross indicator of body fat and health)? I guessed 20%. Survey says: only 3%. My mouth gaped and I gasped in disbelief.

How does one personally make use of such data? Compare yourself to the measure and start working toward towing the line. Why? Because your body is THE vehicle in which you travel through this life. If you honor it, it will serve you long and well. Life is easier in a body that works and moves pain-free. Really? Really.

“Next,” the lecturer moved on, “Provide basic health coverage for all.” So people can receive health maintenance in a doctor’s office instead of crisis intervention in an Emergency Department. 

Why should we pay for their healthcare, you ask? When people seek primary care in an Emergency Department (ED); who do you think pays for that? When they seek care in free, community, outreach clinics; who do you think pays for that? When they commit petty theft to get prenatal care in jail; who do you think pays for that? When they birth crack-babies that need detox and special schools; who do you think pays for that? When they are in and out of jail because they are unable to function without routine psychiatric medications; who do you think pays for that? When they come into the ED in hypertensive crisis because, due to job loss, they could not afford their blood pressure medicine; who do you think pays for that? When the blister on their toe turns into an ulcer and amputation because they had to choose between groceries or diabetes medication; who do you think pays for that? 

You think the poor, working poor, jobless, and disenfranchised don’t get medical care? Wrong - they get it late in the game and at the highest price - in the ED. Who pays for that?

WE do, our tax dollars pay for that. And who pays the highest effective tax rate in America? The middle class - that’s us my friends. So like the speaker, my feeling is - if we are paying for it anyway - let’s make it infinitely more efficient and cost effective by providing universal coverage. 

Kaiser’s CEO says initially, as we bring 32-million uninsured into the fold, costs will increase but ultimately drop as the cost burden  is shared across a larger pool and we move primary care visits from the ED. There are many parallels to car insurance.

CNN’s Fareed Zakaria (love this guy) did a series on healthcare. He says as other nations create healthcare systems for their citizens, our infamous model is the one to avoid unless expensive and inadequate is the goal. Ouch! There is no shortage of opinion on the topic. Some Christians argue for universal coverage from a place of compassion. Not surprisingly, the Christian Right is vehemently opposed. WWJD?

I know some of you will disagree and I am open to all conversations on this subject. But start your argument thoroughly grounded in reality: we have the highest cost of healthcare in the world, far from penetrating coverage, and a population in health crisis. All solutions welcome!

As healthcare reimbursement dollars shift to successful outcome measures (good BP, BMI, A1c, LDL, etc.) versus pay-for-performance (procedures), there will be increasing pressures and focus to have patients meet the health indicator measures like those in the aforementioned website. How, as healthcare professionals, do we motivate, cajole, enroll, and move people toward healthier lifestyles?

Ah - that’s the billions and billions (adieu Carl Sagan) of dollars question. 

The lecturer continued with requisite items needed for such a system of care and accountability: an electronic health record - check, an integrated delivery system enabling integrated care (translated: the Cardiologist knows the plan outlined by Nephrology) - check, a plan for addressing key medical issues more frequently - (we call it Every Patient, Every Time) - check.

Kaiser Permanente implemented a population management model at least four years ago. I work in a department focused on population management. It is a daunting, unending, ever-changing dilemma ...  and we are lightyears ahead of the country. 

As a people, we are living longer and living longer with chronic disease. How do we live well with chronic disease? If medical reimbursement is tied to “healthy outcomes”; how does my doctor get paid when my chronic disease is out of control? How does my doctor get my chronic disease controlled without my buy-in or participation? In short: how do we incentivize and monetize health?

The tension in the room was palpable as practitioners realized the scope of the task ahead - to which our paychecks are tied. And I - not for the first time - was thankful to work for Kaiser Permanente with its visionary leadership, workflows, and (albeit sometimes painful) expectations.

Lastly, the speaker proposed that if the personal mandate is struck down by the supreme court, expect an expansion of Medicaid and Medicare and an increased tax burden on the middle class. I’ve heard this from multiple sources and either way, there is a silver lining for me. As 32-million Americans enroll for health coverage, the demand for mid-level providers like myself, will explode.

This opening lecture was worth the price of admission against which the remaining conference paled. Hence, I’ll spare you the details of insulins, and incretins, and endocrine blah, blah, blah.

Linda and I hailed a cab to West Village in Uptown, a swanky collection of outdoor eateries an boutiques just north of downtown Dallas and bordering Highland Park. I had a friend in Alaska who hailed from Highland Park. She joked the soil was black with oil and her middle fingers were crooked for the weight of her silver spoons. Magnolia was an outrageous, bodacious, boozin’, schmoozin’, smokin’ gal who lived life large in every way... until la vida loca disrupted the endothelial function of her coronary arteries and her come-to-Jesus arrived prematurely. I hadn’t thought of her in years until I stomped through her old stomping grounds.

The sign said: Cowboy Cool. “This will be an urban cowboy store,” I said, pulling the door open. Swanky? Oh honey, you ain’t seen nothin’ yet! Custom made boots with pricing upon request. These weren’t boots, they were hand-tooled, seamed in braided leather, works of art priced at no less than four-figures. Beautiful? OMG!

We walked the mile from West Village to Javier’s Gourmet Mexicano Restaurante and arrived with the help. The outdoor patio, the cigar bar, and the brass wrapped beverage bar were open until they began seating the dining room. We ordered margaritas. 

Our bartender Jorge’ provided some backfill. Javier’s serves the cuisine of Mexico City in a realistic setting: a masculine jumble of mounted game, large paintings in gilded frames, and hanging plants. Their chips were unsalted, super thin, and made on-site daily.  

Remember Chris? You should know if their food is good from the beginning - by the crispiness of their chips and snappiness of the salsa. They came with ramekins of salsa and whipped butter. Yes - whipped butter into which one could dip their chips if one was so inclined. I dipped one, er - no thanks - I thought, remembering Magnolia’s early come-to-Christos. I did eat an excellent salad of spicy, grilled shrimp, avocados, and cilantro dressing.

As another aside, Dallas is home of the first frozen and blended margarita. As a young restauranteur, Mariano Martinez put tequila and the slushie adult beverage on the map in Dallas at Mariano’s Hacienda back in the 70’s. Let us raise our voices in praise.

Still marching to PST, I was not ready for sleep. I sat against the Hilton’s infinity pond, to the trickle of water, and watched Nebula. Nebula is a tangle of, what appears to be amber glass beads but are, in fact, bicycle wheel reflectors, and cabling - an eight-story, kinetic sculpture that appears to tumble endlessly in the atrium of Anatole's middle tower. In daylight, the clockwork gears overhead are visible and if one tracks a single bead, one discovers that Nebula does not tumble but undulates. Backlit at night, I found its slow somersault overhead not unlike the curl of waves breaking upon the sand, mesmerizing and calming.  See Nebula on YouTube: go to minute-14 of the website below.

You artisans may enjoy the 4-part series recounting the fabrication of Nebula at http://www.youtube.com/watch?v=mSCM-CJlrIg&feature=relmfu

I had no knowledge of this sculpture before my arrival or any concept of what it took to assemble but its presence was undeniable and grand. At night, it brought a touch of magic and silent movement to the overhead cavity, which I enjoyed immensely.

Stay tuned for unlikely assassins and the grassy knoll. (I know I said this before but it is really next.)