Today’s Most Attractive National ACO Model Is Offered By…CMS (at HealthAffairs)

I recently helped write an op-ed at HealthAffairs on the Next Generation ACO Model, one of Medicare’s pilot initiatives aimed at improving the Medicare Shared Savings Program Accountable Care Organization model:

A large national payer recently announced the opportunity for Accountable Care Organizations (ACOs) to share in 100 percent of the savings they create for the payer’s largest book of business. Providers will have complete autonomy in how they manage the health of their population, and the payer will ensure the timely flow of datasets needed to support care improvement activities. The payer will pre-define the ACO’s population and its spending benchmark, which will be adjusted for the risk of the ACO population. Consumers aligned to the ACO will be offered supplemental benefits and financial incentives to seek care from the ACO’s network.

Market-watching ACOs can be forgiven for wondering how they missed the slew of journal articles, blogs, and op-eds lauding the “best practice” design features of this new model — because they never materialized. The deal in question is, of course, the Next Generation ACO model currently being offered by the CMS Innovation Center (CMMI). But perhaps because of the hit-and-miss track record of the Centers for Medicare and Medicaid Services’ (CMS) ACO portfolio over the past five years, the reaction of the health policy intelligentsia has been curiously tepid. Savvy provider organizations, however, are increasingly gravitating toward Next Gen’s market-leading deal terms. Those ACO operators that don’t consider the Next Gen model this spring risk being locked out for the foreseeable future.

You can read it here.

NextGen ACOs and a Comment to the US Senate Committee on Finance

I wrote a post for Evolent Health’s blog and a Comment to the US Senate Committee on Finance’s Chronic Care Working Group (on behalf of Evolent).

First paragraph:

The provision of health care is changing more quickly than any time in recent memory. While this is happening in both the public and the private sector, we’re thrilled about two recent efforts coming from the Center for Medicare and Medicaid Services (CMS) and the United States Senate Committee on Finance: the first cohort of Next Generation Accountable Care Organization (ACO) members were announced, and the Bipartisan Chronic Care Working Group released a policy options document and solicited comments on it.

Check them out, and let me know what you think!

Gratuitous Photography Interlude–Western Europe

Dublin at night

Dublin at night

A sculpture in remembrance of the Irish Famine, in Dublin's St. Stephen's Green

A sculpture in remembrance of the Irish Famine, in Dublin’s St. Stephen’s Green

The Bone Chapel in the Igreja de Carmo in Faro, Portugal

The Bone Chapel in the Igreja de Carmo in Faro, Portugal

Lisbon, from the Castelo de Sao Jorge

Lisbon, from the Castelo de Sao Jorge

Belem Tower in Lisbon, Portugal

Belem Tower in Lisbon, Portugal

Pena Palace in Sintra, Portugal

Pena Palace in Sintra, Portugal

Sunset in Faro, Portugal

Sunset in Faro, Portugal

Notre Dame at night, in Paris

Notre Dame at night, in Paris

Paris.

Paris.

London.

London.

London.

London.

Burundi Falls Apart – Again

Bujumbura, in better days

Bujumbura, in better days

In late 2013, after a day-long bus ride through the rolling hills and lush greenery of Rwanda and northern Burundi – a trip during which one of my seatmates, evidently unaccustomed to facing her own mortality, threw up out the window – I hopped off in Bujumbura with absolutely no idea where to go next.

The Bujumbura bus park is cloistered in the back of a large, bustling market – the type of place that is wholly comfortable when familiar but bewildering and a touch intimidating when novel. My Rwandan SIM card didn’t work in Burundi and I didn’t have any Francs (or, for that matter, any French), so I wandered around until I found an exchange rate that wasn’t unreasonable and mimed a lot in order to make the exchange. SIM cards nowhere to be found and a light rain quickly turning to a downpour, I flagged a motorcycle driver, gratefully accepted his kind offer to call my friend for me, and left the park.

That bus park is likely now the site of protests against a leader, Pierre Nkurunziza, who is eschewing the constitution – if not in letter, then certainly in spirit – and running for a third term as president.

It’s now also a starting point for thousands of Burundians who are fleeing their country, to five-figure population refugee camps that didn’t exist just a few weeks ago. They’re fleeing the all-too-real chance that Bujumbura’s police force, loyal to Nkurunziza, will further turn on its citizens; that the imbonerakure, a youth paramilitary group armed with guns and nail-studded bats, will come for them and their families; that their neighbors, terrified of being thought of as “on the wrong side”, may sell them out to either group.

The prospect of a coup or a civil war has increased in the past few weeks, largely owing to military leaders who voiced support for the constitution (and therefore, the protestors).

And so Burundians are fleeing their present and their future, both inextricably tied to their recent past. A bit of history is useful here: Burundi is a landlocked country just south of Rwanda, and shares with it the bond of being previously colonized first by the Germans and then by the Belgians, as Ruanda-Urundi. The Belgians stoked (created and fomented, really) tensions between the Hutus and Tutsi, which gave way to undulating waves of ethnic violence in both countries, from their separation and independence in the early 1960s to the 1900s.

You’re certainly aware of how this played out in Rwanda: 800,000 Rwandans, mostly Tutsi, were slaughtered in 100 days over the spring and summer of 1994. The carnage subsided, and the Rwandan Patriotic Front, the rebel army that fought and beat the genocidaires, was left to rebuild the burned-out husk of a country. Over the next 20 years, spurred on by an international community flush with guilt, shame, and cash, it did just that, becoming an economic powerhouse in the region and, in the eyes of many, an exemplar for capital-G Good development in Sub-Saharan Africa.

(Obligatory caveat: Rwanda’s President Paul Kagame and his RPF deserve a great deal of criticism for the way in which they have suppressed dissent, crippled opposition, and ruled autocratically. There’s no counterfactual for how Rwanda would’ve done the past 20 years if the RPF would’ve ruled differently.)

Cibitoke, in northern Burundi. Stunningly beautiful.

Cibitoke, in northern Burundi. Stunningly beautiful.

Burundi, on the other hand, didn’t have 100 days of white-hot slaughter; it had 4,000 days of smoldering civil war. At the end of the war, with 300,000 dead, it was also left with a burned-out husk of a country, but didn’t have international guilt bankrolling its recovery; an efficient, effective autocrat forcing development at any cost; or two decades to build.

You probably knew Rwanda’s recent history; you probably didn’t know Burundi’s. The conflict in Burundi was overshadowed by Rwanda’s genocide, and, to the extent that it was news at all, the Great African Wars in the Democratic Republic of the Congo (in which Rwanda played a leading role).

Since then, of the decade Nkurunziza has been president the best thing you could say is that it could have been a lot worse. All-out war was averted and conflict stayed to a minimum.

And yet Burundi is in a really, really bad place. By whatever data source you use, Burundi is competing for the dubious honor of being the world’s poorest country; it is one of the worst places in the world for a woman to give birth; it is one of the population densest countries in Sub-Saharan Africa, with all of the land ownership issues that result; it is landlocked and has very little of value to export.

But things can get worse for the average Burundian, and quickly. In the past few weeks, the government has shut access to Facebook, WhatsApp, and other social media, and shut down the country’s main university, causing hundreds of Burundian students to seek safety at the US Embassy in Bujumbura. Demonstrators have been met with live ammunition, and the imbonerakure have harassed and murdered Burundians around the country.

This is not likely to end well, or soon. Demonstrations continue, and as the election nears, will likely be met with escalated violence. In all likelihood, things will get worse before they get better. More people will disappear or die.

Commentators have (rightly) narrowed their collective aperture to the daily demonstrations and the near-term election, but it’s worth contemplating what comes next.

In the best-case scenario, Nkurunziza wins and Burundi becomes an international pariah; aid may drop off in response, leaving the average Burundian in direr straits (indeed, this is already happening). Unfortunately, as should be obvious above, political uncertainty is just one of many challenges faced by the average Burundian; get rid of it and Burundi is still a poor, landlocked country with little of value to export and, from a tourism perspective, less to recommend it than, say, Rwanda.

In the worst-case scenario, all-out civil war, sparked by an attempted (or successful) military coup, is not inconceivable. Hundreds of thousands would flee to neighboring countries, straining the resources of those countries and aid agencies; Rwanda, worried about its stability and economic growth above all else, would intervene militarily. Economic instability, death, disease, terror, and uncertainty would follow.  What little progress was made in the past decade would vanish.

The likely outcome, of course, is somewhere in between. Nkurunziza will win, but a lot of lives will be uprooted, and lost. Burundians will be no better off than they are today. The bus park will represent desperation, hope, and hardship; one of the only ways out of an increasingly bad situation.

Book-Blogging – Americanah

For all sad words on tongue or pen, the saddest are these, ‘it might have been.’ – John Greenleaf Whittier

The air in Chimamanda Ngozi Adichie’s envy-inducing book, Americanah, is suffused through with saudade.

americanahSaudade is a Portuguese word without a direct English translation, but you probably know it: a sense of wistful nostalgia for something that probably never existed; the what-ifs and maybes that accompany a breakup.

This sense of longing – for a past since relegated to hazy, rose-tinted prologue; for a future perpetually just out of reach – crowds the oxygen from every open space in the book. Many of the characters are caught up in a near-constant fog of saudade, like the minor character Kimberly:

Ifemelu sometimes sensed, underneath the well-oiled sequences of Kimberly’s life, a flash of regret not only for things she longed for in the present but for things she had longed for in the past.

Ifemelu, one of the two main characters, begins her life in Nigeria and emigrates to America in search of a better education and a better life. She finds both, but is drawn back to Nigeria, saudade in tow:

She thanked him, and in the gray of the evening darkness, the air burdened with smells, she ached with an almost unbearable emotion that she could not name. It was nostalgic and melancholy, a beautiful sadness for the things she had missed and the things she would never know.

Ifemelu’s first love, Obinze, could not follow her to America, and ends up in London, where he also sees saudade in others:

It puzzled him that she did not mourn all the things she could have been. Was it a quality inherent in women, or did they just learn to shield their personal regrets, to suspend their lives, subsume themselves in child care?

Adichie is an enviable writer with a powerful and distinct voice; my Kindle is heavy with paragraphs highlighted both for their virtuosity and my edification. She masterfully weaves together the stories of emigrants and those who are left behind, bringing to life the bustle of Lagos and the dark gray winters of the American east coast. This is a book well worth your time.

We Know How Cerebral Malaria Kills Children — But Do We Know How to Save Them?

Donated medical devices are not the solution, part 58

Donated medical devices are not the solution, part 58 – ultrasounds in Kisoro, Uganda (photo: me, 2013)

We now know how cerebral malaria kills children. But do we know how to save them? An otherwise-fantastic NPR story suggests a solution that is, unfortunately, exactly wrong for the scope and scale of the problem: donated medical devices.

And the problem of cerebral malaria is a massive problem. Malaria is a wicked disease, causing an estimated 584,000 deaths in 2013 – 78% of which were children under five. Plasmodium falciparum, one of the five malaria species known to infect humans, is the most common and the most deadly, in part because it can end up in the microvasculature of the brain, causing what is known as cerebral malaria.

Cerebral malaria is particularly deadly for children, but until now, researchers didn’t really know why. A new study in the New England Journal of Medicine indicates that cerebral malaria kills them by, effectively, suffocating them:

Our study design addressed the sources of this uncertainty, and the findings suggest that brain swelling and the likely increase in intracranial pressure that is associated with brain swelling are strong predictors of death in Malawian children with cerebral malaria.

Basically, brain swelling kinks the brain stem, shutting off the autonomic nervous system; the patient no longer breathes independently, and, without assisted breathing through a mechanical ventilator, dies. (Now is a good time to mention that I have no clinical background, so, grain of salt…)

The NPR story highlights a potential solution:

One possibility is to try putting the child on a ventilator, John says. “Then, during a period when brain swelling might affect the child’s ability to breath, you could breath for them,” he says. Then take the child off the ventilator when the brain swelling goes down.

Many clinics in Africa don’t have ventilators or physicians trained to use them, John says. “It’s going to be very hard to implement that across Africa. But I would love to see ventilators tested.”

And if a malaria ward in Malawi can get a million-dollar MRI machine, surely somebody could donate life-saving ventilators.

Emphasis mine. This framing – donation as solution – is the absolute wrong way to think about the problem, for three reasons.

First, medical device donations fail. Predictably. All the time. I am a broken record on this subject.

Even if donated medical devices functioned as they are supposed to, this is too big a problem to solve with second-hand donations. Every mid-sized hospital that can support one (more on that in a minute) should have a ventilator, and it’s wrong to think that a second-hand donations market could support that demand.

And lastly, donated ventilators aren’t built for low-resource hospitals; they’re built for hospitals with consistent electricity, highly-trained clinical staff, and a support ecosystem with trained biomedical engineers and spare parts immediately available. None of this can be assumed for the vast majority of hospitals that would see cerebral malaria patients in low-resource regions.

The solution, then, is not a second-hand donation; it’s a ventilator designed for the environments in which it will be used in. Here I’m a broken record as well.

It is wonderful that we now know, clinically, what it takes to save the lives of children with cerebral malaria. But donated ventilators aren’t up to the task.

Book-Blogging – A Problem From Hell, by Samantha Power

A_Problem_from_Hell_(book_cover)Samantha Power’s masterful book, A Problem from Hell: America and the Age of Genocide, will make you want to do one of two things: drop everything and go work with her from the inside, to embolden our institutions and ennoble our leaders; or rage from the outside about the myriad failures of conscience and the fostering of cowardice that have consistently stymied the better angels of America’s nature.* It’s hard to see much middle ground.

In this thoroughly researched and thoughtful book, Power provides a remarkable history of modern-day genocide. She brings the reader to the death marches of Armenians in the gloaming of the Ottoman Empire to the wanton destruction of male Muslims in Bosnia and Kosovo, all the while cataloging the all-too-familiar costs of all-too-familiar inaction on the part of world leaders – saving her sharpest critiques for her adopted homeland, America. This is a book that could profoundly change the way you view the international system, and those at the top of it.

From the mid-17th century, when the Peace of Westphalia ended the Thirty Years’ War to the mid-20th century, nations were assumed sovereign over their land and their citizens (summed up best in Millennial-speak as “you do you”). Certainly, there were land wars and civil wars, insurrection and imperialism, but nations didn’t question how other nations treated their people.

And then in the early 1900s, the Ottoman Empire began massacring its minority Christian Armenian population. This is important for two reasons: it stoked the passions of an American ambassador, Henry Morgenthau, and caused him to speak out against a sovereign nation’s actions towards its people; and it inspired Raphael Lemkin to change the world.

Generally, the Great Man of History theory – the cum hoc ergo propter hoc fallacy that assumes, for example, that everything good or bad that happens during Barack Obama’s presidency is his doing – is just that: a fallacy. But Raphael Lemkin, a passionate Polish lawyer who eschewed decorum and tact in his zeal to codify genocide (his word) as a crime against humanity, was a Great Man of History. He is one of the the but fors of this story; but for Lemkin, it’s hard to see how the United Nations would ever have adopted the Genocide Convention, in December, 1948 or thereafter.**

The other but for of this story is darker and more deeply depressing: but for America’s reticence to enter the fray diplomatically or militarily, again and again, untold lives could have been saved. Power uses the taxonomy of inaction outlined by Albert Hirschman to underline the stated reasoning against action:

“Economist Albert Hirschman observed that those who do not want to act cite the futility, perversity, and jeopardy of proposed measures.”

Each category is pretty self-explanatory. Futility is the sense that nothing could help; perversity that an action could make things worse; and jeopardy a sense that American lives/interests would be harmed by action.

Power is at her best when presenting her unflinching criticism of the cowardice exemplified by America’s leaders each time they invoked the futility, perversity, and jeopardy of action. Facing genocide, or even the prospect of genocide, leaders cowed to interest groups and genocidal leaders, rather than stand up for the ideals they continually cited – nothing more or less than vague platitudes:

U.S. officials spin themselves (as well as the American public) about the nature of the violence in question and the likely impact of an American intervention. They render the bloodshed two-sided and inevitable, not genocidal. They insist that any proposed U.S. response will be futile. Indeed, it may even do more harm than good, bringing perverse consequences to the victims and jeopardizing other precious American moral or strategic interests. They brand as “emotional” those U.S. officials who urge intervention and who make moral arguments in a system that speaks principally in the cold language of interests. They avoid use of the word “genocide.” Thus, they can in good conscience favor stopping genocide in the abstract, while simultaneously opposing American involvement in the moment.

This book won the Pulitzer Prize in 2003, and for good reason; it is thoughtful, unsparing, and scathing. Reading it and thinking about it helped clarify the way I think about America’s role in the world. From the perspectives of morality and pragmatism, we have an obligation to be better; anything less than our best – the officially sanctioned torture in Abu Gharib, the deaths of innocents in misguided drone strikes, the idiocy of using a public health campaign as a front for espionage – invites bad actors to use those same methods. And inaction in the face of injustice and terror is nothing if not a green light for its continuance.

Power, now the United States Ambassador to the United Nations, has walked back some of her more forceful critiques of American action and inaction of the past, saying at her confirmation hearing that “Serving in the executive branch is very different than sounding off from an academic perch.” Activists worry that she has lost her zeal.

This strikes me as unlikely. While it is certainly true that she speaks more carefully now than she wrote before, it seems obvious that she is brilliant, passionate, and willing to do what it takes to effect the change she earnestly argues for in A Problem From Hell and elsewhere – even if that means softening her speech while sharpening her knives.

After reading this book, I’d drop what I’m doing in a heartbreak to work with her from the inside, which should be all that you need to know to go pick it up.

 

*Full disclosure: while I am temperamentally much more comfortable in the latter group – of realists and cynics, agitators and disruptors – in this case I think it’d be really dumb to do anything but side with Power.

**Lemkin is also a good reminder that Great Men of History aren’t always viewed that way during their lifetime: “Lemkin had coined the word ‘genocide.’ He had helped draft a treaty designed to outlaw it. And he had seen the law rejected by the world’s most powerful nation. Seven people attended Lemkin’s funeral.”

Friday Morning with Frank in Petionville

IMG_7798I’m just now getting to some writing I had started, but couldn’t quite finish, on a trip I took to the Dominican Republic and Haiti earlier this year…

On an beautiful, uncharacteristically quiet Friday morning in Petionville – the neighborhood in a post-Independence Day/New Year’s Day hangover – I met a guy the way a lot of travelers meet a guy (and it is usually a guy): he stops you on the street and starts a conversation.

His name was Frank, or France – he introduced himself a few times and his name flip-flopped – and he spoke “American English, not British English,” as he proudly said more than once. He wanted to know how I was doing.

If you have spent any time traveling in any part of the world, this routine is, well, routine for you. Someone is selling something – a painting, a tour, some currency – and you’re a potential buyer.

Frank, an older-but-not-elderly man in linen pants and an oversized button-down, had drawings he claimed were “special” and “unlike anything you’ve ever seen!”

His secret: “Ball. Point. Pen.”

“You’ve never seen anything like it,” he repeated, and not for the last time.[1]

I demurred, saying I wasn’t interested in them, and mentioned I was looking for some of the ironwork art that I’d heard about: old oil drums that artisans cut into sculptures and then sell to tourists, middle-class Haitians, hotels, and the like. When done poorly, they’re chintzy and the definition of knick-knack; when done well they are simple and beautiful.

Fortunately, Frank knew a guy “two blocks away” who sold sculptures like that. This struck me as… unlikely, but as I was just wandering around anyway and had nothing better to do, figured I may as well see where this would lead. It was a bright, beautiful day, the sun bearing down on the neighborhood, and adventure abounds on such days. So away we went.[2]

Ever the pesky erstwhile journalist, I pestered Frank about his life on the considerably-longer-than-two-blocks walk. He said he was 52 and, without my prompting, mentioned that the 2010 earthquake took his home in nearby Jacmel, his wife, and his three children. The earthquake came up in a lot of my conversations with Haitians, not dissimilar from how I’d talk about the cold weather with colleagues.

He said this in the seemingly-affectless, matter-of-fact way that other survivors I’ve interviewed or spoken to – whether of natural catastrophe, disease or premature death, sexual assault or war – describe near-unspeakable tragedy: as speakabale, commonplace. Normalized.

The earthquake took more than a home and a Home from Frank; it took his health and peace of mind. “I was sick from losing my family,” he said simply.

The earthquake eventually took his job, too. Frank told me that he was once a translator for NGOs and that he could still speak six languages. He ticked off a few for my benefit: English, Haitian Kreyol, Spanish, German. I believed him but must have looked more incredulous than I was, so he spent the next few minutes asking me questions in languages I recognized but mostly didn’t understand. And then he asked why Americans only speak English.

We walked down one street, then another, passing by dozens of storefronts – including a Domino’s. Every time I’d ask how much further, Frank would say “close, close” and continue on. We were perpetually “two blocks away”.

Walking over some rubble on the side of the road, I asked Frank a few questions about the cleanup and reconstruction efforts, and he angrily decried the government’s inability to make the city different; to, as Bill Clinton would say more than once, “Build Back Better.” He said that, even five years later, his country was “much worse than it should be” and that corruption was the proximate cause of this failure. I didn’t have a whole lot to go on, but anecdotally downtown Port-au-Prince was still in shambles, the ghostly hollowed-out husks of buildings still standing on many blocks, so I took his word for it.

 

“We don’t have a government,” he added, and he didn’t expect the impending dissolution of Parliament to change anything.

 

“Why do Americans like Haiti?” he asked me a few minutes later. I gave a few anodyne reasons and asked why he was curious.

 

“It’s dirty, and there’s trash all around. Why would someone want to come here?” Trying to find coming ground, I mentioned that a lot of places have trash all around – New York City, for example – but people still enjoyed visiting them.

 

Eventually, we arrived to his seller of choice, right off of the main road. The items were actually pretty nice and, after a lot of bargaining, I bought a few small things.

 

It was at this point that Frank’s words slurred together a bit more, and I realized he’d been slurring them for a while. He didn’t smell like alcohol, but the combination of slurred words and a suddenly-hostile disposition was a pretty clear indication that things had taken a turn for the worse.

 

Playing it cool, I gave him some money as a token of appreciation for bringing me to the ironworks shop; when he said “this is nothing, this is shit!” I gave him a bit more and made my way back to the part of the neighborhood I knew.

 

After that mini-encounter, Frank’s story made a bit more sense. The earthquake took his home, is family, and – likely – his sobriety. It took his peace of mind and his mental health, and there were too many physical problems for NGOs and governments to attend to already.

 

Some part of me is tempted to turn this into a Friedman-esque tale of how mental health problems, left to rot, impede economic growth and opportunity for future generations. How a small investment in counseling could have helped bring Frank and others back from the brink.

 

But this is not that story; it’s just a story about a man and the things he lost in an earthquake.

 

[1] I had seen something like it, actually – in Kigali a while back – and, to my great discredit, the fourth of fifth time he said this to me I said as much (I. Know.)

 

[2] Yes, you’re right: walking off with a stranger in an unfamiliar direction in an unfamiliar neighborhood of an unfamiliar country can be almost poetically stupid.

 

But really, most of the time it’s not: no matter where you live or travel, people are, on average, pretty great; anyone who has spent a bit of time traveling, and has been in a situation where help was needed, knows this – the young kid who steps in to translate your awful Kinyarwandan for the moto driver; the kind woman who offers you a blanket on an overnight bus from Nairobi to Uganda; the man who, for no reason other than human kindness, drives you from one city to the next, late at night in southern Malawi – and refused to accept any money for gas. If traveling has crystalized only one thing for me, it’s that people are wonderful.

 

NB: This is not to say you should be willingly naïve or unnecessarily risk-seeking – testing your luck is a great way to run out of it – merely to point out that there are times to be over-vigilant and times to be calm.