If so, enter the 2010 DiabetesMine™ Design Challenge before April 30, 2010.

Last year’s grand prize winner was a design to integrate a diabetes management system with smart phones. What will win this year?

In short, I’m an engineer.

But I have to say that the uncertain future of healthcare change — I’m hesitant to call it “reform” or “improvement” these days — is really dragging me down. It challenges my fundamental belief that we can come up with good, equitable solutions to social and governmental problems, that we can form a more perfect union. It’s getting harder for me to push down the unwelcome, paranoid, elitist, (probably) untrue feelings that the demagogues are tricking the hoopleheads into ruining my life for inscrutable (but certainly nefarious) reasons.*

But that’s not really helpful. So today I’m going to muddle through in the only possible way I can: by writing unit tests, going to meetings, and listening to Tracy Chapman. (Oddly Tracy’s music — I’ve seen her twice, so we must be on a first-name basis by now — usually cheers me up by reminding me that it could be worse, that it was worse in the late 80s and early 90s, that there’s pain and heartbreak, that we’ve got to keep going.) Because if I can’t make things better right now, at least I can calmly carry on get excited and make things. I can keep doing what I do well and wait to get back into the right frame of mind to think about healthcare again.

* — I do recognize that there are legitimate reasons for disliking the current proposals and/or the way that the legislation might be passed. I’m limiting my resentment to those who object with questions like “Why now? Why here? Why so far-reaching? Why should I give up anything I’ve got? Why should I pay anything to help someone else?” despite all of the evidence of the need for change in order to improve the health, economic security, competitiveness, and essential fairness of the nation.

It seems like I have a lot of answers about healthcare, but I really don’t. However, I do have some anecdotes and a few facts. And I have done some research when prompted or to fact-check other people’s claims. I even have a lot of opinions that I usually try to keep to myself.

But mostly I have a lot of questions and a rubric for evaluating options. I have a lot of questions. That’s what I do: I ask myself questions that I’d love to have answered before I come up with a firm opinion, if I come up with one at all.

I’ll tell you what I wonder, and I would love to know your questions about healthcare reform and costs.

Here are some of my questions, which I’ll number in case you want to provide your own answer:

1. How should we pay for insurance?
2. How much should individuals have to pay for their healthcare? Should everybody pay the same amount? Should we have tiers of service? Should it be tied to income? Is the important thing equality of coverage or equality of access?
3. How would allowing health insurance competition across state lines impact costs, benefits, and outcomes?
4. Would cross-border insurance competition lower insurance premiums? If so, what are the mechanisms? Would it cause a “race to the bottom” in covered services?
5. What are “health insurance compacts?” Are they run by states, nonprofit organizations, or for-profit companies? Would they promote competition, lower costs, lead to cuts or improvements in covered services, etc.?
6. What’s the proper amount of regulation of insurance companies and healthcare costs and services?
7. How would simplification — going from 51 or so different regulatory schemes and hundreds of insurance plans to a dozen or fewer — affect costs, coverage, and patients’ health?
8. What should be mandated? Why should this vary by state? What’s the right way to determine what’s covered?
9. If we continue to have a system with different mandates, aren’t we going to end up exactly where we are now, with some people covered for some illnesses and others not?
10. What’s the proper role for federalism in healthcare?
11. Does actively preventing chronic illness cost more than treatment?
12. How much of our healthcare spending is attributable to “unnecessary” incentive-based, fee-for-service activities? What are these “unnecessary” services?
13. Is radiology too expensive? Do hospitals buy the appropriate power of scanner? Is there a point where spending more doesn’t get us better results?
14. What impact would electronic health records have on costs and outcomes?
15. What is the cost to hospitals, governments, and the insured for “uncompensated care” provided to the under-insured?
16. Is it okay to bring currently healthy individuals into the insurance pool (thus lowering premiums per capita) without enacting a plan to reduce total healthcare costs at the same time? How will we sustain momentum for cost containment if we don’t?
17. What are the subsidies for insurance premiums and/or healthcare costs that are part of the (current) Democratic plan? How much are they? Who would get them? Where do the funds come from?
18. How do the plans proposed by the House and the Senate reform delivery to “ensure better outcomes” as Kent Conrad (D-ND) said they would on “Meet the Press?”
19. How does the Medicare pricing and reimbursement model impact providers, patients and costs?
20. What does the Congressional healthcare plan do to Medicare? Would the President’s plan move people to Medicaid, as the GOP says? How would it affect taxes, the costs to the states, insurance premiums?*
21. Why does everyone hate Medicaid?
22. Will the fees in the President’s plan increase the cost of healthcare, as John Kyl (R-AZ) suggests? What are these fees?
23. How much healthcare do we really need? Is there a target number?
24. What is the rationale for more government involvement? How do we know its influence won’t mess everything up or politicize coverage?
25. Why aren’t the administrative costs and overhead lower for private insurance companies?
26. With as many people paying so much for care, everybody must know someone who is having a hard time or paying a large part of their income. Why isn’t there something like a “pink ribbon campaign” to mobilize for lower healthcare costs?

Okay, now it’s your turn. Feel free to give voice to what you know in the comments, and please share your own questions. Opinions are fine, but data/evidence-based opinions are even better. Everything civil is welcome.

* — Senator Lamar Alexander (R-TN) said some rather unflattering things about the Democrats’ plan Sunday on ABC’s “This Week.” They’re all unsourced, so I’m going to leave the actual claims unstated. But it’s worth checking them out.

1. How will it improve patient health outcomes?
2. How will it contain or reduce the cost of healthcare?
3. How will it increase access to healthcare for all Americans?

The first question focuses on the basic purpose of medicine: making or keeping us healthy. In general, it makes little sense to make a change that does not improve our wellbeing. I feel like this frequently gets lost in the conversation. Of course, treatments have costs along with benefits, so . . .

We should also ask, “What kind of value will we get for the money that we spend?” After all, it makes no sense to spend money on healthcare that doesn’t make us healthy or to pick an expensive option that is no better (medically) than a less costly one. Not every drug, procedure, or policy involves such a choice, but many do.

And finally, a variety of changes aim to move people onto insurance rolls or improve access to medication and services. These solutions ideally encourage wellness and move patients away from using the emergency room as a primary care option.

Personally, I think that we have been focusing almost exclusively on the second question: “How will this change reduce my insurance premiums and out-of-pocket costs?” And we rarely ever ask the last one: “How will this change improve the health of my relative, neighbor, coworker, or the guy I don’t know on the bus?” We seem to think that we’re not all in this together, that we’re autonomous healthcare consumers, that we can improve our own outcomes and costs without making changes at the societal level. (Ironically, if we improve everyone’s health, we should see lower overall costs. These questions/issues are all related.)

At least, that’s how I see it.

No, not that kind of modeling. And I don’t want one of those other kinds of models, either. (Although it’s certainly nice to watch Heidi Klum every week on Project Runway.)

I want to develop a model that helps me figure out how to balance exercise, insulin, and food — a model that helps me have a pretty good idea what to do before and during exercise so that I can start exercising in a healthy range and end within it, too. It doesn’t matter to me whether it’s a set of more-or-less repeatable actions that are loose and fuzzy but get me to my goal or a table of values where I put in starting values and how much exercise I’ll be doing to end up with an action plan. Either one would work for me, and I suspect it’s going to require both. But consistency (and safety) are my goals.

I know this is possible. When I exercise in the morning — before giving myself any bolus insulin — I just have to lower my basal insulin rate to about 30% of normal and I can go for hours and hours. Of course, I usually eat a little something beforehand; and I need to eat about 30-40 grams of carbohydrate every hour from the second hour onward. But that’s easy enough to do.

But I know that it’s possible to do even better. Olympic nordic skier Kris Freeman seems to have developed something that works most of the time. (His hypo during the 15 kilometer pursuit notwithstanding.) I’m no Olympian, but I know that with the appropriate amount of personalization, I can have the same level of predictability, too.

And do I ever want the ability to predict better! And I don’t mean, “I predict that I’m going to have a low blood sugar event during tonight’s swim.” (That’s what happened tonight, when I started out at a very respectable 156 mg/dL a couple hours after dinner and ended at a very thin 47 mg/dL, complete with shiny spots in my vision provided by my glucose starved brain.) No I mean the ability to more accurately and precisely target all of my BG readings at all parts of the day.

Modeling isn’t always easy. It depends on the problem, how well it generalizes, how sensitive the phenomena are to small perturbations, how many variables there are, whether the relationships between variables are simple (e.g. linearly related) or complex, etc. But I work at a company that develops modeling software. The expertise I need is just down the hallway.

But first I need data. I need to identify the relevant independent variables and collect them. To that end, starting today I’m keeping track of much more data and being much more diligent at recording it. I hate experimenting on myself, but that’s diabetes. Soon, I’ll share more data and maybe ask for your help, too.

In December 2006, the Keystone Initiative [which used checklists in the ICU and integrated executives to help remove roadblocks] published its findings in a landmark article in the New England Journal of Medicine. Within the first three months of the project, the central line infection rate in Michigan’s ICUs decreased by 66 percent. Most ICUs — including the ones at [Detroit's troubled] Sinai-Grace Hospital — cut their quarterly infection rate to zero. Michigan’s infection rates fell so low that its average ICU outperformed 90 percent of ICUs nationwide. In the Keystone Initiative’s first eighteen months, the hospitals saved an estimated $175 million in costs and more than fifteen hundred lives. The successes have been sustained for several years now — all because of a stupid little checklist.

This is the kind of thing that has to happen in every department of every hospital if we’re going to have affordable, first-class healthcare everywhere in the US. Unlike some other changes this one is relatively easy to implement and costs very little, with almost immediate payback.

I’m going to take a short break from my usually nonpartisan, constructive mode of looking at healthcare costs and reform. Please forgive me.

The fact that I might be inclined towards partisanship here is not something I relish. Sure, I have my political opinions. (Oh, do I have opinions!) But I’ve changed affiliations a couple times, so I believe that I have a little standing when it comes to understanding the opposing viewpoint. I don’t think either side is the enemy or stupid or destroying America or whatever mean thing one side says about the other. (Yes, it’s sad that’s what gets passed off as political debate at the present time.) So I do believe there’s more than just simple partisanship going on in Congress and around the water-cooler; I can understand why each side is deeply suspicious of the principles that underlie the other’s position.

But I am so very, very angry about what is *not* happening to get the legislation passed. And don’t even get me started about the weak content of the proposals and the counterproposals.

And when I say that I’m “angry,” I don’t mean rhetorical anger. I don’t have the luxury of rhetorical anger. Well, that’s not exactly true; unlike the under-insured, I do have very good coverage, and I live in a place with multiple care-providers for the same condition. But I do have a disease, and I use a lot of healthcare relative to the majority of the population. I don’t want to spend ever more money out of my own pocket each year for something that isn’t going away anytime soon. Worse, I strongly believe that a good portion of each dollar spent on my healthcare does not actually go very far toward providing a better chronic illness experience. And I suspect — but could probably never prove — that if we were able to spend less on disease management, we could probably invest enough of what we might save into actually finding the cure for diabetes and other expensive long-term illnesses.

I also have a nagging fear that I’m only one unfortunate life-event away from being in a truly terrible place with healthcare. If we’ve learned anything over the last couple years — and I’m not sure we have — it’s that even the “good jobs” aren’t always secure and that our wellness depends on being well-employed, which is somewhat out of our control. That’s unconscionable. In fact, it actually sounds un-American to me; and I think that if you disagree with that statement, then you and I have such vastly different notions of the American dream and our possibilities that I wonder whether we actually live in the same country, whether we were taught the same things about who we are as a people, whether we actually are or can be the great nation that we claim to be.

Why am I so angry? After all, I had planned to keep posting rational, dispassionate, argument-by-argument analyses of the different aspects of healthcare and insurance reform, building up to a convincing argument about why we should make a particular set of changes. So what’s happened to make today the day that I lose my composure and get ahead of myself?

It seems that after today’s White House-organized bipartisan healthcare summit, returning to an honest discussion about the need for changes and putting aside ideological differences seems unlikely to happen. So I’m going to be a little petty and then try to redeem myself with some realistic, practical suggestions that ought to be able to get bipartisan support. But right now, I’m angry.

In my black heart, what I really want is (a) for half of Congress to be without health insurance until a law actually fixes what’s broken with American healthcare delivery and spending and (b) for the other half to pay the same percentage of their income for healthcare as the 12% of Americans who pay completely out of pocket. Deep down in that dark place I don’t talk about at parties, I want to take this group of 535 people who are mostly beyond middle age and tell them this: “You haven’t been working, so you’re fired. You don’t have health insurance anymore except what you can get through COBRA (which was passed via reconciliation, I might add). And many of you will have pre-existing conditions so good luck getting reinsured under a generous plan. And since you don’t like governmental influence in the health system, we’re going to deny you Medicare or Medicaid — and SCHIP, too. (Because as rotten as you have been to us for the last few years, you deserve to worry about your whole family, too.) And you have to go home to your district for healthcare; I hope you live in a big city with lots of services, because you’re going to need them eventually. Some of you won’t be very lucky. If these new circumstances bankrupt any of you, I don’t care. Now you can suffer with the rest of us.”

I know, I know . . . it’s petty. But the social justice and humanitarian arguments have been ineffective in moving us toward consensus. Nor have purely economic arguments.* I don’t feel like I’m being hyperbolic when I say I believe healthcare reform is a matter of national survival. If the well-being of the nation isn’t enough to move the Congress forward, then I suspect greedy self-interest is our last hope to get meaningful reform passed. And right now Congress isn’t feeling any pain.

What do I think is “meaningful reform?” Without tipping my hand too much about what it could look like or how it might get implemented — I would like to continue investigating the various aspects of healthcare spending without favoring or dismissing any particular idea — here’s a broad outline of what I would very much like to see:

1. Insure every American by mandate. You can refuse treatments if you want. That’s your business. But you can’t refuse to pay for insurance and/or healthcare. This is the very basis of insurance: Share the economic risk as broadly as possible so that over our lifetimes we pay the lowest possible amount.
2. Ensure that no American can be denied insurance coverage, be dropped from any plan, or be forced to pay more than they can afford. Again, the goal is two-fold: everybody pays a reasonable amount at the same time that everyone has access to healthcare. (BTW, you can’t have this without an individual mandate. Universal coverage requires a universal mandate.)
3. Reduce the administrative costs of private sector health insurance — if we keep that system — to the same level as government run programs (currently 2%).
4. Discourage the use of the E.R. for routine care. For example, we might encourage producing more primary care physicians. We might also need to build more community-based, 24-hour primary care clinics for non-emergent care.
5. Aggressively target the elimination of preventable chronic illnesses. Chronic illnesses — preventable or not — constitute up to 85% of all medical spending.
6. Incentivize the use of evidence-based medicine. This means doctors and hospitals should get bonuses when patients do well and costs are low.
7. Focus on waste reduction. In medicine this means choosing lower cost options (such as generic drugs and older scanners) whenever the outcomes are the same; lowering administrative costs; preventing medical mistakes; reducing the number of unnecessary, duplicated, and purely defensive tests; using electronic medical records that are shared by all healthcare providers; etc.
8. Establish a national health strategy. We lack systemic coordination and goals. Ideas for goals include making wellness more prominent in policy, reducing preventable illnesses by encouraging positive lifestyle choices, improving rural medical access, implementing electronic health records, creating high-quality protocols, etc.
9. Do some one-time changes that are politically palatable but won’t really do very much to lower costs: prohibit companies from advertising prescription drugs on television, over the radio, and in non-medical publications; reform medical malpractice; etc.
10. Create a panel of medical professionals who can set reimbursement rates and maximum costs for all providers and insurers.

I am purposefully steering clear of issues where I think there are multiple good solutions. I don’t know enough about the potential costs, revenues, and savings of the choices. Maybe a single-payer system will make implementation of these goals easiest. Perhaps interstate competition between private insurers will lead to lower costs. If so, how would different states handle different requirements for covered services? Should we eliminate antitrust exemptions for insurance companies? Encourage co-ops? Create public plans? What role should the individual states play? I suspect there’s a place for federalism, with states as laboratories for innovation, but how much? Should we tax Lexus Cadillac healthcare plans? Reasonable people can come up with different conclusions on all these proposals.**

There’s one big, lingering, completely untouched question: “How much healthcare do we really need?” I won’t propose an answer. Everyone wants their healthcare completely covered, whether that’s continuous glucose monitoring supplies, fertility treatment, or experimental therapies for a rare disease. It’s something I grapple with myself. Unfortunately, it’s also the issue that led to the first (tragically) effective attempts to derail reform. (Remember “death panels?”) From a selfish perspective, I would also like to see a system where the chronically ill aren’t forced into higher cost plans.

And for most Americans that’s what it all comes down to: “What’s in it for me?” For Congress it’s a political game. For all the rest of us, it’s our health.

* — Healthcare costs are higher in the US than in any other developed nation. In fact, healthcare spending as a percentage of GDP is 50% higher in the US than in other countries, limiting what companies can pay employees and what individuals can spend and invest. Healthcare costs employers more than $2 per hour per employee, harming US competitiveness. And it’s only getting worse; by the end of the decade, spending will account for 20% of GDP. One out of every five dollars spent in the US will be go toward returning us to health or keeping us well. And on top of all that, Medicare will be insolvent by the end of the decade at current levels of spending, requiring higher taxes or reduced services if costs don’t come down.

** — Simply saying something is “socialism” is not a reasonable counter-argument. Show me why it’s bad. Prove to me that socialized health systems in other democracies have worse outcomes than the United States — because they don’t, and they’re less expensive. If you’re just “red baiting,” then perhaps you should stop, take a moment to reflect, and grow up. I’m back to being civil now; so let’s carry on our conversation without poisoning the well any further, shall we?

It’s Olympics time. Woo! I don’t understand people who profess not to love the games. You may not like every event — bobsled, ice dancing, whatever — but how can anyone not love the whole Olympic ideal? Me, I particularly enjoy the nordic events, especially biathlon.

DiabetesMine interviewed skier Kris Freeman, the first type-1 Olympian in an endurance sport before the 30km cross-country race and afterward — I think he’s my new role model. They’re both great reads for any athlete with diabetes.

Freeman was “pissed” about going hypo during the 30km race, but he was “really, really pissed” about a bad ski choice during the 15km. I’m sure he will rock the 50km on Sunday!

Thinking of Canada, Lisa and I went to Montréal early in January. It was sooo cold (-14ºC for a high). How do people live that way? We went to see a J. W. Waterhouse exhibit at the Musée des Beaux Arts. While there, we ate some great food — check out Paris Crêpes on the corner of Ste. Catherine and Crescent — and I enjoyed the city’s polyglot lifestyle.

(And as for art: Last week the MFA installed its first painting in the new Americas wing. I can hardly wait!)

While we were in Montréal, I procured a bit of Francophone music. 90% of Canada’s population may live within 100 miles of the border that sees the most commerce between any two nations; but it’s almost as if there’s a Mounty-patrolled iron curtain separating the US from bootleggers French music. You can find a little bit on iTunes, but it’s hit or miss. Here are some names to look for: A.D.N., Amadou & Mariam, Marie-Luce Béland, Daniel Bélanger, Carla Bruni, Cali, Camille, Caracol, Les Charbonniers de l’Enfer, Cœur de Pirate, Les Cowboys Fringant, Étienne Drapeau, Dumas, Mylène Farmer, Grimskunk, Indochine, Kaïn, Karkwa, MC Solaar, Prototypes, Mara Tremblay, etc., etc., etc. The CBC nominated the top 50 Canadian francophone bands from this decade if you need more choices.

We also saw “Up in the Air” a month or two ago. Definitely recommended. It stars George Clooney, opens with a fabulous sequence of arial footage, uses a version of “This Land Was Made for You and Me” by Sharon Jones and the Dap Kings, and has a really strong story line. From time to time, I feel a bit like intern George’s character — at least I share his attitude toward flying, but certainly not his brand loyalty (though I do have my preferences). But I’m not very savvy when it comes to getting the most of my air travel dollar, which is why I’ve been reading the Cranky Flier’s web log.

Are you going on a trip anytime soon? Need reviews of places to eat, stay, visit? The Times gives a rundown of where to go online and in-print to figure where to go in real life. They mention TripAdvisor.com, IgoUgo.com, Oyster.com, and printed guidebooks. I’m starting to use TripAdvisor for hotel reviews, but books and magazines are still my destination for where to go and how to get there. Give me glossy pictures, a travelogue, and a map or two and I’ll be ready to pack my bags.

But my travel dance card is kinda full for a little while. I actually can’t believe how much I know about where I’m going in the coming years. Australia in just over three months. Bicycling in Provence, France sometime next year. England (and maybe Paris) in 2012. It’s not what I usually do . . . but I’ll take it.

More substance to come soon, I promise.

(If I weren’t at work with a lot to do, I’d write about how it aggregates some of the best articles in print from the web concerning culture and the life of the mind. I’d say something about how it goes a little way toward fostering the kind of society-wide philosophical debates that are a common fixture in a certain Gallic country that I love. I’d delve deep into the contradictions between those last two sentences, digging into the inherent conflict between a time-shifted, remixed, excerpted, low-bandwidth form of communication (web sites) and the more active but ultimately futile discourse (about, say, the “hyperreal” in Jean Baudrillard’s Simulacra and Simulation) that tends to occur in the café or coffeehouse. But I am at work, and no one really wants to read about that anyway.)

But our checklists have gotten a little long and messy, which raises the risk that people won’t use them at all. Part of my job is to improve our team best practices and checklists, so I’m working out how to make all of those checklist-bound countermeasures fresher and more accessible.

So I’m very hopeful that Atul Gawande’s The Checklist Manifesto: How to Get Things Right, which arrived on my desk today, will give me some in-the-trenches perspective. I’ll keep y’all posted on what I learn.