Watching the MA laboratory of democracy

People from other states would be wise to watch the sequence of events happening here in Massachusetts with regard to health insurance rates. As I described below:

Things are playing out just as one might predict in the Massachusetts small business and individual insurance market. The Insurance Commissioner turned down proposed rate increases, the state's insurers appealed to the courts, and now they can't write policies.

Now, Rob Weisman at the Boston Globe reports on yesterday's hearing in Suffolk Superior Court. The insurers argue that the action by the Insurance Commissioner is arbitrary and capricious, the traditional standard used to overturn a decision by a regulatory agency. The Division of Insurance argues, in part, that the insurers have not used up their administrative remedies before the agency, another traditional argument. A ruling is expected on Monday.

Meanwhile, columnist Scott Lehigh offers thoughts on "The State's great health care standoff," noting that "Unease is in the saddle in the state’s health care sector, and chaos looms on the horizon." He says,

Everyone is awaiting the next big political development. And here it is: Senate President Therese Murray will step into the breach when she speaks to the Greater Boston Chamber of Commerce Wednesday, unveiling a proposal she hopes will resolve the great health care standoff.

Senator Murray is a thoughtful and decisive person, and I, for one, look forward to her taking the reins here as many other elected and appointed official ignore the remarkable conclusions reached by the Attorney General. Just a few weeks ago, the AG issued a report, after months of study, in which she clearly explained that insurance price increases in the state were the result of two factors, the underlying increase in health care costs and a disparity of reimbursement rates that pay some providers substantially more than other providers. "Price variations are correlated to market leverage as measured by the relative market position of the hospital or provider group compared with other hospitals or provider groups within a geographic region or within a group of academic medical centers."

She also noted that the movement by some insurers and providers to capitated contracts did not result in a different growth rate in underlying medical costs from the traditional fee-for-service payment method. "Variations in providers’ per member per month expenses are not correlated to the methodology used to pay for health care, with expenses sometimes higher for globally paid providers than for providers paid on a fee-for-service basis."

In a comment below on one of my posts, astute observe Barry Carol offers the following thought. While he focuses on just one of the better paid hospital-doctor systems in his first paragraph, his second paragraph makes it clear that his approach could apply more broadly to others as well:

As I see it, the key problem from the insurers’ perspective is that employer customers felt it was absolutely essential to have Partners in their networks because that, presumably, is what the employees wanted. While narrow or limited network insurance products are quite well accepted in CA especially, it’s a different story in MA. Harvard Pilgrim, I believe, offered an insurance product that did not include Partners in the network but it didn’t gain much traction with customers.

This is why I keep coming back to disclosure of contract reimbursement rates and quality information to the extent that it’s measurable to help referring doctors steer their patients toward more cost-effective healthcare choices. I think that’s the best and most viable way to create countervailing power against Partners and other hospital systems with significant local or regional market power. Insurers could develop a mechanism to reward referring doctors who actually do this most effectively but they would need the price and quality information first. I think I know why insurers resist disclosure of contract rates but I don’t know why the regulators do.

To which I add one other thought in my comment on Scott's article:

Let's also look at the 10% of premiums used by the insurers for administrative costs, a percentage that has stayed remarkably steady over the years. As overall premiums have gone up, the number of dollars collected for non-medical costs has risen dramatically. Other financial services industries have been able to achieve improvements in their administrative and transaction-related expenses. Why has that not been possible in the health insurance field?

And just to make it clear that providers have a role, please review what I have said below about the potential for real quality improvement and cost savings to be achieved. An excerpt:

[I]t is possible for the participants in the health care system to accomplish major changes in the rate of medical cost inflation. Two articles have this theme. One is by Business Week's Catherine Arnst. The other is by Lucien Leape, Don Berwick, and others in Quality and Safety in Health Care. Both are worth reading, and they overlap in recommending several areas -- reducing infections and other preventable harm; empowering patients and families to participate in their care; and disclosing and apologizing for mistakes.

[T]here is a remarkable consensus on these items, and yet hospitals and doctors often fail to implement them. . . .

It is not unusual for industries facing structural change to be slow to move. Why? Because the leaders of those industries were promoted based on their success in the past financial, political, and social environment. They were hired for their ability to maintain the status quo, rather than for their ability to make change. Eventually, though, societal forces make themselves felt. If an industry does not adapt, the government will step in.

That is what we is happening right now in Massachusetts. Watch us closely, other 49! Do we go the route of short-term political expediency and bad regulatory policy, or do we show the wisdom and maturity to put in place directionally appropriate policies? There is an old legal expression: Hard cases make bad law. As things founder in the judicial and executive realms, brava to Senator Murray for having the courage to step in.

A no-brainer

Jennifer Devine is a fellow at BIDMC in Cognitive Neurology. She writes:

I'm training for the Boston Marathon, as a fundraiser for AccesSport America, a Boston-based program that organizes sports programs for adults and children with disabilities. To attract attention to the cause, and to inform people about the role of exercise in the maintenance of overall health, I'm posting blogs on details of my research interest (exercise and cognition in brain injury) and various posts about my pre-medical life as an Olympic athlete. The latest post, "Your Brain on Exercise", is especially relevant to a general audience.

Please check this out and help Jennifer with her cause.

Catch this (fish)

I know I am playing into the hands of two commercial enterprises, one of which I patronize (with pleasure!) and one of which I know hardly at all. By repeating this, I am helping them go viral, but I think they deserve it because of the creativity they show. Here's the letter:

Hi Paul,

Our client, Legal Sea Foods Restaurants, wanted to spread the word that no one has fresher fish than they have.

We wanted to do something unexpected that makes the point and gets some buzz going.

As one of their restaurants is adjacent to the Boston Aquarium, we opportunistically placed a sign for the restaurant right next to the direction signage to the aquarium.

We made these signs and actually put them up.

Yes, a bit of a stunt, but strategically right on the money. That's the kind of work we like to do.

Best,

Kristen Czyzak
DeVito/Verdi
New York, NY

Sarah and Amy get acquainted

OK, this is not a big deal in some ways, but it is a nice story about communication between the academic staff and the administrative staff in our hospital. I like what this email exchange stands for -- environmental concerns, staff concerns, safety issues, etc., but especially the respect that our folks show to one another.

To whom it may concern,

My name is Sarah, and I have been here for three years as a researcher in the Neurology department in Palmer 127. I bike here to BIDMC everyday from Somerville, which takes about half an hour, rain or shine, blizzard or intense heat. For the majority of the time I have been here, I have locked my bike outside the railings of the Farr building (directly across the street from the emergency room in the West Campus). Last week, however, I received a note from public safety notifying me to lock my bike elsewhere because it is a hazard to lock my bike along the railings outside of Farr.

For the most part, I do not see how my bike being locked there can be a hazard. It is merely an exit—and not even the main exit—and not many people traverse that way. The part that bothers me more however was that public safety suggested I lock my bike in one of the garages instead. I tend to work late and not leave until well after dark, and as a woman, I am incredibly anxious about walking into a garage alone when most people have already left. For this, I find it unsettling and ironic that public safety suggest I lock my bike in the garage. If they are indeed concerned about my safety, they would have suggested otherwise.

Prior to construction work right outside of the Farr building entrance, there used to be bike racks opposite of the Farr building entrance. While these racks were not sufficient during the heart of summer when most people chose to bike here, they provided additional spaces to lock bikes. The majority of them have since been removed a few months ago when construction took place there.

I merely ask that these bike racks be put back where they were (opposite the main Farr entrance). Barring that and my desire to not lock my bike in the garage, is there another area relatively open and near the Farr building where I can lock my bike if public safety feels that I cannot lock it outside the railings of Farr?

As a hospital and health institution, I hope BIDMC supports those who wish to promote a healthy lifestyle by biking. I do not believe that placing the bike racks back where they were would intrude on anything.

Thank you for your time and consideration,
Sarah

Hi Sarah,

Thank you for your email. It was both timely and helpful. As someone trying to encourage more employees to ride to work, I want to thank you for continuing to do so.

I understand your frustration with having the racks in front of the Farr Building moved so I want to first explain why we needed to do that. Earlier this year the hospital began a series of projects designed to make the facilities more accessible to patients with a variety of disabilities. As I have begun looking for more rack locations I have learned that what looks like plenty of space to a biker is often not enough clearance to a wheelchair or false information to a blind person navigating a railing with their hands. We attempted to communicate the reason for the relocation via the portal and an email to managers but it is clear that we did not succeed in reaching everyone so I want to apologize for that.

When I learned that the racks needed to be relocated my priority was to find safe sheltered spots that could serve as a fair substitute for the spaces being lost across from the Farr entrance. I ruled out several locations that did not pass my "5 '2" female leaving alone after dark" test. We decided to put them in the garages because there are parking garage attendants in both West Campus garages. In LMOB the racks are right next to the booth and has the added of advantage of being accessible directly from the building. In Pilgrim, you need to walk by the booth to get to your bike. Since you are one of our hardy cyclists who ride, regardless of weather, I hope you will feel comfortable using the garage spaces, particularly on days when you want to protect your bike from the weather.

That said, we share your expectation that bike traffic will increase as the weather warms up so Chief Casey has been working for awhile to get more racks added. Space is a challenge, but we have identified a few spots in well let areas closer to some entrances so we hope to have some racks installed soon.

A similar email exchange with a bike commuter last week was really helpful in changing the criteria I was using to find additional spots. Doing so opened up a few more options, so please feel free to contact me both with any questions about this email or any thoughts for alternative locations.

Thanks!

-Amy Lipman, BIDMC Environmental Sustainability Coordinator

Dear Amy,

I would like to thank you very much for your quick response. It is really great to work at a place where people (especially the executives at the top) take your concerns seriously and try to implement a solution right away. I think that is thoughtful and wonderful and though I have limited experience with the customs here in the U.S. (I am from Switzerland and have spent a total of three years here), I am almost certain that this is a sign of the openness and community of BIDMC. I am very grateful for that.

That being said, I have thought about the bike racks again and have three suggestions for possible locations. Though these locations may not be the most viable, I am merely keeping the conversation open and exchanging ideas:

1) How about replacing the parking spots opposite to the Farr entrance with bike racks? Hardly any handicapped people get out there and most people park right in front of the entrance, along the sidewalk anyway.

2) How about racks in front of the Main entrance of the West Clinical Center (similar to the racks in front of the Joslin Diabetes Center)? There is plenty of space - again especially for the cars - and some of that could be yielded for bicyclists? Or even under the awning, there would probably be some space for both pedestrians and bikes.

3) How about converting some space in the emergency room parking lot? While there is no overhead sheltering, space is abundant and seem like a decent place to lock some bikes.

I know by now that cars are really important to Americans and that it is just normal for them to put the car anywhere. While I understand everybody would like to be in front of the main entrance, arguing for bicyclists, I think it’d better if such spaces could be shared between bicyclists and motorists?

I apologize for being bold, and I don't mean to offend anybody. I am grateful for the opportunity to openly share my concerns and suggestions. Thank you!

Best,
Sarah


Hi Sarah,

Thanks for your thoughtful response and your ideas. Even if we can't put racks in the exact locations you suggested, hearing your suggestions helps us understand priorities as we look for places that can work. It sounds like the closer to the building entrance the better. Sheltered spots are helpful, but you'd be willing to trade shelter for proximity. This priority list echoes that of a second bike commuter who sent me some suggestions. Initially we prioritized sheltered spots, resulting in covered spaces far from main entrances. For the next set of racks we are going to prioritize proximity to building entrances.

In response to the specific locations you suggested, I am afraid they won't work, so I wanted to quickly explain why. As I walked past MIT last night I couldn't help but notice all the of bike racks lined up under major buildings, some of them running the length of the building, and all of them filled almost to capacity. The sight of them made me jealous. Most of the people I interact with are the 7,000 or so healthy employees who come in and out of here every day. Many of them are trying to find greener ways to get to work. However, as a hospital, our primary mission is to treat people who aren't 100% healthy. This means we need to share our streets, sidewalks and entrances with patients, many of whom are here to treat conditions that limit their mobility or who have received treatments that temporarily impede their mobility. Add the challenge of being on 2 sides of a busy street and we find ourselves much more reliant on motorized transportation than a place like MIT or typical office building that caters to a vibrant healthy population. This means that we need to a decent amount of car access available for ambulances, patient drop-off and shuttles. Like handicapped spaces in a parking lot, the key here is that they have to be available even if they are underutilized.

While we can't put racks in any of the places you suggested, we have identified places that I hope will be almost as good. The rack in Lowry that was installed incorrectly is going to be moved outside the Deaconess building on the concrete slab next to the entrance to public safety. My hope is that it will serve the bikes that can't find space on the racks under the bridge. It isn't sheltered but both you can see both the WCC and Farr entrances from it. We are hoping to have this moved on Monday.

If we are able to purchase more racks for the West Campus, the plan is to install them to the left of the WCC entrance. There are two jogs in the building, just past the shuttle stop, that give us enough extra sidewalk space to put bike racks.

Thanks again for thoughts and suggestions. I look forward to your feedback on the new locations.

-Amy

It's easier to beat up the insurers

Things are playing out just as one might predict in the Massachusetts small business and individual insurance market. The Insurance Commissioner turned down proposed rate increases, the state's insurers appealed to the courts, and now they can't write policies.

Meanwhile, policy-makers ignore the underlying causes of the problem:

Just a few weeks ago, the Attorney General issued a report, after months of study, that explained that insurance price increases in the state were the result of two factors, the underlying increase in health care costs and a disparity of reimbursement rates that paid some providers substantially more than other providers.

As noted by my colleague Ellen Zane, in remarks consistent with the findings of the AG, "The funneling of dollars disproportionately among hospital and provider groups serves to warp the overall system balance."

Taking a page from the debate on national health care, local officials seem to have decided that it is easier to beat up on the unpopular insurance companies rather than address the root cause of the problems. Here, though, the insurers are non-profits. If they are forced to charge prices below those that are based on actuarial determinants, there are no shareholders to absorb the losses. The most direct result is a reduction in capital reserves, a key metric the Division of Insurance is statutorily charged to protect.

I see a salad, so I choose the fries

I was talking with the MBA students at Duke's Fuqua School of Business about the obesity epidemic in the United States, and they told me about some interesting research published last year. Gavin Fitzsimons, professor of marketing and psychology, and his colleagues describe an effect called "vicarious goal fulfillment." Excerpts:

In a lab experiment, participants possessing high levels of self-control related to food choices (as assessed by a pre-test) avoided french fries, the least healthy item on a menu, when presented with only unhealthy choices. But when a side salad was added to this menu, they became much more likely to take the fries.

... Although fast-food restaurants and vending machine operators have increased their healthy offerings in recent years, “analysts have pointed out that sales growth in the fast-food industry is not coming from healthy menu items, but from increased sales of burgers and fries,” Fitzsimons said. “There is clearly public demand for healthy options, so we wanted to know why people aren’t following through and purchasing those items.”

An abstract of the article from the Journal of Consumer Research is available here. (You will need a subscription to read the full text.) Here's another quote from the news story:

“[T]he presence of a salad on the menu has a liberating effect on people who value healthy choices,” Fitzsimons said. “We find that simply seeing, and perhaps briefly considering, the healthy option fulfills their need to make healthy choices, freeing the person to give in to temptation and make an unhealthy choice. In fact, when this happens people become so detached from their health-related goals, they go to extremes and choose the least healthy item on the menu.”

Readers, is this what you do? Does this ring true?

Blue Devils fans

Fortunately, my presentation at Duke's Fuqua School of Business did not conflict today with the celebration at Cameron Indoor Stadium welcoming back the victorious men's NCAA championship team. If it had, no one would have come. But as you can see from these pictures, many of the students came from that event in appropriate attire.

A good day to be at Duke

I am honored to be meeting with a group of MBA students at Duke University's Fuqua School of Business. (By the way, it is a very good day to be at Duke!)

Many of them are part of the Health Sector Management Program. The Faculty Director, Dr. Kevin Schulman, is in this picture on the left.

Alarms should go off in our heads

There is a quote about telemetered alarms that caught my attention in a recent Boston Globe story by Liz Kowalczyk about one of the Boston hospitals:*

“If you went to any hospital floor in America where there is monitoring and asked the doctors and nurses, they would say there are too many alarms and too much background noise,’’ said Dr. Gregg Meyer, senior vice president for quality and patient safety.

Gregg is excellent at his job, and I believe him to be correct on this point. Hospital people around the country would likely admit him to be correct, too. We found that to be the case in our hospital and, like MGH, made some changes in our use of telemetry as a result.

This is a classic problem in human factors engineering. There is a recent article on the topic by Heather Comack at Health Leaders Media.

As in other complex settings like power plants, safety systems are often added in response to sentinel events that have occurred or because of regulatory concerns. But the addition of safety systems carries the risk that those systems themselves cause new safety problems to arise.

I am sorry to say that this is yet another area in which the hospital world is woefully behind other industries. We lag in understanding how to undertake process improvement and in training our medical staff to understand care delivery systems, but we fall even farther beyond when it comes to human factors engineering.

Maybe Don Berwick can use some of his knowledge and skills at CMS to help move this along, but I think he can only nudge. Change must come from within the hospitals themselves, but we need to be modest about what we know and borrow shamelessly from other industries.

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*I mean in no way to cast aspersions about a sister institution by writing this post. BIDMC has been through a similar regulatory review to that described in the article, by the way, but related to other types of issues. The topic raised in the Globe article has broad implications for all institutions, and that is why I write today.

Should we let the death issue die?

Did you read yesterday's New York Times article by Anemona Hartocollis, entitled "Helping Patients Face Death, She Fought to Live"? It was about a palliative care doctor who faced her own end-of-life issues in a very different manner from the way she would have advised many of her patients.

An excerpt:

[A]s the doctors began to understand the extent of her underlying cancer, “they asked me if I wanted palliative care to come and see me.”

She angrily refused. She had been telling other people to let go. But faced with that thought herself, at the age of 40, she wanted to fight on.

While she and her colleagues had been trained to talk about accepting death, and making it as comfortable as possible, she wanted to try treatments even if they were painful and offered only a 2 percent chance of survival.

It is never right to be judgmental about these matters. Each person faces this kind of situation in his or her unique way, and we have no right to dispute the choices people make.

But I was struck by how this doctor personified the public policy debate that surrounds terminally ill patients. Here's a an example of that kind of discussion from Canada (single payer, government run system!):

The high cost of dying has more to do with soaring health care costs than the aging population does, according to the Canadian Institute of Actuaries. In its submission to the Romanow commission on the future of health care, the institute said that 30 to 50 per cent of total lifetime health care expenditures occur in the last six months of life. Noting the sensitivity of the subject, the group suggested greater use of less expensive palliative care and living wills.

Dr. Pardi's experience shows how hard it is to go from a policy-level discussion of such matters to the decisions made by individual patients and their families. Without giving credence to the nasty and politically inspired debate about "death panels," the ambiguity in such situations suggests the difficulty in adopting formulistic approaches to the decisions around end-of-life care.

Besides abortion, it is hard to think of a part of medical practice that is more likely to be politically divisive and personally uncomfortable. Given that, is it worth the debate? Alternatively, how can we best have a productive discussion about it?

Fenway Park at sunrise

The Red Sox have a tradition of mailing out a photo of sunrise on Opening Day. Here it is.

Adverse selection

There is an excellent article by Kay Lazar in today's Boston Globe about a perverse result in the Massachusetts insurance market that has been partially responsible for the higher insurance rates in the individual and small business sectors. Here's the lead paragraph:

Thousands of consumers are gaming Massachusetts’ 2006 health insurance law by buying insurance when they need to cover pricey medical care, such as fertility treatments and knee surgery, and then swiftly dropping coverage, a practice that insurance executives say is driving up costs for other people and small businesses.

Wikipedia offers a concise description of this adverse selection problem:

The term adverse selection was originally used in insurance. It describes a situation where an individual's demand for insurance (either the propensity to buy insurance, or the quantity purchased, or both) is positively correlated with the individual's risk of loss (e.g. higher risks buy more insurance), and the insurer is unable to allow for this correlation in the price of insurance.

Concierge service?

A funny cartoon by Christopher Weyant in the March 8, 2010, New Yorker here, entitled, "On the upside, you're only one heart attack away from reaching our platinum V.I.P. status."

My big mistake

I want to tell you a story about corporate governance, a mistake I made, and the lessons learned.

Years ago, I was a member of the Board of Directors of a publicly traded company. Our CEO and senior management presented us with a take-over offer from another company. We did our due diligence, and we determined that the deal was in the best interests of our shareholders, and we approved the buy-out.

But, here was the mistake. The Board acted as a passive recipient of the CEO's proposal, leaving us only with the ability to "take it or leave it" or perhaps suggest minor modifications. We had not insisted on an opportunity to participate in the negotiations independently of the CEO while discussions were going on with the ultimate purchaser or with other possible suitors.

Part of the deal included a very generous payout for the CEO and a few other senior managers. That payout added no value to our shareholders, and indeed reduced the value to them. In essence, we had let the self-interest of the CEO drive a portion of the transaction that reduced its value to the public. We had not recognized the potential for a conflict of interest, to the detriment of the people we were supposed to represent. We failed in an aspect of governance responsibility.

I believe that this problem may be common in corporate takeovers. If a Board does not do its job properly, the public is left only with the power of elected officials or regulators to make sure that this kind of conflict of interest does not result in personal gain for a CEO and reduced value to the public.

April flowers bring Sox showers

Christine from Case Management sent me this today:

Good Afternoon, Paul,

I have attached some photos of flowers around BIDMC that I’ve taken over the past day or two. I never travel without my camera, and as the recent foul weather has given way to some sunshine and warmer temperatures I have found myself struck by the beauty of the flowers and greenery that are beginning to emerge. Springtime is always good for the soul! I love the random pictures you sometime post on your blog, so if you feel like sharing any of these, please feel free.

One last thought, especially given that the REAL start of Spring (sacred to this lifelong Bostonian and devoted Red Sox fan) is only three days away at Fenway, I can’t help but share with you that when I was looking at the beautiful magnolias outside the Farr Building this morning, I found myself thinking of George Scott talking about hitting a tater for Magnolia, his mother (do you remember that?)…a kind of crazy random thought I realize, but one that made me smile and that really is always a good way to start any day!

Go Sox!

Regards,
Christine

Wait a second . . .

You know how you sometimes read a newspaper story and then, a few days later, you say, "Wait a second. How could that be true?"

Steven Syre and Robert Gavin at the Boston Globe wrote this column on the recently announced acquisition of the Caritas Christi system by a private equity firm. The thesis presented by people they interviewed was that Caritas could gain market share by being "a competitive lower-cost provider of medical services in Massachusetts."

Well, that got me thinking. I reviewed the recent report prepared by the Attorney General comparing reimbursement rates for the hospitals in the state. This chart, displayed at the recent Division of Health Care Finance and Policy cost trend hearings, shows the rates paid to the Caritas Christi community hospitals compared to their competitors in the same geographic areas. It turns out they are not the lower-cost providers.

In the Brockton area, Caritas Good Samaritan competes with Brockton Hospital. See the map below to see how close they are. Good Sam is paid more.


North of Boston, Caritas Holy Family competes with Lawrence General, and it is paid more. In and near Boston, Caritas Carney competes with Milton Hospital and Quincy Medical Center, and it is paid more. In Fall River, Caritas St. Anne's competes with Southcoast Charlton Memorial, and it is paid more.


The article's premise was that, in a cost-sensitive medical environment, the Caritas Christi hospitals would become attractive alternatives to the Boston teaching hospitals. However, if relative costs of care actually start to be determinative of where people seek care, why wouldn't these other community hospitals be even more attractive alternatives? How would that affect the business plan posited in the story?

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Note that this discussion is based on current insurance company payments. It does not reflect the increased costs that a for-profit system will face: Property taxes; sales taxes on the purchase of goods and services; taxable debt; and a return on equity. Plus whatever amount of money the Attorney General might recommend to fund a new community-centered foundation. Perhaps the investors feel that they can make improvements in efficiency to offset these increased costs and avoid the need to ask insurance companies for higher rates. But to underprice those neighboring hospitals, i.e., to reverse the current payment pattern by having lower relative rates, would require dramatic efficiency gains.

Medical education reform on WIHI

Today's edition of WIHI (2pm-3pm EDT) promises to be timely and informative. The topic is "The Next Wave of Reform for Medical Education." The guests are Donald M. Berwick, MD, President and CEO, Institute for Healthcare Improvement; Lucian L. Leape, MD, Chair, Lucian Leape Institute at NPSF, and Adjunct Professor of Health Policy, Harvard School of Public Health; Dennis S. O’Leary, MD, President Emeritus, The Joint Commission; and Diane C. Pinakiewicz, President, Lucian Leape Institute at NPSF.

We've covered this topic a bit on this blog, but there is more to be said. Get more information and instructions as to how to participate here. You can join in from anywhere in the world!

My friend Katherine . . .

. . . today learned that she had been accepted by the college of her choice. That she was headed to college before today was already clear, in that she had been admitted by others, but she was anxiously awaiting the news from this particular school.

I'm just a family friend, so when I called to congratulate her, I asked, "Am I allowed to be proud of you?" Her reply, "Oh, yes you can!"

I was really happy to get that response. I had nothing to do with her success. But I reserve the right to be proud. She worked hard for this -- academics, athletics, volunteer service -- and she did it her way. Notwithstanding a college application system that sometimes felt like a random process, she deserved to get in.

But, I am not just proud of her. I am proud of the dozens of kids I know and the many more I don't know who made a multi-year commitment to personal and academic excellence in high school and who are now set for the intellectual and social growth they will experience in college.

But what of that random process, the one that left equally hard working and talented kids disappointed? For many years, the late Boston Globe columnist David Nyhan published a column at this time of year entitled, "The college rejection letter." It has probably helped thousands of kids deal with the disappointment of not being accepted at their hoped-for college. The final paragraph says it nicely, in the somewhat rough language David would sometimes employ:

And the admissions department that said no? Screw them. You've got a life to lead.

Berwick --> CMS

The New York Times reports that President Obama will name Don Berwick, CEO of the Institute for Healthcare Improvement, to be head of the Medicare agency, CMS. Don is an extraordinary leader in the quality and safety movement, and his appointment would send a strong signal as to the direction of US health care policy.

The Real Life Body Book

There is a new book coming out this week. It is called The Real Life Body Book, and is written by Dr. Hope Ricciotti (from BIDMC's Ob/Gyn Department) and Monique Doyle Spencer. You can read an excerpt and pre-order it now.

In the words of one reviewer*:

"I predict this will be the current generation's Our Bodies, Ourselves. The awesome talents of Ricciotti and Spencer are brought to bear on the hardest question of the day: how to provide young women with accurate and helpful health and wellness advice that is interesting and engaging enough to want to read. They have nailed it."

The publisher says,

"When you have questions about your health, you want answers from a trustworthy source. In The Real Life Body Book, a Harvard ob-gyn has joined forces with a humor writer to explain the full range of health issues facing young women today. This comprehensive and authoritative guide focuses on whole body wellness and prevention.... If you’re between the ages of twenty-one and thirty-five and you want the latest facts about your health in a language you can understand, The Real Life Body Book is the go-to resource for keeping your body healthy today and for the rest of your life."

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* er, me!