Author Archives: Ari Kramer

Stress: Withstanding the Waves

Sep 23, 2014, 11:42 AM, Posted by Ari Kramer

As a kid, when you went to the beach, did you ever play that game where you’d wade into the ocean and test your strength against the waves? You'd stand your ground or get knocked over, and after a few minutes, you'd head back to shore.

We didn’t realize it at the time, but as we felt those waves roll by, we were getting an early glimpse of the stresses of everyday life. The difference is, as adults we can't choose to stand up to just the small ones. And for the most part, going back to shore is not an option.

In a survey RWJF conducted with the Harvard School of Public Health and NPR, about half of the public reported experiencing a major stressful event in the past year. In more than four in 10 instances, people reported events related specifically to health. Many also reported feeling a lot of stress connected with jobs and finances, family situations, and responsibility in general.

Over time, those waves can take their toll. And when they become overwhelming, they can truly wear us down, seriously affecting our both our physical and emotional health.

So how can we deal with these waves of stress? Certainly, there are proactive things we can all do help manage its effect on our lives—exercise, for example. At the same time, we’ve probably all experienced instances when we’d love nothing more than to get up early for a run or brisk walk—but don’t have the energy because stress kept us up at night. Or we may just be too tapped out from long hours, relationship struggles, caring for loved ones, etc., to spare the energy or the time.

If this sounds familiar, consider yourself human. Right next to you, whether at work, on the train, in your grocery store, is probably someone whose waves are similar to or bigger than your own. So at the same time as you try to manage your stress, ask yourself: What could be done to help others achieve a solid footing? In this ocean of ours, there’s never a shortage of opportunity to lend a helping hand.

Have an idea to help move from a culture of stress to a Culture of Health in the home, workplace or community? Please share below—we’d love to hear from you.

A Model for Equity in Specialty Care, Part IV

Sep 10, 2009, 11:30 AM, Posted by Ari Kramer

The Pacific Vision Foundation, with support from the Pioneer portfolio, is piloting a new clinic in Northern California that will provide the same level of specialty care and other services to all patients regardless of ability to pay, while maintaining sustainable profit margins. Over the last week, David Green and David Roe, two of the project’s leaders, joined Pioneering Ideas to discuss the inspiration and behind their work and the challenges and implications. Below, find out why they believe the Pacific Vision Foundation might serve as a valuable model as the national health reform dialogue plays out.

What do you see as some potential long-term implications for health care?

David Roe: One of our marching orders was make this work within the existing system, not assuming or banking on any change from health care reform.  Within the existing system, the implication of success in ophthalmology would be that the same approach could work in other medical specialties – particularly ones that use repetitive procedures that take lots of expensive equipment – so that the more patients you put through, the higher the efficiency you can get. Cardiology, for example, certainly comes to mind. And of course, if health care reform does increase support for low-income patients, the economics of this approach will only get better.

The electronic medical record point is also worth making. Apart from the potential efficiencies in EMRs in general, you really want to be electronic if you’re going to be a model, because you want all the skeptics in the world to come and pick at what you’ve done and satisfy themselves, through hard digging, that the quality of care is there, and the numbers do add up. We’re planning in advance for that by making sure that everybody involved is committed to a very high level of transparency and, of course, to having our data collected and kept in electronic form, so all of the information can be looked at and manipulated.

Have you been in any discussions with the folks doing health reform at this point?

We’re staying in contact. Some of the people who think about this full-time for a living are very interested in what we’re doing, but quite properly they’re saying, “Let us know when it’s actually happening.”  

Have any opportunities or barriers been presented by the current political climate and economy?

Well, all of our business planning assumes working within the existing system, with doctors in private practice, whose patients are paid through private insurance or Medicare. And of course, people who need eye surgery, particularly cataract surgery, tend to be older, and so are eligible for Medicare.  For paying patients, Medicare reimbursement rates are what we’re generally assuming.

As far as health care reform is concerned, our working assumption is that the first big steps in any reform that may happen will focus on primary care, because there’s such a serious shortage and such a large need there. We don’t think specialty care is going to be in the first wave of reform, if reform takes place. But if it does take place, the next wave will be looking for innovative ways to increase the delivery of specialty care to the indigent – in other words, things like what we are trying to do. If we are up and running by then, it will help encourage health care reform to move into specialty care, without thinking you have to incur crippling new costs for government to do it.

This commentary originally appeared on the RWJF Pioneering Ideas blog.

A Model for Equity in Specialty Care: Part III

Sep 8, 2009, 5:32 AM, Posted by Ari Kramer

Last week, in Part I and Part II of our series, David Green and David Roe discussed the business model for the Pacific Vision Foundation, a self-supporting eye care center in San Francisco that will provide equal service to paying and non-paying patients. Today, they join us to discuss some of the challenges they face let us know when they expect this operation to be up and running.

What have been some of the major challenges in moving this forward?

David Green: In India, there are many procedure-oriented specialties or subspecialties in medicine that have a self-financing model, where it’s basically the same procedure performed over and over again, where you have para-medicals trained to do just a few things rather than many, and that helps bring the cost down. So how do you have the right clinical and business model combined with more affordable consumables in a procedure? It all adds up to how you source your goods, how you train your people, how you acquire and organize your patients.

David Roe: Given the legal differences and the very different regulatory structure for medicine between the United States and places where this has worked before, as well as the very different income expectations, it was natural to question whether this can work here in the U.S. The answer is, while there are some serious challenges, nothing in the law, business structure, or medical regulations stands squarely in the way. The big obstacle is the notion that since it’s never been done here, it can’t be – the intellectual inertia, or gut inertia. You can’t point to this city or that city and say, “There’s your example.” A lot of our work is to help overcome that inertia. Once you’ve done one, then it’s much easier to recognize that it’s doable.

What is the status of the project?

We pretty much have the legal and business homework, the structure, ready to go. What we need is to nail down exactly where this happens and who is involved, and those two things depend on each other.

One thing I should emphasize is that, in all of our business planning and modeling, we have hardwired a commitment to 20 percent of all surgeries being devoted to safety-net patients. In other words, however many patients come in the door, a fifth of that is what we’re planning on doing without being reimbursed. Those unreimbursed costs, in that proportion, are an integral part of our cost structure.

Who will the eye clinic serve in the beginning, and how will things evolve from there?

The clinic is being designed, initially, to meet the needs of indigent patients in the 10 counties of the greater San Francisco Bay Area, and eventually to expand to be able to cover all of northern California.

This commentary originally appeared on the RWJF Pioneering Ideas blog.

A Model for Equity in Specialty Care: Part II

Sep 4, 2009, 3:48 AM, Posted by Ari Kramer

Yesterday, David Green and David Roe discussed the inspiration and history behind their work to create a self-supporting eye care center in San Francisco that will provide equal service to paying and non-paying patients. Today, they join us to discuss the business model of this project. Visit Pioneering Ideas again on Tuesday to learn about some of the challenges they face and when they expect this operation to be up and running

What is the business model for the new clinic you are creating?

David Green: The notion that this kind of specialty care can be provided in a self-sufficient business model is very attractive and compelling, but also sounds impossible. I think the main obstacle is that by serving low-income people, doctors initially think that somehow they’re going to make less money. What actually happens in practice is that they make more money as the practice becomes more like a hybrid model, where the volumes are higher, costs are lower, and margin is greater per surgery. I’ve seen many instances where the work to reach lower-income strata helps to bolster overall profitability and also the amount of money going into the pocket of those involved. It’s quite counterintuitive to think that if you serve low-income people that somehow you’re going to make more money, but that’s in fact what’s been going on. 

Does any of your cost structure depend on a willingness of providers to make less money?

David Roe: The short answer is, not at all. It depends on efficiency, meaning getting more procedures out of the same number of operating rooms and the same pairs of hands. The other piece of the puzzle, the stage we’re at now, is trying to implement this approach in an actual facility here in the U.S., under U.S. law and U.S standards. One key is doing this kind of surgical work in an outpatient, ambulatory surgery center. For cost reasons, we don’t think it’s doable in a hospital. The second key is that it must have considerably higher volume than a standard profit-making surgery center, and efficiency is what makes that happen.

David Green: In the U.S., some ambulatory surgical environments are nearly as efficient as Aravind and these other programs. The business question is, how do we structure the ownership to achieve two goals? One, to have enough control of the operation and its cash flow to make sure the safety net care happens; and two, to meet the salary expectations of the staff. Whether I look at the salaries at Aravind or the income and salary projections here, it's the same: it's based on whatever the competitive expectation is in that market. That's what we're working out now - bringing in investors with the right expectations about financial return, who also want social return, and figuring out how the doctors can get more income because of a better-run facility, so that even though a certain percentage is going to serve low-income people, the actual overall revenue is higher than before.

This commentary originally appeared on the RWJF Pioneering Ideas blog.

A Model for Equity in Specialty Care: Part I

Sep 3, 2009, 5:42 AM, Posted by Ari Kramer

In San Francisco, the Pacific Vision Foundation is piloting a new model of specialty clinic that is designed to be able to accept and treat paying patients and non-paying patients exactly the same: offer the same procedures, by the same doctors, under the same roof, while maintaining sustainable profit margins. While seemingly implausible in the U.S., this model, which is being developed with support from the Pioneer portfolio, has hundreds of successful examples overseas.

Below is the first of a series of interviews with two of the project’s leaders: David Roe, who trained as a lawyer and has 30 years of experience in public interest strategy and environmental and human rights advocacy; and David Green, an Ashoka fellow, vice-president and a recipient of the MacArthur “genius” award, who helped to create an eye care model in southern India that has been replicated in several other countries. Check back over the next three days to find out what needs to happen for this model to work in the U.S., what opportunities could emerge through health reform, and the potential for replication in other locations and other forms of care.

What is the history and inspiration behind this project?

David Green: Through my work and the work of the Aravind Eye Care System in southern India and other training centers, we have helped maybe 250 eye-care programs become self-financing, where the volume is high and revenues cross-subsidize care for those who can’t pay. (Editor’s note: Last year, the five Aravind eye hospitals performed approximately 250,000 eye operations – 53% of them for free, 22% at two thirds cost, and 25% paying well above cost – and realized a substantial profit.) I’ve been involved with four or five programs in India and two in Nepal. I worked in Bangladesh, in China. In Egypt, we set up the largest eye care program in the Middle East. It now is basically self-financing, where revenues from paying patients support care for those who can’t pay. So it’s a well-proven model.

Over two years ago, Susan Day, chair of the Ophthalmology Department at California Pacific Medical Center,and I came up with the idea of doing a feasibility study on aspects of the Aravind model that we might adopt here in the United States to make eye care more equitable. The huge advantage we started with was that the eye department of San Francisco’s biggest and best-known private hospital and its chairwoman, a very distinguished ophthalmologist, really wanted to see if we could give this a go. So it wasn’t like “build it and they will come.” It’s more like, we’ve got real doctors who do this work every day, who are interested in pursuing this unprecedented business model, where revenues from insured patients will cover care for those who aren’t insured.

David Roe: The core idea is to care for people who can’t afford it – how can you function in a profit-making context, and essentially give away a fair amount of the care you’re providing, and still have it pencil out? This odd-sounding idea has been proving itself in other countries for close to a third of a century.

What are some significant ways that the model you’re advancing differs from standard specialty care?

David Green: What we’re doing is demystifying cost and margin structure. Back when we started, intraocular lenses cost $300. Everyone thought we were nuts to think that with no background in manufacturing, we were somehow going to make these. But an initial feasibility study showed us that we could probably make and sell these lenses for $5 and have it be profitable. Today, the manufacturing arm of Aravind, Aurolab, manufactures these lenses for close to a dollar each. We sell them for $2.

We are also penetrating the true cost structure in a hospital and surgical center. For instance, what assumptions do we want to test to see where we can get our cost structure down, where we maximize the margin from Medicare and other third-party insurers? What type of control, governance and shareholders do we need to have to use profit margin to support care for those who are too poor to pay, or to match up some of our profit margin with appropriate fees that they can afford to pay?

David Roe: I think a lot of what we’re doing that’s innovative will be in that realm of financing.  We’re looking to bring together investors – possibly the doctors but also foundations doing program-related investments, which count against the amount you have to give away as grants each year; or mission-related investments, which are really the same as investing in anything that a foundation would put its principal into. The problem is, these MRIs and PRIs have to stand on a solid business footing. One thing we have to offer is that the business underneath this is very familiar. It’s the business of the practice of medicine and surgery, so when you look at our business plan and where the money comes from, it’s not from some untried idea. It’s from a very familiar kind of business, within a structure that has high social value as well.

This commentary originally appeared on the RWJF Pioneering Ideas blog.

A Model for Equity in Specialty Care: Introduction

Sep 2, 2009, 5:39 AM, Posted by Ari Kramer

Paying patients and indigent patients in the United States frequently have separate treatment options and receive care from separate sources and doctors, with quality and comprehensiveness that too often vary with the patient’s income. This country is in chronically short supply of publicly supported services for people who cannot pay, and even more so with specialty care than with primary care.

The Pacific Vision Foundation– a foundation closely affiliated with the eye department at California Pacific Medical Center– is piloting a new model of specialty clinic that is designed to be able to accept and treat paying patients and non-paying patients exactly the same: offer the same procedures, by the same doctors, under the same roof, while maintaining sustainable profit margins. 

While seemingly implausible in the U.S., this model, which is being developed with support from the Pioneer portfolio, has hundreds of succesful examples overseas. Over the next four days, Pioneering Ideas will feature a series of interviews with two of the project's leaders, David Roe and David Green.  

David Roe trained as a lawyer and has 30 years of experience in public interest strategy and environmental and human rights advocacy. David Green, an Ashoka fellow and vice-president and a recipient of a MacArthur “genius” grant, helped develop an eye care model in southern India that has been replicated in Nepal, Malawi, Egypt, Guatemala, El Salvador, Tibet, Tanzania and Kenya.

Visit Pioneering Ideas over the next four days to learn about what inspired the project, what needs to happen for it to work in the U.S., opportunities that might emerge through health reform, and the potential for replication in other locations and other forms of care.

This commentary originally appeared on the RWJF Pioneering Ideas blog.

What's New on the Pioneer Blog?

Jul 31, 2009, 7:15 AM, Posted by Ari Kramer

Innovative health care delivery, hospital-acquired infections (HAIs) and the OpenNotes demonstration project were hot topics on Pioneering Ideas over the past several weeks.  

  • Sanjeev Arora, M.D., director of Project ECHO (Extension for Community Healthcare Outcomes) shared his experiences and perspective on how to tackle health care delivery issues in rural and underserved areas.  Dr. Arora outlines real examples of how Project ECHO’s system is working in New Mexico.
  • Steve Downs recently shared his thoughts on Open Notes, a demonstration project at the Beth Israel Deaconess Medical Center where patients will have access to their physician’s notes about a visit.  This month, the team announced the full details of the 12-month study funded by a Pioneer grant.  What will be the outcomes from patients having full, real-time access to the notes from their doctors’ visits?
  • In early July, Ramanan Laxminarayan of Extending the Cure co-wrote an editorial that sparked the question: Can best practices in infection control reduce HAIs and save billions of dollars a year? Ari Kramer talked about this and also discussed research by Health Care Without Harm that explores whether alternative cleaning strategies for the health care sector could prevent infection in a way that would be both healthier and friendlier to the environment.  Take a look and let us know what you think.

Keep up with Pioneering Ideas to see what inspires us next month – or join the conversation and add your own ideas. And don’t forget to follow Pioneer Portfolio on Twitter for real-time updates.

This commentary originally appeared on the RWJF Pioneering Ideas blog.

Can a Reduction in Hospital Acquired Infections Cut Health Care Costs?

Jul 7, 2009, 1:56 AM, Posted by Ari Kramer

There is no denying that hospital acquired infections (HAIs) are an expensive drain on the system and impact the lives of an estimated 1.7 million hospital patients a year – killing nearly 99,000 annually. Is it possible that simply instituting best practices in infection control can substantially reduce these infections and save the nation’s healthcare system billions of dollars a year?  Yes, according to an article in last week’s Roll Call by Ramanan Laxminarayan of the Extending the Cure initiative, a Pioneer grantee, and Ed Septimus from HCA Healthcare System.  Laxminarayan and Septimus propose several ideas and incentives, which they believe will reduce the rate of resistant HAIs and control the rise of antibiotic resistance. 

Are hospital acquired infections really the low hanging fruit that will benefit patients and cut health care costs?  Check out the article and then come back here and let us know what you think.   


This commentary originally appeared on the RWJF Pioneering Ideas blog.

Five Questions from Games for Health

Jun 16, 2009, 12:39 PM, Posted by Ari Kramer

After a few good nights’ sleep, I think I’ve finally started to process some of the intriguing concepts I took in at 2009 Games for Health. Newbie that I am, rather than offer my own rudimentary take on what’s happening out there, I want to use this post to just pass along a few nuggets that really made my ears perk up and pose some questions. I’m eager to become more involved in this space, so I’d love to hear any thoughts or nagging questions that other participants or observers took away from this conference. Thanks again to everyone who took a couple of minutes to talk with me last week, and please help me keep the conversation going!

  • Steve Brown, CEO of 3Banana, posed the following as the fundamental design challenge of health games: “Games are for fun and health issues are an unwanted intrusion into our lives.” That could be interpreted as: because games are fun, they are more likely to compel certain people to deal with health issues; or as because games should be fun, people may consider the incorporation of health issues as an intrusion. How can the industry strike the right balance between former and the latter?
  • Tim Chang of Northwest Venture Partners, speaking to a standing room only crowd, offered the VC’s perspective on short- and long-term opportunities for health games: “If a product does not tap into one of the seven deadly sins, it will not succeed.” Is this good advice for developers and other stakeholders? Why or why not?
  • At the second morning plenary, an investor with a strong interest in cognitive games described a recent family retreat where a centerpiece of the entertainment was a Wii Fit. At one point 14 folks were playing together – including an 80-something who was particularly into it. So clearly, exergaming is heating up on many fronts. What other areas of health games may soon be ripe for the mainstream? What internal/external developments must unfold for this to happen?     
  • At one point, there was reportedly a queue out to the door for the “accessibility suite,” where vendors were demonstrating products that allow people suffering different levels of paralysis to play health games. The devices were incredibly cool, but what really got me thinking was a video clip of an interview posing one question to game developers: "Have you ever thought about disabled people who play games?" Undeniably many have given thought to this question, but as you can see from "The One Question Interview" on the Able Gamers website, it seems many also have not. How would you rate the health games world on the accessibility question on a scale of 1 to 10, and what do you think are some of the key barriers and opportunities?

Finally, in addition to being my first real exposure to this field, Games for Health provided me my first opportunity to live tweet from a major event – and I was obviously far from alone. Since last Thursday there have been a combined close to 450 tweets from more than 100 people with the #gamesforhealth and #g4h09 tags – and the numbers keep growing. To find out what really has people talking, check out the streams yourself.

Well that’s it for now. More tidbits/questions to come… 

This commentary originally appeared on the RWJF Pioneering Ideas blog.

Games for Health: A Thought from Day One

Jun 12, 2009, 5:16 AM, Posted by Ari Kramer

Well, now I finally know firsthand what the buzz is about! Day one of this year’s Games for Health conference was a thoroughly enjoyable primer on this incredible field. Having been up since about 4 a.m. in addition to being brand new to this space, many of my notes unfortunately make less sense to me at the moment than I hoped they would. So rather than get into any of the specific topics raised during some sessions I attended, I’ll start and finish this health games post with a brief personal note. 

The one time I might have ever been anything approximating a gamer was during the Atari 2600 days, when like so many of my pals, I sported blistered palms from marathon sessions of Pitfall and Track and Field. During some background reading a few days ago, I came across some telling industry information from the Entertainment Software Association. One statistic that really stuck with me is that the average age of the most frequent game purchaser is not 17 or 18, but 39. I don’t recall if that stat spoke to people buying games for themselves or for their children, but either way it got me thinking. With all the incredible developments taking place in the field today, when my little guy hits the gaming age, I have a feeling his dad is going to catch the bug again, too.

This commentary originally appeared on the RWJF Pioneering Ideas blog.