Istanbul – Two Thumbs Up

It’s hard to believe, but I’ve been in Istanbul for exactly one week. This city is HOT. I mean that in every way imaginable. I arrived in the middle of a tremendous heat wave:

This has been the 10 day forecast every day since I arrived

My first night was spent in a hostel that was nice but in the epicenter of the club scene in Taksim Square. Taksim literally means water reservoir or fountain, named for the reservoir where water used to flow to the rest of the city. It now serves as one of the city’s major hangouts, particularly on weekend nights when it is packed with thousands of people. The main street in this area is Istiklal Caddesi, the ‘broadway of Istanbul’ packed with shops, restaurants, bars, clubs and stores. There are tons of side streets that are full of smaller shops, cafes and back-alley mazes that are lively, bustling and noisy around the clock.

One of the first Turkish traditions I experienced was the meyhane, a chill café-turned restaurant where you can get food, listen to music, play backgammon (which I’ve seen more people play in 5 days than in the rest of my life combined) or smoke nargileh, or hookah.

Turkish Coffee at a Meyhane

I moved into my apartment in Cihangir, which is apparently the artists district. Orhan Pamuk is said to live here, and writers are said to come here to channel his talent (so far…no luck!). Nobel Laureates aside, there are scattered beatniks and hipsters selling paintings and artwork in some of these hilly side streets, but by and large I’m happy to say I feel like I’m really living in Turkey. Few people speak English unless spoken to, and I’ve been living like a local by buying groceries at the local corner store (My first time making peanut butter and rose jam sandwiches) and sipping turkish coffee at a café up the street. On a sidenote, I found yet another reason to love coffee – you can use it to tell your fortune. Fal, or tasseography, involves upending the small mug into the saucer; the murky grounds remaining in the cup are said to tell your fortune. If I’m lucky enough to meet somebody who’s good at this, I’ll try to share the experience here.

Living situation aside, I am definitely a far, far ways from home. I’ve found the language barrier pretty substantial, and while people are generally very friendly and patient, it’s taken my tongue a while to get used to the soft, fluid phonetics of the Turkish language. Finding vegetarian meals is also a challenge, though there are definitely options available – lots of stuffed peppers, rice and vegetable dishes, and of course, plenty of ice cream. (Dondurma is Turkish ice cream made with a special type of flour, so it’s incredibly stretchy and textured. You have to watch this video.)

After a week of living here, I’ve seen a handful of the major tourist spots: Dolmabaçhe Palace, The Bosphorous cruise, Suleiman’s mosque to name a few.  Next week are the major ones: The Blue Mosque, Aga Sofia (aka Hagia Sophia), Topkepi Palace, and the Grand Bazaar. A few of my favorite pictures so far:

The pictureque suburb of Ortakoy, seen from the Bosphorous

View from the underbelly of Galata Bridge, crossing into Sultanahmet

The interior dome of Suleiman's mosque

I’ve been lucky to have an amazing, amazing view from my rooftop balcony at home, and every night so far I’ve spent at least half an hour marveling at the city. At dusk, the sun sets while lights flicker on and the nightlife begins. You can hear the house music and dance beats from the clubs, as well as the muezzins’ calls from various mosques echoing around the hills of the city.

This was just the first few days – there’s plenty more to come including the major sights, my visit to probably the best Turkish hospital in the country, and whatever else happens in the meantime. Thanks for reading!

Bon Voyage

If I knew everywhere I was headed I'd add in the Indiana Jones lines...

If you are between the ages of 10 and 100, you’ve probably thought about dropping everything you’re doing and traveling around the world. I definitely have. I decided to give it a shot this spring, so I finished up school, quit my job, sold my furniture, and bought some plane tickets.

Today I leave the US for Istanbul, where I’ll spend three weeks sightseeing, traveling, eating, drinking, reading, writing, making new friends and getting to know an entirely foreign (to me) culture firsthand.

From there I’ll head to Bengaluru in South India for a cousin’s wedding, where I’ll also spend three weeks sightseeing, traveling, eating, reading, writing, seeing my grandparents, aunts, uncles, cousins and other relatives, and reimmersing myself in a culture that has been a part of me for as long as I can remember.

The last ten days of my trip will be spent in or around Singapore, my old study abroad stomping grounds, sightseeing, traveling, eating, drinking, reading, writing, visiting old friends and being nostalgic, lah.

I’ll be posting pictures, (mis)adventures, musings and other stuff as best as I can. Thanks to HealthGlobe, old friends and the internets, I should be able to get in some face time with hospital adminstrators from around the world for some interesting (to me) discussions about health care abroad. Stay tuned and stay in touch! (I will be sending postcards…if I have your address)

- Naveen

Moonshine and Fool’s Gold

The social media bubble is inflating.

I was out in Boston yesterday with some friends. We wound up on a roofdeck for a while with a terrific view of the Prudential building in front of a near full moon:

While admiring this backdrop we discussed future plans, travel, relocation. Two of the people I met both mentioned they’re headed west in the coming months. One was a girl who had just finished her undergrad degree and was headed to the Bay Area to find a job in in marketing, PR or social media.

When I suggested to her that tweeting, blogging and using other SM outlets were an underrated way of finding connections and landing jobs, particularly in SF, she rolled her eyes. She didn’t have a Facebook or Twitter account and ‘really couldn’t be bothered with the whole social media thing.’ When I asked why she was looking into a social media job if she didn’t believe in it, she responded, ‘because that’s the big up and coming thing now.’

The funny thing is, I had just read an article  earlier in the day about the startup culture out west in Silicon Valley – this scene illustrated it perfectly. For all the young, intelligent talent and promising tech startups out there, there seems to be a general sense of complacency when it comes to tackling new challenges. Instead, so many new businesses seem to be re-hashes of the same few ideas, focused on specific market segments or niche audiences. Even worse, the promise of social media as a true force for making society better is being increasingly glossed over as businesses integrate web engagement into their operations. Things will probably continue down this road as we start inflating the bubble with IPOs over the next few years.

Without getting too cynical, it’s worth noting that the social media startup scene is not without its share of altruism. The second soon-to-be-San-Franciscoan was a guy a  few years out of school who was joining a company to work on ‘a Tumblr clone geared towards people with Autism.’  With so many photoshare clones, check-in plug-ins and recommendation apps, it was nice to hear about a more solution-oriented idea of leveraging social media taking root through a startup company.

I’m sure there are plenty of others who are working on ideas that are going to change the world for the better. Those with true passion and vision are probably too busy working  to be drinking beers on a rooftop, anyhow. The bottom line is, people go where the money is, and it’s well documented that social media is a new goldmine. Launching the next foursquare will be tough – but  improving the design of existing products, apps or programs is frequently a quicker path to entrepreneurial success.

It is always bothersome to see people settle for jobs that they are not really excited about – particularly when they are young and talented (both folks above went to top 20 universities.) The silver lining however, is twofold: One,  new ventures, however unoriginal, are cementing the legitimacy of social media startups as viable ideas through securing funding and paving the way for future innovations; Two, they are helping people gain employment and pumping money back into the economy.

Edit: just saw this on techcrunch.

Sunday, July 10

• A nifty blog post involving a different story about UK journalism. This one covers health care coverage of the NHS in the US among a few other things:

“Media outlets in the UK and the US have something in common—they aren’t much interested in reporting good news and what works. It’s in our journalistic DNA to ferret out the evil, bad, and ugly with the hope that press exposure will change practice.”

• Dan Dunlop writes a nice blog about healthcare marketing. His latest post was a reminder that ruthless provider consolidation – big hospitals gobbling up smaller ones – isn’t just about the gobblers, but about the gobblees. I was wondering: If an underperforming hospital gets bought, it becomes part of a bigger system that can demand lower prices from insurers (see the comment exchange for more context). In essence, isn’t this rewarding poor performance? I guess the bigger question here is, what would happen if insurance companies could consider a provider organization’s business performance in addition to their quality scores when determining payment?  Is this even relevant for a health plan to consider? Medicare does it to some extent – but on the private side these relationships are dictated more by the market.

• A shameless plug for the Health Affairs blog. Jon Kingsdale, in addition to looking similar to Larry David of Seinfeld fame, wrote a very nice piece at Health Affairs about Massachusetts’ reform scene, and why political interests tend to trump common sense reforms (emphasis added):

“Coordination of care and global payment are good stuff, but all systems have their downsides and any reform requires major effort. Why we focus on solving our cost crisis by extremely complex, time-consuming efforts to reform payment and care-delivery is a mystery. After all, it’s not as if Americans use more services than less costly (i.e. all other) medical economies: per capita, Americans see the doctor less frequently, swallow fewer pills and are hospitalized far less often than citizens of other economically developed countries. But we pay 2-3 times as much per unit of service. As T.R. Reid observed in Sick Around the World, most other countries share one simple tool of cost containment—a uniform, administered fee schedule for medical services.

By comparison with global payment and care coordination, there are simpler interventions to right the balance of market power in the short-run: a “Public Option” for Massachusetts; hospital rate-setting, a la Maryland; the anti-trust enforcement that Martha Coakley’s predecessor ignored; and/or caps on payments to providers with out-sized market leverage. (In full disclosure, I recently helped the Mass. Association of Health Plans craft a bill along the latter lines.) But capping prices means capping resources for those who save lives. It is far more PC to talk of re-organizing care and payment reform.”

• I approve.

Coakley Redux: Capitated America

EDIT: My father, a primary care physician of 30+ years, told me this post was way too nerdy for its own good. A better version appears at Healthglobe.

The Attorney General of Massachusetts, Martha Coakley, gained broad popularity in the health policy world last year when she released a report detailing the findings of a comprehensive market survey of providers and health insurers in the state of Massachusetts. Its release coincided with the emergence of a national dialogue about Accountable Care Organizations, and provided timely insight into the issue of market consolidation. I wrote about some of these issues earlier this year.

The original report’s primary finding was that those health care providers who charged the highest prices did not deliver demonstrably higher quality health care. Rather, they were reaping the benefits of an advantageous market position through network dominance, strategic partnerships and by exercising this clout over health insurers. As Massachusetts was the first state to implement universal coverage, this raised a red flag for the rest of the nation, whose collective eyes were fixed squarely on the health reform bill: simply covering more people will not be enough to fix our nation’s health care cost problem.

Global Payment is Expensive

Coakley released a second report on June 22. In addition to building on the conclusions of the first report, it delivers a set of insights about the nuances of building effective financing mechanisms in the current health care market. The six conclusions outlined are all worth reading, but the most interesting conclusion was as follows: “Globally paid providers do not have consistently lower total medical expenses.”

I’d agree with you that the headline “Capitation won’t always save money” is not groundbreaking news. Skeptics have been questioning the viability of global payments in the light of the start up costs of building ACOs as well as the ability of bonus payments to offset the perverse FFS incentives widely in place throughout the delivery system. Coakley adds a layer of evidenced analysis however, suggesting that capitated payments can work, but should not be considered a magic bullet by any stretch of the imagination.

Capitation might work, but there are a quite a few issues to iron out. First of all, any cost savings achieved will need to be reinvested into risk management and care coordination activities. The report contains an analysis of Blue Cross Blue Shield’s (BCBS) Alternative Quality Contract (AQC), which is an arrangement with six state providers to lower the total medical spend over a five year contract period while maintaining high quality scores. In the first year of the program, costs actually increased an average of 10 percent for those doctor groups, compared to 1.7 percent for non AQC providers. Part of this is because BCBS paid more for quality, another reason is because of infrastructure investments. While these increases are built into the program (and should not be taken as a criticism of BCBS’ foray into value based purchasing), they illustrate that before it will save you money, high quality health care can be expensive to set up.

• IT Sidenote – During the recent Health IT Summit in Washington, DC, BCBS of MA spoke on a payer panel about their AQC program. The speaker revealed the sophisticated data exchange model between the plan and provider: Excel spreadsheets that BCBS e-mails to providers, who populate it and send it back. This shows that A) it’s not just about the IT systems, but B) there aren’t these types of compatible, functional software solutions out there yet.

Second, global payment rates can be high; this can potentially deter physician referrals and/or muddle the incentive to bring down utilization. Third, relationships hold a trump card over price – physicians will refer to, and patients will seek care from, the specialists and hospitals who they know and trust.

More broadly, Massachusetts shows us that capitation needs some policy adjustments before being unleashed more broadly in the market. Providers are not used to managing insurance risk; capitation may spur further consolidation as practices try to safeguard against unpredictable costs by applying upward pressure to prices. Also, specifics of capitation need close monitoring – for example, if provider group A sets a budget of $200 per member per month but spends $205, and provider group B sets a $250 budget and spends $245, Group A may get penalized even though they are spending considerably less than Group B, who may get a bonus for “saving money.” As always, the devil is in the details.

Coakley is saying that as health reform moves forward, it is not the policy ideas that will drive success. It will take concerted efforts and hard work from all stakeholders – officials, providers, payers, patients, who all remain ensconced in their own worldviews. We can all agree to teamwork and cooperation as general platitudes – but the report suggests that a halfhearted reform will likely lead to further market inequity – meaning even further price and quality variation (emphasis added):

“We should not expect to fix the system by shifting the risk and responsibility for efficient care management from health insurers to providers through Accountable Care Organizations (―ACOs‖). A shift of payment methodology by itself is not the panacea to controlling costs. Moreover, the information we reviewed shows that the shift to global payments without other fundamental changes may not only fail to control cost, but may exacerbate market dysfunction and market inequities by establishing widely different per member per month rates based on historic pricing disparities.”