Primary Health Care

Today’s New York Times had an interesting article featuring Iora Primary Care, a startup with a business model more like Starbucks than your current primary care facility (except that you can’t walk in off the street and buy a cup). You can read the article, A Starbucks for Medicine, in the Business section.

Iora is a subscription service that only works with employer partners (not with individual patients), so your company has to buy in. The value proposition to the partner is lower costs that are more or less fixed. The value proposition to the patient is more individualized customer service, and, sometimes, service that goes well beyond what we have come to expect from primary health care providers.

One of the features of their model is a “health coach”, a much lower cost person than any of the medical staff, whose function is to help the patient with not-necessarily-medical, peripheral issues, such as transportation, diet, exercise and advocacy—at least within the practice office.

Iora is a startup, and there are still many issues to be resolved. They aim for a large number of practices instead of the one, or a few, that most innovators expect to have. Some things in the model scale well, such as knowing what to stock when a new practice opens. Some things scale poorly, such as the CEO interviewing most of the new staff. It isn’t clear yet whether they will actually be able to reduce costs for employers (mostly by trying to provide care that will head off trips to the hospital and ER, I think). On the other hand, the kind of care described in the article seems attractive from the patient point of view, and finding ways to move in that direction has got to be good.

From the provider’s point of view, they aim at far fewer patients per provider, allowing the provider more time with each patient. And, (here’s a note for you Victo) they have a staff of about 20 engaged in building their own proprietary EHR system. On the one hand, that means that individual providers will have more input into how it works, and more influence when it doesn’t. This could also be a cost reduction idea—EHR/EMR systems are already a very big business. On the other hand, as the number of small practices increases, this effort may be hard to sustain—another area that doesn’t scale particularly well.

On the surface, Iora looks like a good idea. I currently get primary care through a corporate entity. While I like and respect the providers and other staff, the corporation stands in the way of getting to them and pretty much controls what I get from the providers. I admit I haven’t yet had much interaction, and so far, I’m glad because the interactions have been painful or at least irritating. I’m interested to hear what others of you think of the Iora idea or other innovative delivery ideas, particularly those in the health care industry.

Silence

A few days ago, Victo Dolore published Étude to Silence. It fit my emotional state exceedingly well since I had just returned from a trip that embodied silence in several forms. This post is a few variations on the theme of silence.

Victo and several commenters talked about being alone in the car and being uncomfortable with the silence that occurs when you don’t have your usual distractions–the children, the radio, music from your phone, or whatever. On the surface, to my literal little mind, given the actual meaning of the word “silence” as being without sound, this is a strange interpretation, since the car is a pretty noisy environment. But, it isn’t a lack of sound that produces the “silence,” it is the lack of distractions. The background noise in the car doesn’t count. We don’t hear that, and if we don’t hear it, it isn’t there. Without distractions, we are in silence.

I live and work at home in a variant of the silence of the car. There is no radio or tv in my workspace, no music from a computer player or Pandora; there is only fan noise from lots of computer equipment. But, mostly, I don’t hear that. I don’t listen to it, and if I don’t listen to it, it isn’t there. Then, there is the tinnitus. I don’t listen to that either, so I work in silence. For me, this “silence” is the best work environment. I could not work with audio distractions because it would be––distracting. When I play music, I find myself listening to it.

Last Saturday, the men’s ensemble I sing with performed a concert at Ghost Ranch in northern New Mexico. Ghost Ranch is remote: 15 miles from the nearest village or small town; an hour or more from anything you could describe as a city. A place of great beauty and great silence–no cell phone coverage with my carrier; no road noise; a noisy airplane 35,000 feet away every few days. At night there is no visual noise from city lights, and you can see so many more stars than in the city. One of the great beauties of the earth available only in silence.

One of the pieces we sang was Loving Kindness by Stephen Paulus. It is a setting of a text adapted from the Digha Nikaya that begins “Put away all your hindrances, let your mind full of loving kindness pervade one quarter of the world…” You can read the text here. This is not a prescription for passive contemplation–these are acts that can only be accomplished with effort in an environment of silence.

Sunday morning we sang at a Benedictine monastery that observes the rule of silence. It is completely off the grid, 15 miles off the paved road on the side of a river valley in a place that is amazingly beautiful. They have a small church–20 visitors at their Sunday morning mass is a crowd. Our ensemble sang after the completion of the mass in a room so filled with smoke from the incense that you could barely see across it. The result was a sublime interruption of the monks’ normal silence. Combined with the surpassing beauty of the location and the chill of the spring morning, it was a perfect experience breaking the silence in just the right way. For the monks, it is a small break in the silence–not an end to it. It allows the monks to return to the silence with greater appreciation.

So, here are a few variations on the theme that highlight silence as something to be sought, rather than something to be avoided. Let the silence itself direct you to beauty. Let your mind fill with loving kindness.

Loving Kindness

The men’s ensemble I belong to included a beautiful composition for male chorus by Stephen Paulus entitled Loving Kindness. Its text is adapted from the Digha Nikaya, a scriptural text of Theravada Buddhism. We should all live thus.

Put away all your hindrances,
let your mind full of love
pervade one quarter of the world, and so too the
second quarter, and so the third, and so the fourth.
And thus the whole wide world,
above, below, around and everywhere,
altogether continue to pervade
with love-filled thought, abounding, sublime,
beyond measure, free from hatred and ill-will.

The Race is O’re…

DC-RnR-2015-medalThe race is over, and we’re back home. We left Thursday for the DC Rock and Roll Marathon and returned today.

The race was Saturday morning, and the temperature was perfect, in the low 40s. The rain, however, was not perfect. It had been raining since before midnight and continued until at least noon. By the end of the race at RFK Stadium, we were all soaked and pretty cold–the ambulances running from the medical tent at the finish were unusually busy.

I haven’t examined my splits in detail, but I was ahead of schedule at 5 miles and still on schedule at 10 miles. I finished about 4 minutes behind schedule, so I had to have lost that time in the last 5 k. I didn’t feel bad, and there were no notable terrain features. The rain got a little worse and the wind came up, and I guess that slowed me down (oh, Ok, I suppose the milage had some effect, too).

Surely the weather took some toll, and being somewhat under prepared had an effect, but overall I was still happy with the race. The worst part was standing around in the cold rain after I finished waiting for my Muse, who walks, to finish her race. There was almost no shelter and close to 30,000 people to be accommodated. There were lots of crazy folks there that day. And then there was standing in line to get into the metro station and trying to ride with a waterlogged metro card. When they are that wet, they don’t go through the machines.

Our schedules are pretty busy for the next few months, so we may not do another half until September. But, maybe we’ll try to find something close to here in June.

Aside from the miseries of the race itself, the weekend was wonderful. Our main purpose in going was to celebrate the return to health of Middle Daughter who has spent the last year dealing with breast cancer. We took Older Sister with us, and Brother lives in the District, so we had a glorious celebration. Saturday was, of course, Pi-day (3.14.15) so Daughter-in-law made pie and we all got together for that at the end of the day. Sunday was more family time. The ladies went shopping for running gear, and Brother and I played with the granddaughters.

“Cancer free”–a wonderful reason to celebrate!

 

Pictures of my Heart

The front page of this blog has four pictures that show places I’ve been, but more importantly (at least to me) they give some insight into me. That is what this blogging stuff is all about, right?

The first picture is a place called Ward Lake. Ward Lake is in a state park north of Ketchikan Alaska. I took this after finishing a 10k trail run in the rain. I love this picture. It is so peaceful. It is so green. I have painted this scene several times, and will paint it again—somehow I don’t ever manage to get it quite right. It isn’t that the painting doesn’t look like the subject, but that  the painting doesn’t quite capture the feeling of repose that I remember. I would like to go back and experience the place again, although I probably never will. As a contrast to the peacefulness of the green, I especially like the drift of little yellow flowers on the bank. It speaks of optimism in the return of spring.

The second picture is Beijing at night. My Muse and I went to China with our local Chamber of Commerce, so I guess it was a business trip. I should probably go back and amend my tax return for that year. This was taken while waiting for the bus after dinner one night. Beijing, of course is a large city with all the expected hustle and bustle (well maybe more of that than we westerners expect), and Lots (and Lots) of people. We were taken to large restaurants that serve Chinese food that westerners would eat without asking too many questions. I think it was probably because we were Americans that one entree every night was French Fries. China is one of those places that you cannot adequately learn about by reading, or even by listening to someone who has been there. You have to go there and see it yourself. I remembered those pictures from the ’90s of a thousand people on bicycles waiting for the stoplight to change and I expected to see that. No. That’s all gone. Everybody has cars. Imagine a city of a million cars, all driven by people with almost no experience. That is what “chaos” means.

There is a concept in Celtic spirituality of places where the veil (between earth and heaven) is thin. Ghost Ranch, in northern New Mexico, is one of those places. This is a summer sunset—frequently spectacular. The feature at the left is, appropriately, Chimney Rock. The area is full of high mesas with steep cliffs of red and yellow rock. The ranch headquarters is in a canyon surrounded by these cliffs and looks west across a lake to mountains 20-30 miles away. The veil is, indeed, thin, and once you have settled into the rhythm of the ranch, the place itself encourages, perhaps even demands, mediative spirit. We spend a week there every summer, and just returned from spending yesterday and last night there. Even one day is enough to reset your clock.

There are a few other places I have been that appear to be thin places—places where the spirit feels the nearness of heaven. Another such place is St. David’s in southwest Wales. Small village, lovely old cathedral, but most of all the feeling that it is a sacred place and has been since long before these “modern” fixtures were put on the land. You may have been to places where you felt that there is something special here; this place is not like the rest of the world. Think back and find those places and tell me about them.

Thin places can also appear because of events that happen there. My Muse plays the harp and spends much of her time playing for hospice patients. I haven’t been there with her, but she says that the veil is thin at the time that someone passes out of this life.

The final picture is the Cliffs of Mohr on the west coast of Ireland, south of Galway Bay. This is a place where peace and ruggedness collide. There is a strong sense of remoteness even though the area is developed for sightseers and there are lots of people there. I read one travel writer who whined that, while visiting the cliffs is free, it is remote and there is only one car park for which you are charged 6€. They thought that demanded a boycott. What a mistake that would have been. I didn’t feel it as a thin place, but rather a place of power: 600 foot cliffs falling straight into the ocean; a pretty constant wind. The place is immense, and you are tiny. Strength and power abound.

So, you see 4 pictures. One representative of life in a dense urban area, and 3 exuding remoteness, peace, and the beauty and power of nature. You have some idea of where my heart lies.