I don't know about you, but the first week of September always feels like getting a bucket full of cold water dumped on my head. The kids are back in school. A lot of people are still walking around in that post-Labor Day haze thinking, "Where did the summer go? Can it really be September?” And there's no holiday break on the work calendar until Thanksgiving.

So, as we ease back into reality, let's dip into the H&HN mailbag and see what's been on your mind.

As always, Ian Morrison had a thought-provoking look at a hot topic. Earlier this week, Ian analyzed the exit of health systems from the Pioneer ACO project and what it means for health care as a whole.

Sue Sutton wrote:
The retrospective review of the early ACO pioneers will only help all of us as the new payment systems — Medicare, Medicaid, private insurance — evolve. Thank you for the nice summary Ian.

My blog on the fact that consumers are still very confused about the ACA and insurance exchanges elicited the following responses:

Melissa Taylor:
I feel that the ACA's purpose is to focus more on preventive care. If more individuals utilize their primary care physicians, this could prevent chronic illness, which will keep hospital admissions down.

Gayla S. Sleeper:
I am not surprised at the numbers. In Texas there has been great political opposition to the ACA. Our governor, Rick Perry, chose to opt out of providing the exchange. Fortunately United Way of Tarrant County, which received a $5.9 Million grant to form the largest educational and enrollment group in Texas, the Consumer Health Insurance Marketplace and Education Services (CHIMES), recently advertised for 80 navigators. That gives them one month to train and send forth.

Texas has 4.9 million uninsured. From the Fort Worth Star Telegram, posted Thursday, Aug. 22, 2013. In my opinion it is time to put politics aside and educate Americans instead of trying to make sure it fails!

David Ollier Weber undertook a two-part series looking at ways health care organizations can battle physician burnout. In part two, Weber argued that "temperament and training, while often making physicians their own worst enemies on the psychological firing line, might also be their best weapons for remaining happy warriors."

Dike Drummond, M.D., responded:
Thanks for posting this David. What a great spectrum of people working to help with the burnout epidemic!

I love Rachel Naomi Remen's quote and would add a little to it ... "A calling is work in which you get to express every day the deepest values you have as a human being."

The key is a job that is a calling at the same time — being able to have your calling support you and your family in having a life. Then the challenge is understanding how to continue to offer your gifts / deepest values / empathy / calling without burning out in the process. There is nothing more tragic than a gifted physician who is unable to give to the patient because they are tapped out. All of this is avoidable. The key health care innovation of our time is the creative destruction of burnout. This is partly filling an educational hole about the "disease" and building a culture that emphasizes the humanity of the people on the front lines.

And Marsha W. Snyder, M.D., said:
Thank you for this wonderful series of articles, David. I am a physician and a psychiatrist who has specialized in physician burnout and wellbeing for over 20 years. I also have master's degree in applied positive psychology, am conducting research in positive health as a tool in physicians' health and wellbeing, and have a textbook on that topic which will be published in the near future. Statistics tell us that burnout starts as early as the first year of medical school, and, there are many aspects of medical culture that feed into this trend. If we truly want to reverse this trend, we must have the courage to look honestly at our own culture and make positive changes. One small but significant example is that ours is a culture which encourages competition, getting ahead, and being the best. Therefore, there is little, if any camaraderie in medical school or cooperation among faculty. In fact, the rate of bullying and abuse reported by medical students (mostly verbal) approaches 80 percent. Positive relationships, however, are a key ingredient of positive health and wellbeing, and are associated with longevity, decreased morbidity, decreased anxiety and depression, increased capacity to learn, and overall flourishing.

Finally, Michael Alkire's column about the need for health care organizations to turn into life-care companies caught the attention of David Green, who wrote:

One area of life-care not discussed is the relationship between the hospital and long-term care facilities — nursing homes and assisted living. Much could be accomplished by closer working relationships where LTC staff train hospital staff on addressing the life needs of LTC residents, and hospital staff prepare LTC staff to deal with issues that could otherwise require hospital admission.

And from Anthony Cirillo:
Maybe it's in the name — Heartland — because it takes a lot of heart and courage to move to a lifestyle company. We marketers talk about this all the time. We must get providers out of the fee-for-service mentality. Sadly, what gets paid is what will be chased. Even with patient experience there is a nuance between satisfaction and experience. Hospitals are chasing satisfaction scores and often that can actually harm the total experience. We have heard it said time and again — do the right thing, follow your heart and the rewards will come. Maybe that is naive. But there is a certain amount of risk and hope needed in the health care equation these days. And don't forget the other parts of the continuum that can be invaluable partners in this journey. Thanks Mike.

Thanks for all of your comments. We'll open up the mailbag again next month.