December 1, 2023
Dear Interested Readers,
Something New For You To Check Out
If you are reading this letter on a computer, look to the right side of the page and click on “References.” If you are reading the letter on a cell phone, scroll down to the end of the letter past “Elizabeth McCarthy’s Story” and click on “References.” Alternatively, click here and then click on the download or view option. Any option you choose will lead you to a PDF entitled “Transforming Patient Care: Quality, Innovation, Social Responsibility.” It is a great document with pictures and testimonials from people like Don Berwick, Joe Dorsey, Glenn Steele, and others who were part of the history and development of Harvard Community Health Plan, Harvard Pilgrim, and Harvard Vanguard Medical Associates.
The original printing of the document was distributed in November 2008 when we were celebrating the tenth anniversary of Harvard Vanguard and approaching the fortieth anniversary of the launch of Harvard Community Health Plan. The document was produced by a very talented woman, Roanne Weisman, who has written several interesting books about healthcare and the patient experience. In 2003 she had written Own Your Health: Choosing The Best from Alternative & Conventional Medicine. I wrote an “afterword” for that book entitled “A Call to Action: Comments from an Allopathic Physician.” My comments were based on what I had learned from being her physician for many years.
As she describes in the book, she required a mitral valve replacement after a lifetime of Marfan’s syndrome and severe scoliosis. Her father had died in his mid-thirties when his aorta ruptured. Her surgery went well except for the fact that when she awoke she had experienced a massive embolic CVA to her non-dominant middle cerebral artery that left her left arm useless and compromised her ability to walk. The neurologists at the Brigham told her that the damage was permanent and that she should learn to live with her disability.
She did not accept their pronouncement and began a multiyear, self-designed program of recovery using many treatment modalities like Pilates but also other less utilized techniques that can only be classified as “alternative” management. During her recovery, she battled insurers that refused to cover many of the treatments that she thought would help. In retrospect, she was vigorously stimulating the benefit of neuroplasticity. In the end, she got back everything she lost except the excellent vibrato she could generate on her violin. She took up the French horn as a second instrument. Click here for an informative review of the book which is still available twenty years later on Amazon.
By 2008, I was in my first year as the CEO of Atrius and Harvard Vanguard and wanted to regenerate some of the lost enthusiasm for our mission. As you will read later in this letter, we had been through some pretty tough times that had left scars on our battered corporate body. I had been doing my own research into the origin of HCHP with the help of Barbara Ebert, the widow of Dr. Ebert. On a very memorable day, the two of us had gotten permission to go into the “bowels” of the Countway Library where his papers were stored in large locked boxes and could only be accessed with special permission that took several weeks to obtain. It seemed like what we had learned should be put together in a document for posterity, Roanne came to mind as the perfect person for the job.
As I have been describing much of the history of HCHP and HVMA/Atrius in my quest to demonstrate how moral sensibilities can arise and also be violated by interactions within a medical community, it occurred to me that the document, like Dr. Ebert’s Kate McMahon Lecture, belonged in the reference section of the website. I hope that you enjoy looking at it.
Leadership Transitions Attempting To Avoid Disaster
On January 1, 1998, things were looking good for Harvard Vanguard. Finally, we were the captains of our own fate. One objective of leaving Harvard Pilgrim was to be free of losing patients whose employers dropped Harvard Pilgrim from their health care options. To achieve this objective we had to negotiate relationships with Blue Cross, Tufts Health Care, Aetna, Cigna, and other insurers in our area. We had always been capitated and had almost none of the infrastructure required for negotiating those contracts or the billing systems to do fee-for-service business if fee-for-service contacts were the only avenues our patients had to come to us.
We were starting from scratch. We knew it would be hard work. I was confident that we would be successful because Glenn Hackbarth was the right person for the job. Not long after the work started, it became clear that we needed to be more specific about reporting relationships, roles, and responsibilities.
As I mentioned last week, as long as we were the Health Centers Division of Harvard Pilgrim we enjoyed an equal partnership between Glenn and Jennifer Leaning, our Chief Medical Officer. As a stand-alone 501c3, Glenn emphasized that we needed an accountable relationship between our CEO and the board which meant that technically the Medical Director needed to report to the CEO. When the board concurred with Glenn’s recommendation, Jennifer resigned to pursue the fabulous international opportunities that would lead to her professorship at the Harvard School of Public Health.
With the board’s approval, Glenn quickly promoted another very knowledgeable physician, Dr. Robin Atlas, to the position of CMO. Prior to assuming the role of CMO, Robin had been our very capable Chief of Medical Specialties. She was widely respected for her management skills and was loved for her fabulous sense of humor. With our new team in place, I felt that all was well.
Glenn and I developed a regular meeting schedule. I would come to his office every Thursday morning and we would discuss our business plans and developing initiatives. I thought that all was well, but in just a few months things changed. He surprised me one Thursday morning when I arrived at his office. After I sat down, he announced that he wanted to retire. I was relieved when he said he would stay until we found his replacement.
Glenn was in his early 50s. The men in his family died young, The year before he had suffered a serious accident while skiing in Colorado. He told me he needed to spend more time with his family and planned to move to a home in Bend, Oregon where he could ski and play golf on the same day. He planned to rest for a year and then decide what was next for him and his family. I was flabbergasted.
The board got busy. We interviewed several national search firms, made a selection, and began our search. Not long after we began our search, I was reading the Boston Sunday Globe when I saw the picture of Charlie Baker on the cover of The Sunday Globe Magazine. The article was entitled something like “What’s Charlie Baker Going to Do Next?”
A few years earlier, I had enjoyed a brief encounter with Baker. The first Chairman of the Board of the newly merged Harvard Pilgrim Board was Allan Morse. He was a banker who had been an early supporter of HCHP and had been on the HCHP board for many years. I knew him well. Allan had also been appointed as the state’s banking commissioner by Governor William Weld. Weld had also appointed Baker as his Secretary of Health and Human Services. Allan suggested that Baker would be a good speaker for one of the first meetings of the new Harvard Pilgrim board. Baker was a rising star in Republican circles who had a great pedigree. His father had served in the administrations of Ronald Reagan and the first President Bush.
I can remember Charlie’s presentation as if it occurred yesterday. My memory begins with him striding into the board room when he came up on the agenda late in the meeting. He appeared very relaxed and exuded confidence. At six feet six he was a commanding figure. He had a big boyish smile and radiated uncommon confidence. He had no notes, no slides, and no handouts. He just talked and answered questions with ease and confidence as if he was having a personal conversation with each of us. What he said made a lot of sense to me even though I am a yellow dog Democrat. I was saying to myself, “What’s up with this guy who has spent a lot of time at the conservative Pioneer Institute?
In my mind, I keep a short list of people to whom I have been exposed who are so exceptional that I imagine that they must be from another planet. Charlie immediately joined that short list that included Dr. Ebert, Joe Dorsey, Don Berwick, Jack Russell who was my favorite college professor, and just one or two others whose intellect and communication skills seemed otherworldly to me. Since that day in 1995 when Charlie made the list, I have only added Barack Obama and Atul Gawande to the club.
Between early 1995 when I first saw Charle, and the Sunday when I saw his picture on the front of the Globe Magazine, Charlie had been running Massachusetts as Governor Weld’s Secretary of Administration and Finance. In essence, the Secretary of Administration and Finance is the COO of the state. The article stated that Baker was interested in working in the healthcare sector. He had been talking to a hospital on the North Shore.
The “head hunter” we had hired to help us with our search was a fabulous woman, Carol Emmott, who had served in Jimmy Carter’s administration. At the time I did not appreciate that she was becoming a legend. I did know that she had placed the CEOs and other corporate officers at some of the nation’s most impressive healthcare institutions. She was to become a person to whom we would turn time and time again over the next decade when we needed to make an important hire. During those engagements, I frequently spoke with her when I needed candid advice from a wise counselor. A few years ago Carol died after a short battle with cancer. There is now a Carol Emmott Foundation that seeks “to achieve gender and racial equity in healthcare leadership.”
On the Monday after reading the article about Charlie, I called Carol and told her what I had read. I asked her if she thought Baker would be a good candidate for our job. If so, would she find out if he was interested in our job. She said that he would be a great choice, and she would find out if he was interested. Shortly afterward, she called me back and said that Charlie would meet me for coffee at a little shop on Beacon Hill across from the State House. He took our job.
Charlie Baker is an amazing force. In short order, our future seemed very bright except for one thing, Harvard Pilgrim was being led down a road of financial disaster by a leadership team dominated by executives from Pilgrim after Manny Ferris retired. If Harvard Pilgrim were to fail, we would probably also fail because more than 95% of our patients were still coming to us through our contracts with Harvard Pilgrim. We were still in the process of developing relationships with other payers and developing the infrastructure we needed to do fee-for-service billing. Our joke was that we did a lot of “free-for-service” practice.
Along the way, after the merger and before Vanguard exited Harvard Pilgrim, I had wrangled my way onto the finance committee of the Harvard Pilgrim board. I had remained on the Harvard Pilgrim board after Vanguard separated, and there were Harvard Pilgrim members of the Vanguard board. I became very concerned about our medical loss ratio and expressed myself at meetings of the finance committee. I was convinced that we were selling health insurance at a price that was less than the cost of care plus our administrative expenses. We had no viable strategies to reduce our administrative expenses through greater efficiencies. We were headed toward big losses, and everybody just kept pointing to our growing market share..
The only person who shared my concern was John Parker, the CEO of Dedham Medical Group, who was also on the finance committee. John and I became so expressive of our concern that we were invited to leave the finance committee. I was reassigned to a medical quality committee where it seemed my expertise would be a “better fit.” After we hired Charlie and he began to try to work with the Harvard Pilgrim executives, he shared my concerns. We began a conversation about how to address the problem.
Charlie was a great success within Harvard Vanguard. His style and openness were immediately embraced. Everyone felt that with Charlie’s business experience, we were on the right road. As time went on, there were several other members of the Harvard Pilgrim board including Allan Morse, the chairman, who began to share the concerns that John Parker and I had about our deteriorating financial position as we “bought market share.” Informal conversations began about what we needed to do to avoid a disaster when the management team said there was no problem.
In my conversations with Charlie and others, it became clear that if Harvard Pilgrim failed, Vanguard was probably “toast.” A secret meeting of the Harvard Pilgrim board was called. We met at the offices of one of the board members in Boston’s financial district. Charlie was invited to join us, but he was asked to wait in an outside room while decisions were made. After a discussion, the decision was made to turn the fate of Harvard Pilgrim over to Charlie as its new CEO.
In retrospect, it was a good decision that was almost the end of my career as a healthcare leader at Harvard Vanguard. The HVMA board was furious with me. They loved Charlie, and by then they had no love for Harvard Pilgrim. They wanted to know how I could be a part of giving up our great CEO. I apologized for acting unilaterally without their approval. I tried to explain that I felt that we could not risk debating such a leadership change without undermining its potential success. I had felt that something needed to be done quickly if Harvard Pilgrim was to be saved. I tried to get them to agree that If Harvard Pilgrim failed, our future was bleak. In a way pushing Charlie into the position of CEO of Harvard Pilgrim was a “Hail Mary” maneuver. As painful as it was to lose Charlie, I argued that giving him to Harvard Pilgrim was our best option. The Vanguard board disagreed, and they promptly fired me as the chair of the Vanguard board.
For the next three hours, they debated various things. I am not sure exactly what was said because I had been invited to leave the room. I felt very upset, but what could I do? I walked around in a daze for a while trying to process all that had happened in just a few hours. Perhaps, I had been part of the right action but participated in the wrong way.
I was surprised when I got a phone call asking me to return to the boardroom. The board was still angry, but they had not been able to decide on a new chair, I apologized some more for excluding them from the decision to give away our CEO, and then I was allowed to resume my role as chair while accepting a short leash and promising never to act again without involving them, no matter how risky the situation might be.
As the dust from a difficult day settled, I hoped that the worst was behind us, but it wasn’t. Charlie worked hard to turn things around, but he did not have enough time. Harvard Pilgrim had lost more than 100 million dollars, and by the end of 1999, it would be in receivership despite Charlie’s heroic efforts to keep it afloat.
Baker’s performance as the CEO of Harvard Pilgrim in receivership is a remarkable story. Despite working long hours and making some very courageous decisions, he could not keep Harvard Pilgrim from going into receivership because too much damage had been done before he was given the reigns, but with his connections and great abilities, he was just the man to lead Harvard Pilgrim out of receivership. In the long run, we all survived because of Charlie’s efforts. How it all happened and what we did after losing Charlie will be next week’s story.
The Sun Is Low And The Light Is Different
Today’s header was taken from the same spot that I have taken several other headers over the years. I like that the same spot yields a different picture at different times of the day, in different light, in different weather, and in different seasons. Sometimes from this spot which is about 1.3 miles into my usual walk on Little Sunapee Road, I can’t see Mount Sunapee because of low clouds or foggy mists. The mountain lies less than ten miles to the West.
If you look closely, you will see the top of the mountain, and you will be able to discern that the ski trails are covered with snow. The season started yesterday! It’s been a few years since I last braved the mountain. I grew up where most of our ice was in tea glasses and you could make it through “winter” with a sweater and light jacket. Snow was an event that occurred every few years with its duration measured in hours.
I didn’t put on skis until 1981, and then I quickly lost my right ACL to rental skis on an icy trail at Stowe. Without an ACL my right knee is still my “good knee” since old football injuries to my left knee have left it bent and devoid of any cartilage. I resist surgery since I rarely have any pain in either knee and can hobble along as I am. Maybe someday I’ll do it, but I am not ready yet.
Yesterday evening was another treat. We had very cold weather Tuesday and Wednesday with the temp staying in the 20s for more than 48 hours. When I awoke on Thursday morning I was delighted to see that my end of the lake was completely frozen. Even though the temp reached 40 yesterday afternoon, the ice persisted. The reflection of late afternoon light from a setting sun on the smooth new ice makes a pretty picture. It will be a while before I take a walk on the ice.
Most of my walks are in mid to late afternoon after the “business of the day” is over. I move much slower now than just a couple of years ago. I amble along at 23 to 26 minutes a mile. If I am walking with someone else like one of my visiting sons, I will turn on the afterburners and get under a twenty-minute mile. It is hard to believe that I once could run a marathon at a pace faster than seven minutes a mile. Once, in 1980, I ran a 10K race at a pace of less than six minutes a mile while carrying a beeper. I was on call. I was lucky that no calls came my way until after the race.
Time collects its tolls. I am just happy to say that I am better than I was six months ago. A summer of swimming and biking, coupled with a steady course of Pilates and some recent PT and dry needling gives me the hope that I might get better yet and continue to avoid surgery. Who knows? A fifteen-minute mile may be in my future.
Walking late in the afternoon and late in the fall is interesting. The sun is low, the light is different, and the darkness of night comes suddenly, and not gradually, as it does on long summer evenings. The low angle of the sun gives an effect that is hard for me to capture with my iPhone camera, but it is a joy to behold, and moments, like I tried to capture and share with you, add to my conviction that I am in the right place.
I hope that where you are this weekend there will be some moment that convinces you that you too, are in the right place.
Be well,
Gene
