20 November 2015

Dear Interested Readers,

Inside This Week’s Letter

Welcome to the first letter of the third year of Volume II of these weekly letters. The first section of this letter is a brief trip down memory lane that reveals that the scenery has not changed much over the last two years.

The second section springs from a comment made by an “Interested Reader” in response to last week’s letter. You might remember that the Green Mountain Care Board has decided to kick the can forward by continuing FFS as the mechanism of specialty compensation. That fact caused one thoughtful reader to write me about his frustration with the difficulty rationalizing differences in compensation between specialists and primary care physicians. There is a lot of emotion and a lot to think about in this conversation. The problem it addresses is a real barrier to overcome on the road to the Triple Aim Plus One. It is my hope that the conversation in this section will stimulate many others to join the discussion. This is a specific request to you.

I have struggled this week with the raw wound we all feel in the aftermath of the terrorist attack in Paris after learning for sure that the Russian Airplane was brought down by a bomb planted by ISIS. A brief essay from my son asks why we focus on what makes us different when we share so much. Then there was the game with the Giants.

I am writing to you this week from Sayre, Pennsylvania where I am attending the board meeting of Guthrie Health. I have been a member of the Guthrie board for almost five years and have great pride in its accomplishments and service to the “two tiers” community of North Central Pennsylvania and South Central New York that is snuggled in under the beautiful Finger Lakes Region. Guthrie delivers care to people as far to the east as Binghamton, north to Ithaca, further west than Corning and south down the Susquehanna toward Geisinger’s service area. I also know how real the issues are that I write about each week because my connection to Guthrie gives me an insider’s ability to see how one health system is contending with the preparation for the new world of value based reimbursement and the confusing world of APMs (alternative payment methodologies). It is not an easy task to move away from years of success in FFS, even for a system as blest with assets as is Guthrie. The header this week is a shot of Robert Packer Hospital, the largest of the four hospitals of Guthrie Health. It is frequently identified as a “Top” hospital in its categories by the “100 Top Hospitals” listings.

I hope that you will not forget to check out strategyhealthcare.com. On the site you under the “Elizabeth McCarthy” story you will find a tab on the right labeled “Reference Materials” where the two older letters that I reference this week are also posted. You may also access them by clicking on the links in this letter when they are mentioned. Have you suggested to a colleague that they check it out and sign up for these letters at the same time?

Starting Another Lap Around The Calendar

I have always enjoyed birthdays, anniversaries, New Year’s Day and other celebrations of another lap around the annual track. At my med school the students referred to themselves as HMS 1 or HMS 2 and so on, to signify how far they had come or how far they had to go. I have retained the concept throughout my career. I am proud to be and call myself an HMS 49. There have been 48 laps completed since that first day of med school. Unlike birthdays, we include in the count the lap that we are running; not the one last completed.This letter is the start of the third consecutive year of Volume II of my letters. Volume I was the 298 letters written to the Atrius community from February 2008 when I became CEO of Atrius Health and Harvard Vanguard, through the last letter on October 25, 2013 when I passed the day to day leadership responsibilities to others and began preparation for my retirement at the end of the year.

I thought with that last letter that my writing days were over. As you will read below I was wrong. I picked up my pen (actually, opened my laptop) three weeks later to begin Volume II with these words.

22 November 2013
Dear Interested ReadersVolume III was amazed and quite shocked when at the recent Harvard Vanguard awards dinner I was
presented a bound copy of my letters to “Atrius Health and other interested readers”. The
tome looks something like the old library sized dictionary that sat on its own reading table in
my father’s study. It dwarfs the reliable Physicians Desk Reference that once had a place in
every practitioner’s office or made a good doorstop. All in all the 298 letters are printed on 1097 pages. Perusing them I sometimes wonder, “Who wrote this?”

Shortly after I had written my farewell letter, John Gallagher my friend, colleague and mentor
in all things Lean, asked me if I was done. His question surprised and challenged me since he might as well have asked me if I was dead. To my own surprise I heard myself answer, “No, I don’t think I am done!” (Thinking, “Not dead yet”). John had asked me the right question and as I reflected on his query over the next several days I realized that I was not done. I was in transition and I needed to pause for a few weeks to collect my thoughts and look around. I also realized that the weekly exercise of writing added an important dimension to my life that I did not want to give up.

When I write I am forced to be more observant and more reflective about what I hear and observe. Far from being a burden, my weekly exercise sustained and informed me. Writing was as important to me as my daily walk. It had become part of my standard work. I am no longer a practicing physician but I think about the challenges of practice everyday and even as a retired CEO I realized that I could not “retire” my interest in improving patient care by exploring new ideas in healthcare.

John’s question underlined my challenge. I needed to find a way to be a continuing participant in the important conversations of our time. Caring about the future of patient care and how we can evolve a system of care that fits the objectives of the triple aim and is responsive to the personal needs of physicians and other healthcare professionals gives direction and purpose to my life and is an antidote to self-absorption. As long as I live I want to have a sense of purpose and be true to my “calling” and personal mission.

I will no longer be writing to the Atrius Health family because I owe it to my successors not to
be an alternative or distracting voice. My father always thought that a retiring minister should
move his own worship to another church and preferably just get out of town out of fairness to
the successors and I think his advice applies to healthcare organizations as well. In the past I
was speaking to Atrius Health colleagues and to you, the “other interested readers”. “The other or outside of Atrius Health readers are now the appropriate recipients of these missives and I hope that your number will grow without the conversation losing a sense of conversational intimacy. “The other interested readers” began as a surprise to me when I discovered that there were people who were not a part of Atrius but had a connection and interest to the same critical issues that interested me and wanted to read the weekly letter. That discovery was a surprise and delight for me.

The end result of my reflections (Hansei) that John had prodded with his question was the
recognition that I was now moving into a larger more complicated world that did not have the
fine demarcations of a corporate boundary. The opportunity to participate and contribute arises from the reality that there are many of you in the larger world outside of Atrius Health who share my interest in the future of healthcare and my empathy and concern for patients and all of those who find satisfaction working in our industry. I believe that through conversation and actively relating to one another we can all participate in the search for the solutions for which we yearn at this critical moment of inflection in healthcare…

As you might imagine that first letter went on for quite a while after this introduction. When I reread this part earlier this week, I was taken back in time but it still seemed current and appropriate. Its point of view deserves review from time to time. What is a better time to review and update a mission and purpose statement than when you start another “lap”? I realize that today I still feel exactly the same way I did in late November 2013. I am also filled with gratitude for the conversation that so many of you have continued to have with me. With your help and response I have stayed the course and completed another lap. Your support as a reader is more than enough to keep me doing this for as long as I can project myself into the future.

As I thought a little more about another lap, I was curious about what I had written on October 25th in the last letter to Atrius. After more than 400 letters it is hard to remember what you wrote and when. As I reread that last letter of goodbye, I was even more surprised by its contemporary message. In retrospect the last four letters to Atrius were a summation of what we had done and a thank you to those who had done the work, but they were even more a catalog of the work yet to be done and the changes that were inevitably coming. My thought as I read it was that if I copied it and pasted it into this letter it would feel as if it was written today. So here is some of it. We pick up the train of thought in mid letter:

One of my favorite subjects in junior high school was plane geometry. I liked it because you could solve problems with principles or axioms. The axioms were statements of truth that had been proven. There was then a logic to how you used what was known to be true to answer questions and solve problems. The ten concerns for the future that I identified last week are problems that will need to be solved by all of us in healthcare whether we work at Atrius Health, Steward Healthcare, Partners Healthcare, Kaiser Permanente or anywhere in healthcare across this country. We are connected and we draw from the same resources of finance, from the same pharmaceutical and medical device industry, and from the same system for healthcare education. A few of the “predictions” on the list are likely to be inevitable outcomes of processes that will be difficult to change. The workforce shortages of the future are an example of that category. Every problem on the list is hard to think about without some orienting “axioms” to assist us. The problems are much less daunting if they are approached with a set of principles
and a few tools.As a reminder, here is the summary of the ten problems I described last week:

1. We need to get to universal coverage or an unhealthy population will cause greater problems in our economy.

2. We need a better financing mechanism, probably some form of global payment.

3. We need to promote transparency and cost control at the national level.

4. There will be a rationalization of compensation between the various clinical disciplines.

5. Inadequate numbers of professional staff to populate current models of care will cause new roles to be conceptualized and old roles to be redesigned.

6. Primary Care as currently practiced will be challenged by disruptive innovators in lower cost
environments.

7. Behavioral Health, social services, geriatric medicine, survivorship programs in oncology,
musculoskeletal medicine, and physical/occupational therapy all will become increasingly important parts of the ambulatory practice.

8. Hospitals will become smaller as more of the chronic disease complications are managed either in ambulatory environment or in the home.

9. Those that pay for the care will control the conversation and provider organizations will receive less reimbursement.

10. Eventually regulators will approve new affiliations and mergers only for higher quality more efficient care that uses resources more wisely.

So where do we find the axioms and the tools to fix these problems and others that you might add? Dr. Ebert’s wisdom, the Institute of Medicine’s six domains of quality, and the triple aim rise to the level of axioms for me. Lean and other forms of continuous improvement are a combination of axioms and tools. Other important tools are our data capabilities, human resources capabilities, project management skills, understanding of traditional and behavioral economics, and finance and contracting skills…

Again there was much more in the letter but the list still describes much of what is on our plate over two years later and will probably be there several years from now.

Toward the end of the letter I offered:

The axiomatic statements of Dr. Ebert, the IOM, and IHI are necessary, as is a deep commitment to mission. Additionally, successful healthcare organizations will also need continued progress toward a broader spread of new attitudes and competencies if we are to be successful.

Since I am thinking in lists of ten, here is my list of the new attitudes and competencies that organizations will need:

1. Leadership from motivated individuals in every part of the organization.

2. A culture of teamwork and respect that weathers internal controversy while working through the tough issues.

3. A culture of service that is deeply rooted in mission and functions as a natural reflex.

4. Widespread competency in a methodology for continuous improvement and innovation like Lean that becomes a basic business system and a common language.

5. Data literacy that empowers everyone. Just as there was a time when few could read, we now live in an emerging time when only a part of the practice understands the importance of measurement and is facile in the use of data for improvement.

6. Courage and commitment to the task that can endure short term failures and market surprises.

7. The ability to avoid the traps of conventional thinking in the search for solution.

8. The ability to put the interest of patients, the community, and the practice ahead of personal interest.

9. The ability to learn together through experience and reflection and to accept the discoveries of others who are trustworthy as sufficient for the adoption of a better practice.

10. The ability to sell the importance to our business partners of the necessity of collaborating along the objectives of the triple aim if indeed they are to be our partners.

As we begin another lap together, dear Interested Readers, I am sure that there are other items to consider than just the ones on the two lists of ten. My thesis is that all of these issues remain active but I am sure that there are others that need to be added and some that need more emphasis. My experience and observations gained from my travels, conversations with many people in many places and my own experience and reflection suggest that many in healthcare earnestly desire physicians to be more engaged. They want to look to physicians for leadership but as a generalization many physicians are unable to positively respond to this request that they lead. Physician resistance to change and their absorption with their self interests often preclude progress within their organizations and frustrate the other healthcare professionals who are trying to support them. As my colleague Paul DeChant so eloquently describes, many have lost the joy of practice and are spiraling downward, trapped in coffins of burnout.

Another huge problem that I think deserves further discussion is the growing realization that “consumer driven healthcare” with its huge deductibles and copays may become the source of more problems than it solves. That is an opinion that is not shared by all, but needs further consideration and debate in the proximate future. What remains as a central reality and guide is Dr. Ebert’s concise but brilliant theory which in my mind is almost a law or an axiom that still explains much of our current reality.

The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.

Robert Ebert, MD
Dean, Harvard Medical School
1965

His statement may sound a little “wonky”, but its message is my mantra as I begin another lap.
Barriers to Improvement: What is Fair and What Adds Value

This letter, because of the help of some key players, Russ Morgan, Peter Kriff and my wife goes out at precisely 3 PM on the nose every Friday. At that moment I get exactly the same sense of satisfaction that I experienced when I would complete the mowing of a customer’s lawn back when I was 12 or 13 years old. I would stand and look at my work for a few minutes enjoying what I saw and assessing how close I had come to what had existed as my goal. I would usually knock on the back door of my customer and ask her if she would like to check things. My satisfaction and my learning both increased if rather than just handing me a few dollars and a cookie or a glass of iced tea, she would step into the yard and walk around with me to comment both positively and negatively on my work. I knew the places where I had inadvertently “scalped” the turf because my blade was set too low but I also wanted recognition for the care that I had used as I “edged” the lawn at the curb and alongside the walkways. It was these reviews that gave me satisfaction in the moment and the ability to do a better job in the future.Later, I got much of the same satisfaction as I would sit at the bedside of a patient who was being discharged following a successful hospitalization that had achieved our objective; or on that return appointment two months after the surgery that had frightened us both, when my patient would announce that she had not felt this good in years. Now I get the same joy from the response and comments that you provide. The comments tend to show up as early as ten minutes after three, most commonly on Saturday, but sometimes not until Monday or sometimes a week or two later. Often they come when there is a chance meeting and you say something like, “I really do agree with what you said in that letter a few weeks ago.”

Last Saturday evening I had the good fortune to attend the gala of the Boston VNA. I serve on the board of its parent, the VNA Care and Hospice Foundation, and had the joy of being part of the discussions that brought VNAs into Atrius as equal partners in care. There are many “Interested Readers” who are connected to the VNAs of Atrius and other readers of these musings were also in attendance. I really appreciated the specific comments that several people gave me regarding last Friday’s letter about the experience that is developing in Vermont. After the evening I was scanning my email before retiring for the day and discovered the following comment.

Gene,

I was very moved by your most recent post… It just seemed to me full of insights and wisdom, and refreshing to hear the vision and leadership taking the state of Vermont through these difficult waters…One area I am particularly keen on exploring is provider compensation in an accountable care environment. The idea that primary care carries the risk and specialists are paid by RVUs. The whole thorny problem as to how healthcare organizations negotiate the division of funds is delicate and political and fraught. Within the profession primary care is the homely sister of the specialty prom queen. The awareness that profound change is needed and coming is beginning to cause provider indigestion, but no one on the specialty side will willingly give up income or power, and primary care is only beginning to find its voice and move past resentment and failure into an emerging awareness of its own power. But in its perpetual and worsening crisis mode primary care I believe is finding it difficult to organize its voice and manifest its potential strength in real business structures and principles. And who is to say that any gain in primary care will actually lead to better patient care and outcomes? Without the kind of long term vision you describe as being manifest in the Green Mountain Care Board, without the medical profession raising its head to look forward with a shared vision of community benefit, simply shifting dollars within the profession will be of limited value.

A local case in point is my own medical group…Specialists are paid on RVUs out of the primary care pool (as are all other medical expenses.) The specialists are paid a significant premium above Medicare rates. Old and limited …data suggest that some specialists are more efficient than their community counter-parts. Whatever the merits or demerits of this arrangement, one thing is clear, and that is that there is no alignment around population health. And there is no engagement in the co-management of high risk and sick patients beyond traditional norms of professional conduct. Rightfully, specialists may have the most impact on some of the sickest patients. Is it not a strange anachronism that we do not routinely and explicitly co-develop and manage a care plan? We both know that there is a world of difference between clinicians talking to one another about a patient’s care, and a PCP reading a computerized and often templated consultant’s note (and vice versa) often learning more of substance directly from the patient and his/her advocate as to what happened at the last specialty visit.

How do we get specialty skin in the game? I believe everyone now believes that primary care has been and still is grossly under-funded; communities with robust primary care have better outcomes (than those dominated by specialists), lower costs, and better access to care; and cost of care, but not quality, is increased according to the number of specialists in a community. This is not a knock on specialty care, but an obviously haphazard system lacking intentional design which if done better–to my larger point–would involve shifting dollars.

Maybe there is enough waste in the system to allow providers to sustain their incomes and still achieve our broader goals. But I have a funny feeling that that won’t happen without intentional structural reform within the profession and led by the profession that rights the historic wrongs of the RUC and the hugely distorted RVU system. ACOs are the type of structural reform that would allow this to happen but only if we in the healthcare community can figure out a better way to work together for the common good.

When I read this profound note it was quite late at night, but I felt a need to “stay in flow” in what would surely be an informative conversation. This physician leader is positioned to make a difference and he was thoughtfully expressing a huge problem within his organization as well as in so many others. Despite that it had been a long day that began early in Philadelphia with a high energy discussion and a rushed trip back to Logan and from there a drive directly to a very pleasant evening at the fundraising gala of the Boston VNA, I felt that the letter needed a quick “midnight” response. Without the consideration that the letter deserved, I wrote a first response that I knew from the moment I hit “send” was not an adequate answer to the thoughtful comment in the letter that I had received. My less than adequate first response:

Once again you put your finger right on the sore spot. Everyone agrees that primary care has been abused woefully over the 25 years since RVUs were put in place in the early 90s during Bush I. Ironically, they were meant to correct the inappropriate differential between primary care and specialty care. They had the opposite effect.

It is difficult to reduce anyone’s pay for the same work. Most of the people I talk to think we should raise the comp of primary care significantly but would never agree to lower or even freeze specialty comp.

My solution would be to freeze specialty comp and introduce penalties for behavior that does not contribute to better outcomes…Your organization has a specialty legacy. It would be great to see the HPC have the authority that the Green Mountain Care Board has. I understand your concerns about the future.

You probably do not know that I was on the state commission in 2011 that was created to study variation in reimbursement to doctors and hospitals. Clearly, it is hard to decrease anyone’s pay. We found that just holding hospital pay to no increase it would take greater than 10 years to create equity…

Sunday morning on my walk, I could not get the inadequacy of my late night answer out of my head. I had a few ideas about a better response and resolved to immediately restate my points the moment I returned from the walk. He beat me to it. When I opened my iPad to send him my revised thoughts, I found that there was a note waiting for me.

Gene,

I know I was being a little provocative. Often hard to resist. I do like your notion of freezing specialty salaries and letting time and inflation and new priorities do their work. But I need to keep my job. What are your thoughts on putting specialists at risk for TME? That may be too blunt an instrument I suppose. Should we differentiate between predominantly procedural versus cognitive specialties and pay a straight salary to the former ala Mayo and Cleveland Clinic?

The note that I had planned to write to him was very close to what he had come back with. It should not have been a surprise since we generally see the world in a very similar way. I quickly wrote back:

First let me apologize for my illiterate note last night… I see myself now more and more as an advisor which is different than a consultant … I wrote then because I am always so excited when I see someone, especially you, write me that I want to respond immediately to “stay in flow”. Just seeing your name in the inbox is a joy. I know something noteworthy will be inside.

…On my walk this morning I had begun to lay out my thoughts for the next [week’s] letter. Perhaps the ongoing reporting on the front page of the Globe about the surgical greed at the MGH that manifests itself as double booking in the OR plus your letter plus several responses from other readers about the Vermont piece, and an experience I had Friday at UPenn at the editorial meeting of Healthcare: The Journal of Delivery Science and Innovation encourage me to tackle the subject of how to unwind and rewind physician comp in a more just and also more cost efficient way. The imbalance is one of the key barriers to a better future for all and the Triple Aim. Jumping to solutions is not the same as offering potential solutions for consideration. Innovative ideas that are solutions to “wicked hard” problems do need to be concocted, debated, and piloted. The origins of complex problems need consideration.

Since I know that not everyone follows the links, I need to interject here in the middle of this piece of correspondence, that “wicked problems” is not just a slang phrase but is an entity or class of problems that have been studied. If you followed the link, you learned from the Wikipedia note that chronic, difficult to resolve problems of our times fall into this category. The “wicked problems” of our time include what to do about poverty, how do we approach climate change, what to do to find peace in the Middle East, and how do we improve healthcare. There are scores of other wicked problems that plague us at the individual, local, national and international levels. The authors of the Wikipedia citation expand some of the definitions from the 60s and 70s when the term was first conceptualized to include:

  • The solution depends on how the problem is framed and vice versa (i.e., the problem definition depends on the solution)
  • Stakeholders have radically different worldviews and different frames for understanding the problem.
  • The constraints that the problem is subject to and the resources needed to solve it change over time.
  • The problem is never solved definitively.
Back to my response to my pen pal:
You are a “positive provocateur”. Your “rock in the shoe” persistence, coupled with a high level of personal character and an unquestionable work ethic and commitment to good care, give your ideas legitimacy and they deserve to be heard. I have actually had the same idea of making specialty compensation hugely dependent upon savings [lowering TME] and outcomes in the system as a way of aligning them [highly compensated specialist] positively with the Triple Aim. If they are going to be overpaid it might as well lead to the achievement of objectives that serve everyone and not just themselves. The same principles could be applied to the hospital [payment] disparity issue…

If we go back to those lists of continuing concerns and problems to be solved that were listed in that last letter to the Atrius practice we see:

On the list of predictions:

4. There will be a rationalization of compensation between the various clinical disciplines.

5. Inadequate numbers of professional staff to populate current models of care will cause new roles to be conceptualized and old roles to be redesigned.

6. Primary Care as currently practiced will be challenged by disruptive innovators in lower cost environments.

On the second list of competencies for the future are the skills that are necessary but individually insufficient to solve the future concerns about primary care that were underlined by the discussions in Vermont and the comments from my pen pal.

1. Leadership from motivated individuals in every part of the organization.

2. A culture of teamwork and respect that weathers internal controversy while working through the tough issues.

7. The ability to avoid the traps of conventional thinking in the search for solution.

8. The ability to put the interest of patients, the community, and the practice ahead of personal interest.

As we move forward with efforts to improve care while lowering the cost to sustainable levels, there is a general understanding that the future of primary care is one uncertainty that must be resolved. The role of RVUs and the RUC as the infrastructure of the healthcare’s FFS economy was one concern expressed by my partner in the correspondence. Perhaps I should devote a future letter to a discussion of the RUC, the committee within the AMA that makes compensation recommendations to CMS that are the most important determinant of the advantages of specialty compensation and are usually immediately adopted and extended to commercial insurance reimbursement.
Some groups that employ specialists, like my old organization, do modify the RVU value and the relative relationships between the specialties to match internal philosophy, but those modifications are limited by market realities that protect higher compensation for critical specialties. When all is said and done, most of the compensation differences that threaten primary care are explained by different RVU values that are a subjective reflection of negotiated values in a committee where the advantage exists with the highly compensated specialties . To learn more, follow the thread that you can start by clicking on RVUs and RUC. The link from the RUC is what the AMA says about it. It describes the committee. A discerning reader can appreciate how the large majority of the specialty groups has the ability to out vote primary care year in and year out. Many primary care physicians and others have raised concerns and some have launched ineffective efforts to change it.
The issue of pay discrepancies between specialties that may or may not reflect value and, depending upon your point of view, may threaten the future of primary care and the future of the Triple Aim Plus One are quite similar to the variation in reimbursement to institutions. In my response to my pen pal I noted that I had been a commissioner on the commission appointed by Governor Patrick a few years ago to report on the variation in payment to doctors and hospitals in Massachusetts. The commission found as much as a six fold variation across institutions for the same activity. It was projected that the problem could not easily be resolved even if payment was frozen for several years to those with the higher incomes. There was no politically feasible solution to this “wicked problem”. Much of Chapter 224 of 2012 is a response that is an attempt to gently improve that “wicked problem”. Since the passage of 224 it is my impression that the problem has not improved much and may in fact have continued to get worse.
The solution that my pen pal and I considered is also a partial solution to a complex problem but could be an attractive experiment, although it would take the political will of a regulatory agency or the will of a well organized and forward looking ACO. Specialists would carry much of the financial risk for the total cost of care reflected in the global budgets for care of a population after primary care is given a fairer compensation. In such a relationship primary care and specialty care may be mutually incented to work together to improve quality and lower the total cost of care. RVUs may be the best way to compensate specialists for the procedures that they do but they would be discounted by having explicit financial risks for waste and care that they provide that does not improve quality, safety and patient satisfaction. Such a financial risk might encourage a more explicit collaboration with primary care and an interest in population health. That construct is quite aligned with theoretical ACO thinking and the evolving realities in Vermont and in progressive medical institutions.
After getting this far, I sent a rough draft of this section to my pen pal and asked him what he thought. Like a good friend he was honest with me and essentially said that I had not gone far enough. Here is what he said:

The second to last paragraph [He is referring to the paragraph that begins, “The solution that…] is a nice summary of the core of the issue. But it leaves me feeling unsatisfied, like we have not provided a clearer guide to the future. It comes up short. At the end it feels more like wishful thinking, which perhaps reflects our true reality. Have we gone down a blind alleyway?

Well, if we were to back up and ask ourselves what principles could we outline that would define an approach to re-align compensation within a large multi-specialty or integrated system, what might those be? And if we did that, could they be compelling enough to help organizations who have the desire to move in the right direction actually make progress without tearing their internal house apart? It feels like an awfully big ask, and yet shouldn’t those of us in the profession, especially the senior leaders, own this?

The work would call out the most fundamental question facing the profession today: Are we in this for ourselves, or are we in this to improve the health of others and do what we can to improve the health of our communities? Will we, at the end of the day, put our patients first and live up to our timeless professional values?

He is right. The work that he describes will be hard. There is the risk that it might feel like “tearing their internal house apart”. Yes, senior leaders should own this. If not them, who? Many physicians feel that they are losing control and they do not effectively ask themselves why. Could it be that they are not aware of the fact that much of the external world believes that they are primarily motivated by self interest first and patients and community are secondary concerns? Many “senior leaders” have failed to see what most good business leaders know intuitively; take care of your customers if you want to succeed. The search for solutions in complex systems requires trust and risk taking.

I hope that many of you, “interested readers”, will try to answer my pen pal’s question:

Well, if we were to back up and ask ourselves what principles could we outline that would define an approach to re-align compensation within a large multi-specialty or integrated system, what might those be?

Movement from a comfortable financial status quo, which is the position of many specialists and proceduralists, to the assumption of more risk against a background of producing better more cost effective outcomes across the community, is not likely to occur spontaneously. It will require leadership, discussions and then action that could leave blood on the floor. If we are wise we will begin these conversations in earnest now because they will continue for a while. If we can negotiate a solution or even an experiment, I am sure we will be closer to the Triple Aim Plus One and we may see snow in July and flying pigs. The scriptures offer reassurance that what is unexpected and difficult to conceptualize can happen. Camels can pass through the eye of a needle under the right circumstances. We can learn new negotiating skills and develop new leadership competencies. Dilemmas like my pen pal describes can be flipped.

Paris and Our Future

I have been to Paris more often than I have been to any other European city although it has been a little over 20 years since my last visit. On every occasion I have walked and walked. I had some great runs with a friend through the city and the Bois de Boulogne, the Paris version of Central Park. I have enjoyed sitting in sidewalk cafes drinking espresso and I thrilled to the beauty of the work in the Musée d’Orsay. It is not hard to understand why Paris is the target of ISIS because, as all the commentators tell us, Paris is the image of everything that they rule out of their dualistic world. Seeing the world as either with your point of view or against it is common and perhaps realistic. Wanting to destroy completely what is at variance with your point of view is hard for most of us to understand.

Conflicts between points of views represent an explanation for much of the misery in history. We all live with the hope of a future where we move beyond conflict and toward peace and tolerance. The events in Paris this last week show us that we have a very, very long way to go. We have come to a seemingly impossible moment where all of the solutions seem likely to create more loss and pain in a world where the only human feelings not in short supply are anger, loss and pain.

I got a lift this week from my son’s music or should I say his essay and his music.

I like to listen to the news before I head to work in the morning. Lately my day starts with a bowl of oatmeal and the BBC World Service on NPR. That’s the kind of guy I am. This morning the news was understandably all about Paris. I sat with my cinnamon flavored sludge and pondered the situation boiling over all around the world. It’s shitty. Everyone’s got enemies. We’ve got more than just about anybody.
I’ve long been aware that New York’s Washington Square Park is a former Potter’s Field. Not far beneath the cheerful academic setting of my recent graduate studies there lay untold numbers of nameless dead. I was reminded of this a week or two ago when I read that mass tombs have recently been rediscovered there by workers updating some infrastructure or another. Photographs of the tombs are macabre. Scattered piles of miscellaneous human bones and broken coffins abound under ancient stone arches. These people had faces. They had names. So do our enemies. So do we.
Time, the world, the universe and all its powers conspire to destroy us, yet we hasten their work by making enemies while we wait. We’ll all be anonymous dead sooner than we’d like. We’ll all be the same. Aren’t we already the same? Why not reach for understanding while we still have names and faces?
Karl Marx suggested that religion helps us get through the things we should not tolerate. The phrase “give them bread and circuses” is the callous and manipulative expression of how Rome controlled its masses. At least one social critic has suggested that the NFL is our modern version of the “circus” and fast food is our “bread”. After all of the tension following the violence in Paris, I must admit that whether it was the opiate or the circus of watching the Patriots, the tension of the cliffhanger against their nemesis, the Giants, was a relative relief from the real world.
I read one post from someone on Facebook that expressed, with some expletives, what many Patriot fans feel. In essence the jubilant fan said that Tom Brady was the best and other teams should just expect that whether the game was played with an overinflated, an underinflated or a Nerf football, Brady was going to find a way for his team to beat them. Brady said that the win was really a team effort, and it was. Sometimes a cigar is just a cigar and I am not going to try to extract any metaphysical explanations from what was a relief.
Without snow it is hard to take a picture for the header that shows that my walks are getting chilly but the brisk weather plus the effort just makes the fire in the living room feel more welcoming. I hope that your walks this weekend bring you a little relief from our turbulent world.

Be well, do good work, and drop me a line now and then,

Gene

Dr. Gene Lindsey

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