What will be left when the storm is over? It’s the sort of question you might have asked yourself if you were living in Puerto Rico on September 20 when Maria hit. I ask it of myself on a regular basis when I think of Donald Trump’s attack on healthcare, the environment, the State Department, energy policy, immigration policy, and most of the social services that so many Americans depend upon as they struggle to get through each day and not lose too much ground to what have been their hopes for a little better life.
I have a great sympathy for those who voted for him with a misplaced trust in his seductive promise to “Make America Great Again.” It surprises me a little that I harbor next to no ill will for those who voted for him out of their frustration with the status quo and hoping that he could deliver on his promises. I can empathize. I’ve taken some long shots and I’ve spent a lot of money on products that falsely promised to make me run faster, be smarter, be more relaxed, catch more fish, have better hair, play music with more skill, speak Spanish easily, and have more fun if I would just make a purchase.
There is no doubt in my mind that the storm will pass. I think that most of us will survive. What is less clear is what will be left when we wake up someday to discover that despite all of the evangelical Christians willing to vote for a pedophile, or look the other way and vote for a candidate who brags that he is so popular that he could shoot people and not be arrested, and by the way can’t commit a crime as long as he is in office, it will end. Gun owners will probably still be entitled to “open carry” in an amazing number of states, but someday all the losses will end, and if we are lucky there will be a rainbow of civility.
Some years ago I noticed that efforts to improve healthcare in this country occurred in herky-jerky cycles of ten to twenty years. Between 1965 and 2010 most of the cyclical efforts failed, although there were a few minor victories like the CHIP program passed in 1997 after the Clinton health initiative in 1993-94 was killed by Harry and Louise. Medicare and Medicaid passed in 1965 about 20 years after Harry Truman’s ideas for healthcare with a single payer died shortly after world War II ended. The Hill-Burton Act was the consolation prize that Truman won. It was a creative piece of legislation that was flawed in its implementation by many states, but it built a little hospital in thousands of towns across America about the time we started building Interstate highways. Hill-Burton was a little step forward between big events that most people have forgotten. There is a good chance that you, Dear Reader, were either born in a hospital built with HIll-Burton funds or had your tonsils removed in one.
My point is that it’s been a step forward or two followed by a step back for a little while for a long time, but over the last seventy years we have made some progress. I’m certain that Trump will earn a position in history some place way behind Richard Nixon and eventually Paul Ryan and Mitch McConnell will become demonstration projects for how not to legislate, or will be totally forgotten and we will return to making progress toward the Triple Aim.
Where you will begin your part of the recovery when the storm passes will be a function of what you did to weather the storm, and what you did during the storm. Here are some tips. Plan to never have the financial resources after the storm that you have enjoyed up till now. Those resources were not sustainable under any administration. Do not be fooled into thinking that just because the “mandate” goes away and Trump’s executive orders will allow “association” policies that don’t conform to the ACA, that fee for service payment has a future, or that planning on a new bed tower with flat screen televisions in private rooms will guarantee an increasing volume of fee for service “hips, knees, and hearts” to protect your margin forever. Trump and company, if they stay in power, will give Medicare and Medicaid a haircut and those revenues are 60% plus or minus a few points of the total revenue in most systems. Commercial payers don’t like FFS either. Fee for service payments will end with or without Trump.
The competition among payers with or without a Trump defeat will be around price, and eventually even Partners Healthcare will need to live with less. If you have not started to look at your costs rather than your price, you will have more than a cleanup to do after the storm passes. By the way, if your plan is to lower your cost by laying off a lot of employees and ending some of your service lines, you will be walking on your knees. As much as you may hate the idea of managing by process, that is by using continuous improvement science like Lean, attempting to cut your way to success will only aggravate your best employees and disappoint the customers who might have been loyal to you. If you have not started yet, you may have a year or so to get ready.
The ACA survives because with all of its flaws it is the best idea unless we want to go to a single payer. The big problem now, and always, has been the individual market. Someday after trying all the wrong approaches we will go back to community rating and incorporate both of the arms of the individual market in the overall process of creating a competitive market. We will eventually have an adequate penalty for the mandate, or we will grant universal coverage to everyone either by a single payer program or by the development of a public option for the individual market.
It is interesting to note that some experts say that there is no example of a program of social legislation like the ACA being reversed unless you include the end of Reconstruction in the 1870s. It is true that “it has never been this late before” and things that haven’t happened can happen, but given the public support that was demonstrated for the ACA, the core principles still have a good chance to survive in a damaged state that is repairable. The principles of the ACA drive us toward the delivery of care based on concepts of population medicine. If you are still building your budget on expected surgeries and admissions and have not planned to conceptualize your future activities in terms of identifying the populations that you serve, Donald Trump is the least of your problems.
Commercial insurers don’t say much, but they are not going to pay for more and more services when they can use the market and their resources to lower your prices and introduce you to risk. What do you think the sale of Aetna to CVS means, or what UnitedHealth is up to when they buy practices like DeVita’s medical groups? While you are figuring it out, they are preparing to eat your lunch by demonstrating to you that innovation leads to “creative destruction” of the status quo. CVS has 9700 locations in 49 states, the District of Columbia and Puerto Rico. If you are a PCP, try to imagine the impact they will have on your FFS revenue from primary care and chronic disease management. By the way, CVS is on Epic. Why do you think they made that investment?
If I were still in practice I would be less worried about Donald Trump and the day after his departure than how I might develop a strategy to be more appealing to my patients than CVS will be. For starters I would be looking at their experience of scheduling an appointment and the experience they had through the entirety of an episode of care. I would be more concerned about the cost of their care to them than I was about the reimbursement that I got at their expense for things that added no value to their management.
Yes, the storm will end. When it does there will be no distractions from our responsibilities and no place for us to hide if we are not ready. The future of your practice will be a function of your preparation for what you could have seen coming for a long time before Donald Trump and Congressional Republicans became a distraction. I fear that there will be many who will be like deer in the headlights, frozen in place until the inevitable reality hits them that things that are unsustainable don’t go on forever and are followed by new organizing principles. Are you ready for the day the distractions end?