It has been almost ten years since I took on the challenge of trying to lead Atrius Health. The challenges then were very similar to the ones we face now. I was impressed then as I am now with the body of thought and knowledge that had been expressed in Crossing the Quality Chasm and further refined and articulated in the Triple Aim. These ideas resonated with my experience as a clinician. What felt acutely real at the time for me was that whenever we deferred action on our attempts to incorporate the six principles of quality as articulated in Cross the Quality Chasm into operations because they seemed to interfere with the easiest route to short term gains, or we lacked the energy to do the work, we drifted further away from both the security we desired for ourselves and the collective goal of the Triple Aim.
Last week I lifted a quote from Derek Feeley’s introduction to the IHI’s white paper on addressing equity in healthcare. It deserves repeating:
In 2001, the Institute of Medicine described “Six Aims for Improvement” in its influential report, Crossing the Quality Chasm: A New Health System for the 21st Century . The “Six Aims” called for health care to be safe, effective, patient-centered, timely, efficient, and equitable. In the 15 years since the Chasm report, health care has made meaningful progress on five of the six aims (though there is much more work to be done on all). But progress on the sixth — equity — has lagged behind.
As I look back on what I was think in early 2008 and as I was beginning to work with my team to articulate a strategic plan that we could present to our board and our practice for their thoughts and input, a few key ideas emerged that I still find relevant. They were then, and remain now, interconnected realities that like the six domains of quality must be kept in mind as we try to think about a better future.
First, universal coverage will someday be a reality in America, and we are not prepared for it. In 2005 I had heard a strategy consultancy predict that by 2020 there would be one practicing PCP for every 10,000 American adults. The discussion was depressing because given rates of retirement, the relatively sparse number of slots in medical schools, tendencies for new grads to choose more lucrative specialties, the time it takes to produce doctors, the inadequacy of PA and NP training programs to fill the gap to produce enough clinicians, and the model of care that was driven by office based fee for service practice, the outcome seemed impossible to avoid. The American Association of Medical Colleges has been tracking the issue now for a few years. The picture is not pretty, but you can see it for yourself . What worried me in 2005 and 2008 is a persistent problem getting worse today.
Second, the only solution that seemed plausible was a redesign of the care model toward methods of better leveraging the professional skills that were available. That would require a shift in experience and responsibility for both clinicians and patients. Care model innovation was the answer. The metaphoric “factory” of healthcare needed an upgrade and redesign. In most industries you can shut down a factory and “retool” or just build a new factory. The idea of shifting care models is certainly still alive and we have made progress. I would suggest that you look at the “Perspective” article by Duffy and Lee in the January 11 edition of The New England Journal entitled “In-Person Health Care as Option B.”
Third, fee for service payment was an impediment to progress. We needed to find capital to invest or at least be paid differently so that we could invest in our practice. When we were “totally capitated” as a self insured entity, we had more flexibility to be innovative and develop more efficient programs of care. Being paid for value rather than volume is not quit the same as the capitation that I cut my professional teeth on, but risk based contracts were something we understood in our organizational history even though in 2008 only 39% of our patients came to us on HMO like contracts. It seemed prudent to try to shift to a more risked based portfolio of contracts.
Fourth, eliminating waste and promoting operational efficiency, and working with like minded business partners in our “supply chain” would yield more resources for innovation. That idea was the core concept behind my favorite financial expression, “Rescue and Reallocate.” Any money saved (rescued) by more efficiency was “found money” and could be invested in improvements (relocated from waste to investment). Those saved dollars were just as good a source of resources as getting a better payment from a contract. I seriously doubted, and think time has shown me to be correct, that we would ever return to the era of large year over year increases in payment that were multiples of the GDP. File that thought under “If something can’t go on forever, it won’t.” Embracing Lean and making continuous improvement our most significant corporate competency seemed to me to be foundational to our mission, and the best way to unlock the money in the vault of waste.
Fifth, workforce shortages, difficulties with developing workflows and incorporating computers into the care model, as well as a dependence on fee for service revenue constituted a perfect storm for professional burnout. I had read Robert Cole’s 1993 book, The Call of Service: A Witness to Idealism and was impressed by the risk of burnout in any “helping” profession or idealistic endeavor. The book appeared about the time my own professional life was thrown into chaos by the introduction of RVUs, more contracts that were fee for service, and the introduction of Epic. It was a perfect storm that almost sunk my ship since I had zero “keyboard” skills. I had done just fine for twenty years in a system that valued my ability to solve problems over my ability to generate a document that the finance department could use to justify the bill they were submitting. Again, fee for service, and its demand for justifying with no value added lists of negatives seemed to me to be an impediment, and not a support to practice. Being an effective advocate for better practice had put me into a leadership position. In 2008 the only way I could see to make things better was to change the finance and improve the workflows and supports to the practice.
Recently, my Simpler colleague, Paul DeChant, has done a wonderful job advocating for recognizing the threat of burnout and offering Lean as one of the effective tools we have to improve it. The book that he wrote with Diane Shannon, Preventing Physician Burnout: Curing the Chaos and Returning Joy to the Practice of Medicine should be required reading for every healthcare professional. Perhaps more available to you, if you have ready access to The New England Journal of Medicine, are two articles on burnout in the January 25th edition. I recommend them all, although none of them are “the answer,” what is most important is the conversation. Like the issue with opioids, the acute recognition of a chronic problem, is a moment when progress might be made.
All of the above is encapsulated in my favorite quote from Dr. Robert Ebert, Dean of Harvard Medical School when I was a student, and the founder of the organization where I spent the entirety of my career. As you have read from me before, and will see again until we incorporate its wisdom into everything we do:
“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.”
What is not obviously included in that statement, but rest assured, the reason he said it, was the concern that we were failing in our moral obligation to provide patients with care that was centered in their needs and concerns. That thought was the sixth concern in my cascade of concerns in 2008.
Sixth, we are failing in our responsibility to make our efforts patient centric. Even as we pursue safety, efficiency, effectiveness, timeliness, and even equity, if we forget the necessity of putting the patient first it is all for naught.
In a way the problem reminds me of the wisdom of St. Paul in his first letter to the Corinthians where in the 13th chapter he seems to state that the only thing that matters in the end is charity (love). You probably know the poetry of the King James translation even if the scripture is not part of your personal experience. It’s all about purpose and the outcome.
Though I speak with the tongues of men and of angels, and have not charity, I am become as sounding brass, or a tinkling cymbal. And though I have the gift of prophecy, and understand all mysteries, and all knowledge; and though I have all faith, so that I could remove mountains, and have not charity, I am nothing. And though I bestow all my goods to feed the poor, and though I give my body to be burned, and have not charity, it profiteth me nothing.
In healthcare the only thing that really matters in the end is the outcome that the patient experiences. Everything else is an end to that means. We should not worship or feel bound to what is not working if that slavishness to the status quo is impeding our efforts to offer care that meets the needs of everyone in a personal way. It’s why I like the more recent iteration of the Triple Aim. It’s less wonkish and comes closer to the patient while remembering the stress that the call to service places on those who provide the care:
Care better than we’ve seen, health better than we’ve ever known, cost we can afford,…for every person, every time…in settings that support caregiver wellness.
As I look back at 2008, I see that things have not changed much. We have tried to avoid, or at least delay, some of the work that needed to be done. Lately we have been sidetracked by efforts to prevent the erosion of a few of our accomplishments. The real question that we face together is how do we get back on the road to the objective and take advantage of what we have learned from our successes and failures. We must simultaneously be working to achieve sustainable resources, our “means,” and simultaneously improve our methods of delivering care, if we are ever going to achieve the desired end. I have had my time at bat, and now I am mostly a patient. If you are still in the game, I hope that I have said something that might be helpful to your efforts to hit the pitch that is coming to you.