Are systems consolidation, competition and innovation the triple play that will deliver quality care for everyone at a sustainable cost? Perhaps before we try to answer that question we should avail ourselves of the lessons learned over the efforts of the last fifty or sixty years to expand care to all Americans. The vision of the Triple Aim was not articulated until 2007, but by the mid sixties many healthcare leaders and progressive politicians had been concerned for sometime about our lack of universal access to quality care at an affordable cost. Studies were beginning to emerge that documented the experience of thoughtful and observant clinicians that maintaining health and carefully managing chronic disease could produce superior outcomes and a lower total cost of care, compared to the usual practice of getting medical care only after illness or injury had occurred.

Dean Robert Ebert of Harvard Medical School was one of the medical leaders of the sixties who coupled his own observations and vast experience with a vigorous exchange of ideas with colleagues across the country to formulate a theory of a better future. He succinctly summarized his conclusions in a letter written in 1965 to the president of the Commonwealth Fund. The letter was a request for funding to further explore the implication of his theories in the laboratory of a “teaching practice” designed to pilot new forms of care and to produce a new generation of socially responsible physicians. I have published his words in dozens of letters and blog postings. You have most likely seen them before.

“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.”

Now 52 years later we are still searching for those elusive effective operating systems and innovative finance mechanisms. We have made some progress by realizing the importance of a focus on quality and safety. We have clarified some foundational concepts that have brought us closer to a conceptual framework. Our experience has taught us that local variation will probably drive the need for multiple operating systems and finance mechanisms that will vary for local reasons. What we had learned was summarized in Crossing the Quality Chasm in 2001. By that time pursuit of Dr. Ebert’s concepts had led us to understand that the desirable properties of effective organizations could be accomplished through a variety of operating systems and finance mechanisms as long as some key properties were present. In case you have lost the list here again are the ten properties of an effective delivery system.

1)    Care based on continuous healing relationships:

2)    Customization based on patient’s needs and values.

3)    The patient as the source of control. Encourage shared decision-making.

4)    Shared knowledge and the free flow of information:

5)    Evidence based decision making.

6)    Safety as a system property.

7)    The need for transparency.

8)    Anticipation of need.

9)    Continuous decrease in waste.

10)  Cooperation among clinicians. [“I to we” within practices, across practices, across systems and throughout the community.]

I will contend that clarity about how and when to effectively consolidate service into larger systems of care still eludes us. Part of the problem lies in the uneven distribution of medical assets and the variation in market realities across the heterogeneity of the country.  What works in Boston does not always work in Maine and is hard to reproduce in Wyoming or Alaska. Conversely what does work in Alaska may well work with specific populations in New York City or Los Angeles but transferring the experience or methodology is not easy. We will come back to these issues in a subsequent letter.

The same sense of variation in opportunity related to location and context also mightily impacts how market competition can be used to lower the cost of care. With three medical schools and even more world class academic medical centers in Boston one would expect competition to be a powerful determinant of price, and as a derivative of price, cost. Trust me, it does not.

Just as now, back in the early sixties the conversation in Washington was a confusing oscillation between what was needed and how to pay for it. Just as now, people were talking past one another as some earnestly talked about “why” we needed to extend care to the elderly and the underserved, and others were worried about “how” we would pay for it. Just as now, there was not a consensus about what the role of government should be, or what was the proper attitude of a patriotic American. Then as now there were those who thought we were a great country because we are a collection of self reliant individualist capable of pulling ourselves up through effort. Then as now there were many that believed we could be a greater nation if we could use government to help everyone achieve their potential. Then as now, we were confused about how to negotiate a consensus on these complex issues that would allow us to evolve and operationalize a solution.

Much of the language of primary care, quality assurance and population health had not yet evolved in the mid sixties, but some thought leaders had an intuitive appreciation of the principles. In the mid sixties America was still several decades away from reclaiming the continuous improvement concepts of Deming and Juran from the Japanese. We had some start up examples of new models of care like Kaiser Permanente in California and Group Health Cooperative in Washington. At these organizations, in other innovative practices, and in academia there were healthcare thought leaders like Dean Ebert who were beginning to consider the systems thinking that would evolve toward new concepts of care and wellness like health maintenance, preventive care, and integrated multispecialty group practices. There were a few self insured delivery systems others that were accepting prospective capitations for large populations. By the mid sixties there were a few visionaries who realized that their hopes for better care were incompatible with the “overuse” tendencies inherent in fee for service payment.  
Another similarity to these times is that Medicare and Medicaid emerged on the legs of a shaky and time limited bipartisan consensus after two decades of intense disagreement and political gridlock. Healthcare access and finance improved against resistance. It was an era when there was a growing consensus that we needed to squarely face a collection of chronic social and political problems. I was witness to much of what was happening, although I could not fully appreciate it because I was in the midst of my own education and just becoming aware of how what was happening in the larger world might impact my provincial universe.

What seems different in retrospect was leadership. Truman, Eisenhower, Kennedy and Johnson were all engaged and all were contributing participants to the process of discerning the way forward toward a solution. Ironically the AMA was against everything that hinted of any change. The final reality was that it took a focused and experience legislator and president in the form of one man, Lyndon Johnson, to make it happen. We do not have such a leader now. Ironically, we imagined that we would be better off electing the proprietor of a family owned business rather than an experienced public servant who understood political process. If success is a function of well processed failures, then this misstep may offer payoffs later.

If you did not live through the sixties, or were too young to notice what was happening, or were engaged in other activities like welcoming the Beatles to America, I would highly recommend Robert Caro’s four volume biography of Lyndon Johnson. I hope that the fifth and final volume Caro’s monumental exploration of the life of Lyndon Johnson that will cover Johnson’s politically fatal errors involving Vietnam will be in my hands within the next two years. I have already benefited greatly from reading the first four volumes covering Johnson’s early years and then his political activities from the thirties, through the first half of the sixties. Caro’s description of Johnson and the interaction between his personality and the times have given me a richer framework against which to consider the challenges of today.

Books like An American Sickness by Elisabeth Rosenthal and Mistreated by Robert Pearl give us excellent views of where we are now and some information about how we got here, but the greatest insight available (from my experience) on the political journey to the moment when the ACA was conceptualized comes from Blumenthal and Morone in their 2009 book, The Heart of Power. I have recommend all three on many occasions, but now more than ever offer them as a source of perspective as we consider the opportunities that might lie ahead if we have the energy and commitment to pursue a truly bipartisan process with everyone eagerly engaged with the goals of the Triple Aim as the simple statement that describes a destination that we all want to reach.

…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…

Before we discuss the pros and cons of the consolidation of systems, and the benefits or futility of market based competition, I want to discuss innovation and associated ideas of patient engagement, organizational evolution, and healthcare applications of the principles of the “experience” economy. At this time I would say that if your plan is to succeed and lower the cost of care in the future through ill defined and poorly considered “innovation,” I have a bridge for sale. Innovation, as most of us think of it, will be “necessary but insufficient” to sweep us to a future of Triple Aim nirvana.

As a preview of next week’s discussion of innovation, let me give you a few of the barriers that impair effective innovation and must have solutions if we are to harvest the benefits that we can optimistically imagine from “innovation.”

  • Satisfaction with the status quo
  • Complex systems where one unit can exist comfortably for a while as others suffer
  • Apprehensions of middle and upper management
  • Today’s work
  • Effort versus benefit
  • Matching what can be done with what needs to be done
  • Funding in an era of external pressures on finance
  • Incorporating potentially effective innovations into work flows
  • Aging professionals and emerging workforce shortages
  • Red ink and the need to cut the budget

I believe in innovation. I believe that organizations without continuous improvement,  cultures of learning, and effective programs of innovation will eventually fail. I hope that you will be back next week for the next installment.