The conventions are over, and the election lies 63 days, nine short weeks, into the future. It did not take President Trump long to hit the campaign trial. He landed at the Manchester Airport less than twenty four hours after desecrating the South Lawn of the White House with his likely illegal “acceptance speech” spectacular that broke all the rules of social distancing, even as it probably violated several laws that will certainly be overlooked by Attorney General Barr. The speech that the president gave in an airport hangar here in New Hampshire last Friday was a somewhat more aggressive “I’ll say it again” repeat of his acceptance speech. According to the report of the Boston Globe his themes were:
- America would be a dark place under Joe Biden with things spiraling out of control.
- He accused the media of stoking racial hatred.
- He blamed China for planting the coronavirus.
- He positioned himself as a Washington “outsider” still intent on “draining the swamp.”
- He claimed to be the only thing between a left wing mob and the destruction of all that was great about America.
- He claimed that Joe Biden was “old and slow” and would be under the control of “others,” presumably left wing radials
- Kamala Harris is not competent to be Vice President.
- Protests over police brutality and white supremacy have been the work of “agitators,” and under Biden our police forces would be weakened.
- He is trying to figure out how to call troops into a “standby position” to protect Washington, presumably since angry crowds harassed some of the attendees to his South Lawn extravaganza.
Those were the points that kept him going and kept the enthusiastic crowd pumped for more than an hour. He read the South Lawn speech off a teleprompter in a boring monotone. At the Manchester Airport rally, he was in his usual “rally” form, and he continuously delighted the overflow crowd that was primarily made up of his local fans and followers. There were some who came from outside New Hampshire having traveled for hundreds of miles to see him just like the fans of the Grateful Dead had done more than forty years ago. Many of the faithful had arrived the day before or much earlier in the day so that they could be sure of getting in. Near by, a large overflow crowd watched the event on large screens. MAGA hats were everywhere, and those wearing the hats far outnumbered those wearing face masks.
What the president did not do in Manchester was accept any responsibility for America’s disproportionate number of COVID-19 cases and deaths, or the damage that has been done to our economy. What is also clear from his speech is that he is banking on the fear of socialism, the fear of rioting crowds, the miracle of economic improvement that could occur if people returned to normal activities despite the virus, the promise of a vaccine, and his ability to undermine confidence in Joe Biden and Democrats in general to give him a victory in November. Add to his strategy of explosive and dishonest rhetoric the cyberspace intrusions from Russia and North Korea, voter suppression by a variety of mechanisms including destroying the Post Office’s efficiency, and his ability to orchestrate events and control the news cycle it should be easy for you to understand why I am joining many others who worry that Biden’s current margins do not guarantee his election. Donald Trump could quite possibly have a second term. He is not an normal person who is capable of being embarrassed. He is quite capable of shameful acts without remorse. He has emphasized that he does not like to lose. Being a “loser” is likely to be more painful for him than the possibility of being labeled as a cheater. That fact alone makes his election possible.
The president has a “divining rod” that finds weaknesses and biases to exploit. I see weaknesses and biases for him to exploit where I live. We live in a complex and ambiguous world that is ripe for misrepresentation by a person who lies compulsively and cares little about what people think of him as long as they fear him. There are many enthusiastic Trump supporters in New Hampshire, and he thinks he has a chance here. In 2016, Hillary Clinton carried my town by about 500 votes and the state by the slim margin of about 2000 votes. Living in New Hampshire, it is hard to say that he does not have a chance.
If there is a possibility of his reelection, we should ask what we might expect during his second term as we continue to hope for distant goals like the amelioration of racial strife, improvement in the social determinants of health, and movement toward a more just society. What follows is primarily an expression of my own fears and speculations, but I will draw on the observations of others. A good place to start the speculation would be to do what Elizabeth McGlynn did this week in an article in the “Perspective” section of the New England Journal and ask what it would take to improve the quality of healthcare in America. With that perspective we can then ask how the policies and promises of Donald Trump will promote or undermine the objective of improving the quality of healthcare.
Professor McGlynn began by reminding us that in 2003 she and her colleagues reported that patients received about 55% of the recommended care for the leading causes of death and disease. Things have not changed much since 2003 despite a lot of effort. If what we have been doing is not making a difference, what do we need to do to improve outcomes? I would recast the whole question by asking specifically what we must do to achieve the Triple Aim of better care for individuals, while creating healthier communities for a sustainable portion of our collective resources.
Professor McGlynn begins where so many current publications begin by noting that COVID-19 has revealed that we have many more and more deeply entrenched problems than we recognized before the pandemic hit. Her key question then is:
Despite nearly two decades of experimentation with standardized measurement, public reporting, and reward-and-penalty programs, average quality performance remains about the same. In a country like the United States, with its substantial resources and talent, what will it take to improve the quality of care?
She begins her answer by focusing on the primary importance of good outcomes, and what it takes to improve outcomes in a population. She moves on from outcomes to discuss their dependence upon processes, and reminds us that effective processes are dependent upon tools, protocols, and teamwork.
Outcomes, in the context of quality, are the health-related and experience-oriented results we hope to achieve. Processes, in the context of quality, are the ways in which the right health services can be delivered to the right person at the right time every time. As clinicians know, optimizing care processes requires translating the most current available evidence into effective actions that will increase the likelihood of better outcomes and tailoring those actions to the health needs and preferences of individuals. For most chronic conditions, these actions include detection, diagnosis, choosing appropriate treatments, ensuring adherence, assessing treatment effectiveness, and adjusting treatment as necessary. Accomplishing these actions with high reliability is difficult without supportive tools, protocols, and teamwork. Herein lies the heart of the challenge of improving quality systematically for everyone in the country.
So far so good. But, the tools, protocols, and teamwork necessary for the processes that lead to improved outcomes don’t appear out of thin air or from the individual actions of concerned clinicians. There must be an organizing structure.
Structure is the way in which institutions and professionals are organized, resourced, and financed to provide care in the communities they serve. Structure can also include disease registries, point-of-care decision-support tools that enable customized and effective treatment and feedback, staff to provide other services, and aligned financing and delivery-system incentives that support doing the right thing. The structure for health services delivery is the necessary foundation for effective processes and outcomes.
She then moves on to emphasize a tenant of quality that we have accepted as axiomatic since To Err Is Human was published in 1999. The message of To Err is Human was an emphasis on systems failures as the primary origin of error, rather than the deficiency of individual clinicians.
Quality of care is rarely about good health professionals versus bad ones. Professionalism remains a crucial, though insufficient, cornerstone of high-quality care. But in recent decades, policymakers have emphasized three additional levers to drive quality improvement: measurement, incentives, and addressing social factors.
She emphasizes that what we currently measure has more to do with the performance of processes rather than outcomes. The complexities of chronic disease undermine the utility of these “process measurements” and the reward systems that are attached to them, as mechanisms for improving quality when viewed from the perspective of outcomes or patient safety and satisfaction.
Most measures assess processes of care: what proportion of people receive selected services such as preventive care (e.g., immunizations), early diagnosis (e.g., cancer screening), treatment (e.g., medication, surgery, counseling), and follow-up (e.g., visits after hospital discharge). Ideally, process measures are based on clinical research that has proven which services increase the odds of desired outcomes. Because process measures generally focus on one element of care at a time, they rarely capture the full range of care needed by a given patient. It is increasingly common for people to have multiple chronic conditions, and measures are rarely aggregated for patients across all their needs.
Outcomes are less frequently measured, and many present both methodologic and attributional problems for accountability or reward systems. Many health-related outcomes take years to emerge (e.g., diabetes complications), are multifactorial (e.g., premature mortality), or occur too rarely to be measured meaningfully. Measurement is necessary — we cannot improve if we do not know how we are doing — but not sufficient to improve quality.
She then points out that we have been throwing money at the problem with little success. Pay for performance financial systems have been disappointingly ineffective.
Policymakers have increasingly turned to financial incentives, such as pay for performance, value-based purchasing, and bundled payments linked to quality measures, in efforts to motivate quality improvement. Research suggests that these programs have been only marginally effective because of program design, the magnitude of the incentives, the extent of the care affected, and the validity of the measures. Research has also found little relationship between methods of financing and quality. This disconnect may be attributable to the fact that incentive programs have not fundamentally changed the way care is financed. Financial incentives alone cannot fix fragmented and reactive systems or create the operating systems required to enable reliable delivery of high-quality care.
So what are we to do? In a system that is driven by continuous improvement we often set up experiments like the financial incentive programs of the the last twenty years. In essence we are setting up an IF/Then experiment. We are testing the hypothesis that if we do X, then Y will follow. Res ipsa loquitur, the situation speaks for itself, we did something when we tried to use financial incentives to improve quality and outcomes, and then quality and outcomes did not improve. When a hypothesis fails we all know that it is insanity to continue to do the same thing with the hope of better results. What is called for in Lean vernacular is an A4, or in ordinary English, going back to the drawing board using what we have learned that didn’t work, and using any new information we have acquired, we create a new hypothesis. McGlynn proceeds back to the drawing board with the enhanced awareness of the social determinants of health as demonstrated by the pandemic as the basis for a new hypothesis.
Recently the attention of health care leaders has returned to the structure and organization of health services delivery and its operation within the larger social and economic context of the United States. These social factors (or social determinants) — such as housing, food, income, education, and safety — may have a greater effect on health outcomes than the number of hospital beds or doctors per capita or the proportion of institutions and providers that have implemented electronic health records. Social factors have also contributed to disproportionate rates of chronic illness and delays in seeking health care services among Black and Latino Americans and other communities of color, affecting the ability of even the most effective health systems and hospitals to overcome the disadvantages. For example, risk factors such as obesity, physical inactivity, and smoking are significantly influenced by the environments in which people live and work.
If there is any costly lesson to be learned from our terrible experience with COVID-19, it is that the social determinants of health have a huge impact on outcomes. The data about the variation of severity and risk of COVID-19 as a function of ethnicity, race, and economics is beyond dispute. I would postulate that the reason some European nations of equal economic strength have fared better in the pandemic than America has is that they are more generous, or “socialist,” in their creation of social safety nets and equity, even as they have remained effective capitalist economies. The slippery slope to left wing totalitarian disaster that the president warns us of if the nation votes for a Joe Biden who in his dotage is directed by “left wing” progressives is hard to fathom when one ponders the economic and social success of countries like Germany and many of the Scandinavian nations. Are Ikea and Mercedes not market forces arising from countries that have a better balance between social services and commerce than we do? I’m getting ahead of my story so back to comments by Professor McGlynn. I have bolded the core points.
Given the limited progress to date, the path to higher-quality care in the United States requires reconsidering approaches to measurement, financing, and organizational structures and a new emphasis on social needs. We need to redesign for success, spread what works, and stop doing what does not work.
I believe we should start by creating the financial and organizational conditions for changing care delivery from a reactive, fragmented enterprise to one that is coordinated and longitudinal, reflecting the need for systems that can effectively manage chronic disease….Finally, as the Covid-19 epidemic has demonstrated, we need to explicitly link health care systems with appropriately resourced public health and community-based services...As we recover from the pandemic and address structural racism and inequities, we have an opportunity to invest in quality in ways that lay a foundation for a healthier America.
The article that Professor McGlynn wrote in 2003 was part of a great awakening among healthcare professionals who cared about outcomes as the true measure of the benefit we offer to our patients and our communities. Those truths are real. What COVID has taught us is that outcomes are still dependent upon processes and supportive tools, protocols, and teamwork, but as these are necessary, they are not sufficient to accomplish the improved outcomes we desire. If you think about it, our efforts have been largely directed toward the organization of care, and we have not paid enough attention to those who need care, or the barriers they encounter as they seek to receiving care. We have neglected the pursuit of outcomes from the patient’s perspective. We have neglected the correction of the inequalities and the removal of barriers to care that are a huge part of the problem, and just like a storm can reveal the structural defects in a building, the pandemic has shone a light on serious structural defects in our society. The good news is that with this knowledge we can make a course correction that will benefit every American.
What will prevent us from capitalizing on what we have learned? What will we need to do to achieve the better outcomes that we could enjoy? What candidate do you think is most likely to support policies that follow Professor McGlynn analysis and advice? As you ponder that question remember:
As we recover from the pandemic and address structural racism and inequities, we have an opportunity to invest in quality in ways that lay a foundation for a healthier America.
Is it likely that a candidate who has never offered any constructive policies to improve the health of the nation, and is systematically undermining the ACA and what is left of our tattered social service safety net, would ever understand or be interested in adopting the policies that might improve outcomes? Bottom line healthcare profits are necessary to maintain our current fragmented system of care. Shifting our concern from the bottom line only to a balance between outcomes and sustainability will require leadership that gains strength from efforts that are motivated by the desire to improve the lives of people, and not from an administration that presents itself as a bulwark against factitious threats. We need leadership that knows how to create consensus and move toward an appreciation of the unique worth of every American and every person on the earth, and not one looking to get rid of losers and miscreants as defined by the biases of a dwindling portion of an emerging white minority.
If the president is reelected, I will not give up hope for better outcomes for everyone and the eventual emergence of the full flower of an idea that is as inclusive as the Triple Aim. John Lewis lived and died in expectation of something that he believed deep down at the core of his essence would someday come to pass. We have all learned that the arc of history does bend toward justice, and there is no description of the timeline, but we always have the ability to shorten the wait or perpetuate the pain. I am waiting with a combination or hope and anxiety to see whether on November third we will be accelerating the pace toward justice and better health, or condemning ourselves to four more years of needless pain, loss, and collective decline. Your vote will count. Between now and the election, do what you think is right to promote the vision of health and opportunity that you think will best serve America’s future.
