A few years ago Patty Gabow, the retired CEO of Denver Health and a master of using Lean to benefit the underserved, and I were enjoying a dinner together while we were attending a meeting. Our conversation had gotten to the level of sharing and openness where we were trusting one another with thoughts that explored the origins of our strength to maintain hope in the face of mounting adversity and uncertainty. I mentioned my interest in the writing of a progressive theologian, Marcus Borg, who had recently come out with what would be his last book before his death from pulmonary fibrosis, Convictions: How I Learned What Matters Most. We began to discuss our past histories in relationship to personal inquiry and the search for spiritual meaning. That was when Patty revealed to me that she began most days reading the daily letters from Father Richard Rohr, a Franciscan monk who leads the Center for Contemplation and Action, in Albuquerque, New Mexico. Anything that Patty thinks is worth her time is something that interests me.
I have been enjoying Father Rohr’s letters and appreciating his way of seeing the world now for about two years. Along the way I have discovered many others who find wisdom in what Father Rohr has to say, including one of the ministers at the Baptist church that I attend! Obviously his message is not just for Catholics, nor do you even need to have any relationship with Christianity to be moved by his words and wisdom. The first two paragraphs of his post on the Fourth grabbed me as I was thinking about the energy necessary to try to fight for better care and to preserve the little bit of the gain we have made toward the Triple Aim. I have been tempted on many occasions to reference Father Rohr in these letters. I decided that I should share some of the post with you. It begins:
Charles Péguy (1873–1914), French poet and essayist, wrote with great insight that “everything begins in mysticism and ends in politics.” Everything new and creative in this world puts together things that don’t look like they go together at all but always have been connected at a deeper level. Spirituality’s goal is to get people to that deeper level, to the unified field or nondual thinking, where God alone can hold contradictions and paradox.
When people ask me which is the more important, action or contemplation, I know it is an impossible question to answer because they are eternally united in one embrace, two sides of one coin. So I say that action is not the important word, nor is contemplation; and is the important word! How do you put the two together? I am seventy-four now and I’m still working on it! The dance of action and contemplation is an art form that will take your entire life to master. Like Moses at the burning bush, many of us begin with a mystical moment and end with social action or what looks like politics. But it also works in the other direction. Some start by diving into the pain of the world and that drives them toward their need for God.
Thinkers like Robert Ebert and his students that I have known, like Joseph Dorsey and Don Berwick, joined others in both actions and contemplation from the sixties though fifty years of experience to produce the Triple Aim in 2007. Now ten years later and with more action having accumulated, we have more experience to contemplate. Contemplation of what we have learned and what it all might mean allows us to say that our objective is:
…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..
I do not think it is a stretch to say that what began as ideas in the minds of physicians and healthcare professionals in the mid fifties resulted in actions that have made a difference. Those actions have also generated a political conversation.
All movements in history, including “the enlightenment” which gave birth or sustenance to many of the ideals we celebrate on the Fourth of July and our current efforts to use science to save the planet and improve the lives of all of its inhabitants, have encountered resistance. Processes of transformation and continuous improvement appeal primarily to those who are suffering the injuries of the status quo. The status quo is the target of improvement and those who own the advantage of the moment have always preferred that we not examine its inequities or consider a more generous and efficient future. In healthcare contemplating the failures of our current delivery system and methods of care has generated actions and new ideas that have met the resistance of the status quo and that is politics! Péguy was right!
Recently, I spent an evening with colleagues who now have, or have retired from, significant leadership responsibilities in healthcare. We met to discuss over a good meal how physician groups and hospitals might work together to preserve the benefits of the ACA and promote the next positive steps toward the Triple Aim. It was obvious to us that there was little that we could do that will alter whatever the outcome might be. It was clear to us that our focus should be doing what we could to help the organizations where we have influence to prepare for the uncertainty of the future. If Medicare and the ACA were to eventually be the victim of the Better Care and Reconciliation Act of 2017, the path to the Triple Aim would not change much although it would be much more challenging to stay the course.
Under any law the future will belong to those organizations that can lower the total cost of care through operational improvements and innovations that improve the experience of patients and support the work of clinicians so that both patients and clinicians have a higher level of satisfaction and a new sense of engagement. Over the last fifty years we have developed a great deal of consensus around what should work to improve care. A huge barrier to the implementation of what we think will work is the status quo of healthcare finance. How we get paid for the 85% of citizens who will still have access to us needs to change, and it can change without the passage of any law. The flow of money after you subtract many of the recipients of Medicaid and the participants in exchanges will be controlled by the contracts we negotiate and the way we chose to pay ourselves within organizations. I do not think we can achieve the objectives of the Triple Aim by trying to improve productivity through individual compensation that drives volume work and undermines collaboration. Bonuses designed to “improve productivity” but end up enticing behaviors that result in the ordering of more tests and procedures for more patients will never support organizational transformation that lowers the cost of care.
If the goal is clinician and patient engagement to promote better behaviors, self management, and improved outcomes with less waste of resources, then we must allow clinicians the time to be with patients and shift many appointments and encounters from perfunctory interactions that do nothing but generate revenue to other professionals or other forms of interaction on line, in groups, or with other professionals who are quite capable of managing established problems. More effective collaboration within teams should be a prime objective of all organizations who care about the future of healthcare in America. We can never do the work of transformation and improvement while we are exhausted from working in dysfunctional and misdirected systems.
We do not need new laws to permit quality improvement. We need leadership. Perhaps if we could lower the cost of care we could enable covering more lives. Beginning with Romneycare in Massachusetts, Chapter 58 of 2006, and continuing on with the ACA in 2010 we have explored the approach of expanding access first and controlling costs second, hoping that we could lower the total cost of care for the country later as an outcome of universal coverage. We may have had it backwards. We needed to develop more effective simultaneous efforts to lower costs as we attempted to expand access. Those who believe we are wasting money are correct even if their motivation is to try to eliminate waste by disenfranchising many who now enjoy coverage and vastly reducing the resources available for those who do have access.
Medical institutions still have resources for investment. Many think that a new bed tower or another piece of expensive surgical or diagnostic equipment or a new medical record will solve their problems. I doubt that they are right. I fear that what Dr. Ebert said years ago is still correct. We do not need more money, more facilities or perhaps even more people. We need individual organizations to realize that they will survive if they can evolve operating systems and finance mechanisms that support the improvement of health through the equitable distribution of what we already have and the benefits of what we have already learned. A good starting place is to engage everyone in the work of care improvement and waste reduction. Call it Lean or call it continuous improvement. Under any name it requires engaged servant leadership that supports and provides opportunity rather than cuts budgets and eliminates services. Everywhere I look I see more cutting and eliminating than I see creating and improving.
Atul Gawande was right. We are not ignorant. We are inept. Perhaps the good outcome of a bad healthcare bill might be that we will be forced to realize that the way to better care is through deep contemplation about why we do what we do, and then rededication to the difficult task of the actions that will yield the outcomes that we say we want. After we pass through this valley of discontent and disruption and contemplate its miseries, perhaps we will have the courage to take action and move to a new order that provides everyone with the care they need. Perhaps then there will be acceptance of the truth that healthcare is an entitlement that has universal benefits that are best achieved by a single payer.