I am so glad that it is going to be the 20s tomorrow. Bye-bye to a so-so decade. This New Year should be very interesting. There should be events that occur this year that will have a long term significance in our collective experience. I always embrace the New Year as a turning of the page. I am always looking forward to the promises and possibilities of a fresh start. This year we also get a fresh start on a new decade.
Eight years ago, my son who writes songs put out a New Years song that is one of my favorite songs among the nearly 500 songs that he has put up on the Internet on his website. Each week his song is accompanied by a short note or essay and a picture. The note below is from January 2, 2012. We have seen a lot of change in the interval, but his observations are still valid. I have imagined that those are magic goggles that you see him wearing in the picture at the top of the post that allow him to look far into the future. I have bolded the lines from the note and the song that speak most directly to me. Was it those glasses that allowed him to have such a clear view of reality?
This week I once again look to the new year for inspiration, but unlike last week, I am not talking about frustration and anger. This time I’m talking about the ever steady passage of time. I traveled through southern New England on New Year’s Eve to make my way to a celebration in Rhode Island. I avoided all of the major highways and found myself criss-crossing through old mill towns that I had never visited before. They were all remnants of another time, and time had clearly taken its toll. A heavy fog had set in and I could see little more than what was just in front of me. Amazing hulking smokestacks and rubble would periodically emerge from the white, and damnit if I wasn’t driving through a poem about the loss of industrial America and the dawn of an uncertain era. It was truly beautiful, but at first I felt sad. Perhaps if it hadn’t been New Year’s Eve, I would have remained that way. But it was quite clear to me that the strewn remains of mills and factories were part of a natural process. The years will march on, and things will be born and things will die. If time doesn’t pass the future cannot be. I chose to focus on renewal and the potential that exists in the present. Needless to say, I felt the whole thing to be quite profound, so when I came home I wrote a little song about it.
You can click here to listen to the song, but in case you don’t, the most important verse is:
Listen up: It’s not falling apart
Cuz the past isn’t physical
It’s a place we can start
It’s a concept like future and present
And time’s like a beating heart
And one day’s gotta end for the next one to start
And how lovely it is
This time of year I always find myself wondering what I will be reflecting on this time next year. Time is linear, but humans have lived “in cycles” far longer than we have had a linear view of history. Some of our cycles are a year long. Some of our cycles are four years long. Some of our cycles are for a lifetime. It’s interesting that we do notice decades, but what do we do only once every ten years, other than come up with a name for the time period? The only public office I can think of that has a ten year appointment is the director of the FBI. What’s interesting is that we have that term because J. Edgar Hoover was the FBI director for almost 48 years and died in office. Since Hoover, only one director, Robert Mueller, has completed the term.
We do notice decades for what we call them. Most of the time we just use the number like “the fifties” or “the sixties.” Perhaps we gave up on dramatic names like the “gay nineties” and the “roaring twenties” after the twenties ended so badly and were followed by a decade of depression and the emergence of fascism. I have never been comfortable with the names of the first two decades of this century. Officially, 2000- 2009 was the two thousands, and 2010 to 2019, was the twenty tens, but did we ever really use those terms in the aftermath of 9/11 or the exhausting years of continuous war and TSA lines that followed its horror? Were these the decades of debate over global climate change, fake news, and the worldwide emergence of illiberal political leadership?
In a recent article entitled “What should we call the decade that just ended?” from the Christian Science Monitor, Melissa Mohr covers these concerns about what to call the decades since the nineties. She mentions that some Brits refer to the years from 2000 to 2009 as the “Naughties,” and I do remember hearing that label occasionally. She notes that the “teens” are not good for the period 2010-2019 because that leaves out 2010, 2011, and 2012. She adds that some people consider the decade to be such a rolling disaster that they prefer “The Tensions” to the “Twenty-tens.” I enjoyed her piece, and have come to the same conclusion that we should be delighted that the confusion is finally over. Tonight, at midnight I will be delighted to welcome in the “Twenties!”
I have searched the Internet for Healthcare expectations for 2020. Don’t waste your time. There are some decent articles on healthcare and the 2020 election. I think the articles from the Commonwealth Fund are better than most of the other articles from responsible journalists who understand politics, but are not as deep in their understanding of the complexities of healthcare. Most of the other articles that I could find are about the business of healthcare and are written for healthcare investors and systems managers. I found no articles that specifically address the issues for 2020 or for the decade that will impact care delivery for patients and providers. The articles I did find focus on health IT, Big Data, and the emergence of Artificial Intelligence as a clinical tool. One article predicts the continued growing importance of Medicare Advantage. Perhaps the best of the 2020 predictions exercises is from Fortune. The article was co authored by Bob Kocher, MD of Venrock Investors, a former Beth Israel Deaconess house officer and member of the Obama administration who now teaches at Stanford when he is not investing in healthcare. I have heard him speak, and he knows healthcare and healthcare policy. The title of the article suggests that we are above all a money centric industry, and a fertile field for investment. What happened to patient centric professionalism and ideals like the Triple Aim as the objects of our concern? I see no mention of investment opportunity or focus on revenue growth in Don Berwick’s Third Era of Medicine:The Moral Era.
I am not as interested in thinking about 2020 as I am about the whole of the coming “Twenties.” Things move slowly in healthcare, and even slower when we are talking about the reform of healthcare. Whether we look back to the Clinton administration, or the Nixon administration, or the Truman administration, or even back to Franklin Roosevelt, or all the way back a hundred years to Teddy Roosevelt, the reform of healthcare has been a very slow process of incremental change consuming decades. So the real question to consider is not how healthcare will be “reformed” in 2020, but what concerns will we need to watch over the next ten years. Realizing that the “long haul” is likely to continue without much positive change, or any change at all, that we can affect prior to November 3, 2020, I am reminded of the wisdom from my son’s song:
The years will march on, and things will be born and things will die. If time doesn’t pass the future cannot be. I chose to focus on renewal and the potential that exists in the present.
So, what should we be doing while we wait for November 2020, and then January 2021? Even if our national leadership in January 2021 accepts the challenge of achieving universal access to care as a right and the Triple Aim as the objective, measurable systems improvement awaits passage of controversial legislation, and several years of transitional confusion. In the interim, how do we live day by day doing what might prepare us for a better future, even as we fear the possibility of losing what little remains of the hope and progress associated with the passage of the ACA a decade ago? It is easy to project that before a new law can extend care to everyone, even those who now enjoy “the best” coverage will see increased expense and a deterioration of their advantages.
We are well advised to focus on “today” all through 2020. Businesses, including healthcare enterprises like hospitals, health systems and provider organizations, not just insurance companies, consultants, IT organizations, device manufacturers, and pharmaceutical companies, all hate uncertainty. The only certainty that is available to those individuals who provide care is in their day to day opportunity to do their best to address the medical and social issues that challenge the people who do have the opportunity to see them. There is also the larger opportunity to ask the personal question, “How effectively am I personally performing against the template of providing care that is patient centered, safe, efficient, effective, timely, and equitable?” As we approach November, it will also be true that we can individually participate in the political process that will chose a leader who can favor policies and legislation that might make the “Twenties” a decade of transformational change in healthcare. The greatest risk to a new decade of healthcare progress is that voters will accept the short term temptation to vote for what they think is best for their individual pocket book, and not what is best for the Triple Aim, the environment, and their communities.
At the enterprise level, 2020 will be a difficult year as costs rise and reimbursements remain flat to declining. Our president will probably do his best to finish off what little is left of the ACA through continuing administrative abuse, and after the Supreme Court takes another swing at it sometime this year. Management and boards will continue to wonder whether or not they should focus on developing the infrastructure that is required to perform well in population health and value based reimbursement. It is not unreasonable for them to imagine that if the president were re elected we might return to the pre ACA world where their reimbursement will be a function of the number of visits and procedures that can be billed by focusing on the insured population.
There are a few things that I believe will be true and that we will need to address in the coming decade that will face us all including the winner of the 2020 election.
- Without a new healthcare law that increases federal support for healthcare access, we will see more and more financial pressure on individuals and businesses.
- Provider organizations will continue to be pinched as the cost of care will continue to rise faster than the GNP and reimbursement will continue to be flat relative to inflation. The result will be more pressure on all systems, but it will be most severely felt in rural and inner city provider systems.
- The systems that continue to focus on efforts to improve service, improve quality and safety, eliminate waste, and improve the experience of practice through the use of continuous improvement science will perform better than systems that just focus on volume and business as usual in short term financial cycles.
- Healthcare workforce challenges will add costs as access deteriorates. The rural and inner city systems are already stressed and the pressure will only increase as the problem spreads to more affluent environments.
- Pharma costs will increase without a true bipartisan approach to the problem.
- We will see AI used to address some of the workforce issues.
- There will be continuing access issues that force re engineering of primary care.
- External financial pressures and workforce issues will threaten quality and safety.
- Global warming will be an increasing concern in chronic disease management and population health.
Those concerns sound dark. The current momentum in the administration and the courts against the ACA and positive change, and a political climate of deep division make the darker days in the next decade possible. Our hope lies in our previously demonstrated ability to rise to great challenges. As a nation we have turned things around before. Change requires us all to realize that it is rare for individual financial security or health to be durable for anyone as more and more of their neighbors become overwhelmed by problems that they can’t solve alone. Success, as the song suggests, requires that one day’s gotta end for the next one to start. What we have learned from the past is where we start. Your individual commitment to doing your part to improve the experience of care of everyone in your community in 2020 is the best way to start a new decade that against great resistance must salvage the best ideas of the last three decades and weave them into a new remarkable decade of transformation. I am looking forward to celebrating the passage of a great decade of accomplishment on December 31, 2030.
Have a happy New Years holiday, and best wishes for the coming decade. All the best as we begin our journey toward the Thirties.
