8 February 2019
Dear Interested Readers,
Imagine That!
Last Sunday the Associate Minister at my church delivered a wonderfully crafted sermon entitled “Imagine.” She was not asking us to daydream about what might happen that evening in Atlanta as the Patriots engaged in Super Bowl LIII with the LA Rams. The point of her homily was a challenge to the congregation to try to imagine living larger lives with more meaning and more benefit to others. Within the spirit of her message was the challenge that we might imagine how individually and collectively we could get beyond personal worries and our collective inwardly focused concerns about the future of the church and instead consider the needs of the those in the community whose lives were filed with economic uncertainty and the associated challenge of living without the comfort of the personal and financial resources we enjoy. Due to the generosity of generations of previous church members going back over more than two centuries our church has substantial resources that could allow us to exist for many years without collecting a farthing in new offerings.
I assume that my church is not the only church where people are wondering what the relevance of organized religion is in our times. As I looked around at a sea of empty pews, I realized that many people had already answered the question and in so doing were out and about pursuing other interests on this bright sunny day in midwinter. The minister’s question was obviously meant to start a conversation. After the service was over I told her how much her message had meant to me both in the context of my concerns about the future of the church, but also in the context of the wider conversation about the future of our country in its current state of division. I was also thinking to myself that her sermon spoke indirectly to the future of health and healthcare in our country which is riven by disagreement over the question of how much concern and help we owe to one another.
She quickly told me that her sermon was not a “one and done” offering meant to provide a challenge that would soon be forgotten. She was interested in going beyond an academic discussion of “what ifs” toward a real renewal of service to the community. I was not surprised to receive an email from her this week inviting me to join what John Kotter would describe as a “guiding coalition.” Her email had a quote at the top of the page.
The church’s central task is an imaginative one. By that I don’t mean a fanciful or fictional task, but one in which the human capacity to imagine—to form mental pictures of the self, the neighbor, the world, the future, to envision new realities—is both engaged and transformed.” B B Taylor
I would like to co opt and modify her header for a discussion of the future of healthcare. All I need do is swap church for healthcare. It would be easy to say:
Healthcare’s central task is an imaginative one. By that I don’t mean a fanciful or fictional task, but one in which the human capacity to imagine–to form mental pictures of the practitioner, the patient, the community, the future, to envision new realities–is both engaged and transformed.
Imagining is central to continuous improvement. After recognizing that there is a “reason for action” and thoroughly considering the “current state,” the main task in the initiation of change is to imagine what might be better. After bringing others into the conversation about the need for change, the greatest challenge and barrier to effective change is the ability to avoid “jumping to solution.” Following Lean process is a great way to move a “coalition of the concerned” from the inadequacies of the current situation toward a better future. The pain and dissatisfaction of the moment can go only three ways. A bad moment can deteriorate into something even worse, it can persist in all of its dissatisfaction, or it can be improved. The first two possibilities are usually passive and/or the result of ineffective action. Attempting lasting improvement requires the application of energy and resources and when successful usually results in a transformational change. The energy to organize for transformation for a better future arises from a motivating dissatisfaction with the moment.
I do not hear much satisfaction with the moment when I listen to people talk about healthcare. We all acknowledge the progress being made in the science of understanding and treating disease, but even while modern medical miracles occurs we are quick to point out how difficult it is to get help for the most ordinary concerns. We complain about how much time and effort was required just to get an appointment that did not result in a satisfactory resolution of our concern. Even when we get the help we need there are usually complaints about how expensive the process was, how much of our time was wasted, or how rude the staff was. Those are typical complaints from those who have access to care. It is worse and more distressing if we bother to reflect on how hard it must be to be a person with a concern who is at the bottom of the social order and can’t afford the cost of care, or the time away from work to get care. We have many places to apply our imagination when we think about the challenges that persist in healthcare despite all of our scientific achievements and the heroic efforts associated with the ACA to give more people affordable access to care.
This last week David Blumenthal, the president of the Commonwealth Fund, published a piece in Stat that was meant to be a warning to potential candidates for president in the 2020 election. Dr. Blumenthal says that it is already late to be developing their position on the healthcare issues. They need to be past developing a position and far into conceptualizing a plan of action. I am listening closely to what the candidates are saying. There seems to be a relatively uniform collection of issues that the politicians address. The differences in their ideas and opinions have not evolved very much. Some of the items on their list do coincide with my concerns, but not all of the issues that I would come up with if I were to “imagine” the improvements that I would like to see either as a patient or practitioner appear on the lists that the politicians discuss. Politicians will talk about:
- Financing for universal access: Within the Democratic Party the debate is between “medicare for all,” the addition of a public option to the ACA, or a repair of the ACA.
- The high cost of healthcare to individuals even when they are on an employer sponsored plan.
- The high cost of prescription drugs.
- What to do to fight the opioid epidemic.
The first issue overshadows the next three. The barriers to universal access through “Medicare for all” include the fact that it is labeled as “socialized medicine,” or can be characterized as a government infringement on the rights of individuals and states. Many patients and healthcare professionals have a baseline distrust of the government, and despite the success of the public funding through Medicare and Medicaid for the use of our privately owned system of care, they are concerned that if there was not the counterbalance of private or commercial insurance as an alternative to government funding, we would have a disaster. If “Medicare for all” ever gets past those concerns there would be the reality that taxes would need to increase to pay the bill. Economists tell us that premiums and copays would convert to tax dollars with the average family paying less in the exchange and therefore would have more disposable income. That is a big sale to make when there are many people who do not trust the government. For me, the real concern would be whether the program would be more like Medicare fee for service or Medicare Advantage. A hidden advantage to “Medicare for all” might be that it would do away with the local variation associated with Medicaid.
Alternatives to “Medicare for all” include dropping the eligibility age for Medicare from 65 to some earlier age, perhaps 55, offering a “public option” on the exchanges while bringing other improvements to the ACA, or just improving the ACA. A “public option” would preserve the private insurance industry for the moment while challenging them with a powerful, well funded, competitor–the government. There are many transitional concerns associated with a “public option” and it is certain that opponents will see it as a “slippery slope” to Medicare for all.
Revamping the ACA utilizing what we have already learned could be an improved way to expand coverage. It is sad when we realize that this is something that a focused Congress could have done anytime in the last six years instead of having to defend the remnants of the ACA from continuous attempts to “repeal and replace” it or administratively undermine its potential. The president did mention his desire for “great healthcare at an affordable cost” for every American in his State of the Union Address. As usual there was no plan, no indication of how consensus would be generated, no sense of the resources required, or even enough verbiage to confirm that he had any idea at all of how what he was “promising” could be accomplished. His promises do not have a great batting average even on the issues he seems to really care about like a 2000 mile wall that someone else will pay for. I can’t imagine how we would survive the healthcare equivalent of 250 miles of steel slats.
As legislators and presidential “wannabes” struggle with the framework of a system that would offer access to everyone, I have seen no evidence that a critical number of them have asked the question, “If we gave everyone a ticket to ride the bus, are there enough seats on the bus for all the passengers?” Healthcare is currently rationed “defacto” by limitations on access and by limitations created by out of pocket uncovered costs. I know many people who have “coverage,” but still avoid care because they cannot afford the continuously rising out of pocket costs of increased co pays and deductibles. When they do seek care they often find additional expenses in meds, consultants, and testing that are not covered by their plan. We lack more than enough “seats” on the bus. We also lack enough bus drivers. There is no doubt in my mind that when we finally pass some form of universal coverage we will discover that “finance” worries have just been replaced by “workforce” issues as our primary concern.
Dr. Ebert was wise when he advised us that finance and operations, how we pay for and deliver the care, should be our points of focus as we endeavor to “…provide optimally for the health needs of the population.”
Atul Gawande has made two comments in the past that should be considered by our politicians and by those who lead our delivery systems. The first is that we are no longer hampered by our scientific ignorance in medicine. We now have the science and technology to cure or manage an amazing number of medical and surgical problems that less than a quarter century in the past were certain death sentences or long term sources of continuing pain and disability. Now we are most limited by our ineptitude in the distribution of our scientific and technological triumphs. The second piece of wisdom that Dr. Gawande has emphasized in some of his speeches and writings is that “path dependency” is a continuing factor that must be considered as we manage the evolution of the payment and delivery systems.
“Path dependence explains how the set of decisions one faces for any given circumstance is limited by the decisions one has made in the past or by the events that one has experienced, even though past circumstances may no longer be relevant.”
“History matters.” It is rare that we are eager to throw out all that we have done in the past. Systems of production and finance are more easily modified than replaced. We tend to think about the future as a logical extension or “upgrade” to what we know now, even though many of us can quickly think of a process that is an exception to that statement. Was the invention of air travel a totally new process or just an enhanced process of moving people further and faster? In defense of Gawande’s idea it seems hard for many of us to imagine delivering care in the future without hospitals or medical offices financed through a fee for service mechanism. It is the world we know. It appears that many of us think that there is no problem with universal access as long as it does not change the structure or finance that we know.
Can we imagine the future of practice without our current dependence on the doctor’s office? One of my ancestors, 3 greats back, Dr. Ebenezer Childs delivered care from an office in Shelbourne Falls, Massachusetts in the early half of the nineteenth century. Another distant relative now owns the ledgers from his office. It was a fee for service or pro bono practice. Those who could pay did with money or produce. Those who couldn’t pay were still seen. He had a proprietary streak that caused him to attach a letter to his “recipe” for diarrhea that he gave his son, my great, great grandfather, Dr. Eben Childs, who was moving to the Finger Lake region of New York to establish his own practice before he eventually moved to the mountains of North Carolina in the 1850s. Along with the “recipe,” old Dr. Childs the elder included a note to his son stating that he would disown him if he ever shared the formula with another physician. Another ancestor, Dr. Cato Baxter Wiseman, my great grandfather, was the only physician in Rutherford County, North Carolina in the early 1900s. He owned the first car in the county which allowed him to make many more house calls than he would ever had been able to make using a horse and buggy to complete his rounds. Despite these quaint elements of their practice, it is striking to realize that the office that I entered at HCHP in 1975 was still on the same path followed by my ancestors, and the basic structure with all of its limitations still exists today. All of us primarily delivered care in an office setting, and now in 2019 most medical offices function in much the same way as my great, great, great grandfather’s office in 1819, and in my great grandfather’s office in 1919, the year my mother became his first grandchild. The path of care delivery has not changed much even though we now talk about “medical homes” and struggle with EMRs. If we have been using our imaginations to improve the experience of the patient we have been traveling on a narrow trail and not a super highway.
In my years of leadership I found that nothing squelched our effort to innovate more than being paid “fee for service.” As capitated contracts faded in the 90s it became clearer and clearer that unless any proposed innovation or enhancement in service was delivered after the patient walked through the “turnstile” into our office, our lab, or the admissions office at the hospital or EW there was little likelihood of implementation. Any new program needed to appear in the budget as a revenue line that was greater than the expense line, if it had any possibility to be part of the care we consistently provided. I was delighted when we invested in a data warehouse in the late 90s. I saw it as a huge leap forward in our ability to manage quality and understand our patients. I was very disappointed to learn that the management at the time valued it primarily for its ability to help us manage finance, and not as a way of learning better ways to serve our population. The two objectives are not mutually exclusive.
As I think about imagining a better system of care, it occurs to me that we always say that we value our patients and employees. When I speak to patients and healthcare professionals I come away from the conversation realizing that those few attempts to listen to patients and improve the environment of practice fall far short of the brief periods of enthusiasm they initiate. As a result it should be no surprise that they are often viewed as perfunctory and disingenuous. They can breed more cynicism than change. I do know that pediatricians at some sites of Atrius used Lean and worked from the perspective of parents. Using their “imagination” they were able to reduce the time investment of an appointment from ninety minutes to forty five minutes while more frequently finishing all the many forms for camp or sports clearance within the appointment. Eliminating big blocks of wasted time in the waiting room, the exam room, and in the lab and radiology were possible when they looked at the process from the perspective of the family and tried to imagine something better.
In a post earlier this week I asked rhetorical questions about how we use hospitals today and how they might change in the future. I pointed out that in most systems hospitals are “revenue centers” when in fact they should be “cost centers.” When we begin to imagine how to be more effective in our ambulatory practices we may discover that the “office” is just as great a source of waste as the hospital. With rare exception our offices sit empty at least fourteen hours a day. Most medical offices function with such inefficiency that patients often dread the process of “going to the doctor” while doctors dread going to the office.
I do not know if the next president will be from the Democratic Party. Assuming that the Democratic Party does win the Presidency and the Senate, and is able to retain the House, I hope that they will realize that just providing universal access will not fix the complaints and concerns of most patients nor will it really “…provide optimally for the health needs of the population.” For better care, the path that we must surely exit is fee for service finance. Legislation can create “ground rules” that favor competition. The ACA was an attempt to improve the cost and experience of care by creating opportunities for healthy competition. We have not embraced those opportunities effectively. We did not really want to imagine that we could create something better. I wish I could say that the only incentive we need for better care is our concern for mitigating the impact of current practice methodology on the satisfaction of patients. I have no doubt that if we were free of the burden of FFS and that success required us to imagine care that was an answer for the concerns of patients and providers, we would make some surprising changes.
Change of Venue
I am enjoying a February thaw of my own this week and next. It did warm up a little in New Hampshire earlier this week before we flew out to Tampa. Over the next week and a half we will be visiting various friends and family on our way to “Grandparents’ Day” at my granddaughter’s high school in Miami late next week before returning to Tampa to see her play in a big volleyball tournament.
If I were at home, I would be viewing a scene much like the one in today’s header. I hope that my walks this week in balmier climes will produce some pictures of flowers in bloom or vast stretches of beach, water, and sky that I can share with you. Whatever the reality of the weather where you are this weekend, I hope that you will enjoy being out and about.
Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,
Gene
