April 16, 2021
Dear Interested Readers,
How We Get Paid Makes A Difference In What We Do
Over the years I have probably used one quote from Dr. Robert Ebert in these notes more than any other idea, quote, or concept from any other source. Even if you are only an occasional or casual reader, more than once you have probably read:
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.
I think that it has been several years since I have told the story behind the quote. It is the story of a quest for transformational change. Dr. Ebert came to Boston from Cleveland in 1964 as the Jackson Professor of Medicine and the Chief of Medicine at the Massachusetts General Hospital. He had become convinced that we needed to change how care was delivered, and he was interested in starting an academic prepaid healthcare organization that delivered preventative care as a better way for care to be delivered than through the existing fee-for-service practices that delivered care after the fact of an illness.
His ideas were hard to sell at the Massachusetts General where I am sure most doctors were convinced that the care they provided was the best in the world and that their delivery of care was exemplary and not really in need of improvement. My first experience at the MGH was in 1967. I can assure you that doubt about the excellence of their care was not then, and has never been, a major concern for them. In 1966 after less than two years at the MGH, and without success launching his pilot practice because the idea was met with substantial resistance, he moved across town to become the Dean of the Harvard Medical School.
I entered HMS the next year in September 1967, and from that point forward have been a witness to what happened. Dr. Ebert was not discouraged by the chilly reception that his idea got at the MGH, and at the medical school found support from nearby Dr. George Thorne, the Chief of Medicine at the Peter Bent Brigham Hospital, and from Dr. Howard Hiatt, the Chief of Medicine at the Beth Isreal Hospital. With their support, and after a three-year planning process and search for funding, the Harvard Community Health Plan (HCHP) opened its doors in nearby Kenmore Square in October 1969 with about 80 patients who were outnumbered by primary physicians, specialists, nurses, and support staff. All of the doctors were affiliated with the PBBH and the BIH.
I watched “The Plan” grow while I was a medical student, intern, resident, and cardiology fellow at the Brigham. In early 1975 one of my mentors at the Brigham, Dr. Marshall Wolf who provided primary care and cardiology services at his practice at HCHP, called me into his office and told me that he wanted me to take his practice at HCHP because he was going to be the full-time director of the house staff at the Brigham. Dr. Wolf’s offer immediately answered a recurrent question in my mind, “What’s next?” It allowed me to be primarily focused on practice and continue to be at the Brigham. I said, “Sure and thanks,” and that was it. On July 1, 1975, after one brief interview with Lee Younger who was the chief of medicine, who got me to promise that I would give it at least a two-year try, I showed up for the rest of my professional life.
Between the fall of 1969 and July of 1975, the plan had grown from about 80 patients to about 80,000. When I retired from Harvard Vanguard and Atrius Health at the end of 2013 the practice had almost 500,000 patients and all of the Atrius practices together had over 900,000 patients. Dr. Ebert’s idea had evolved and grown. I offer you an article from the Harvard Crimson that describes the progress that Dr.Ebert felt had been made by October 1975. The author says:
What Ebert calls his greatest accomplishment at Harvard is the establishment in 1969 of the Harvard Community Health Plan, a pre-paid hospital care service administered by the University. He volunteered the same type of project in Cleveland and was rejected. Ebert refers proudly now to the list of similar plans the Harvard program has since inspired.
Further on in the article, he writes:
The increased admission of black students and women over the ten years of his deanship, Ebert says, was significant largely because it had an impact on other medical schools. The Harvard Med School class is now about 19 per cent black.
Ebert admits that his administration has been concerned more with issues of public health and the societal role of the school than with academic matters. This is because Ebert views himself, from the context of a detailed historical analysis of the role of the Med School, as the pilot of a school in the midst of a prickly “transition period.”
Looking back it is easy for me to say that when I entered HMS in 1967 neither I nor most of my classmates were aware of the fact that Dr.Ebert wanted us to be leaders in the social transformation of medicine. He believed that Harvard should diversify from its focus on the science of medicine to include interest in the social impact of care. He was convinced that it was time for a transformation of the delivery of care and that the place to start was with the education of the next generation of physicians. In 1969 we did not have terms like the social determinants of health, healthcare inequities, or healthcare disparities, but he was aware that these problems existed just as he realized that there was little or no diversity in professional ranks. He was determined to begin the transformation toward greater concern about the health of the community and the lack of universal access to care. He was several decades ahead of the majority of healthcare leaders. He also knew that healthcare was rife with waste. I have frequently asserted that my favorite quote from him is essentially a statement of the Triple Aim. The language evolved between 1965 and 2008 but the core concept remained the same. Care should be good for the patient, create a healthier nation, and be delivered with stewardship that can be sustained.
I became CEO of our organization in February 2008. 2008 was the tenth anniversary of the “spin-off,” which Dr. Ebert told me he favored, of Harvard Vanguard, the medical practice from Harvard Pilgrim Health Care. Harvard Pilgrim Health Care was the result of a 1994 merger of Harvard Community Health Plan and Pilgrim Health Care, a competing IPO/HMO in Eastern Massachusetts. I had represented the HCHP physicians in the merger discussions and was the leader of the physician group when we negotiated our exit from Harvard Pilgrim as Harvard Vanguard. I was board chair of Harvard Vanguard from 1998 until I became CEO in 2008. One of my objectives in 2008 was to renew our connection to our roots in Dr. Ebert’s concepts of social responsibility. It was my hope that this renewal of our awareness of our history through a celebration of our ten years as Harvard Vanguard and the forty years since the origin of our practice as Harvard Community Health Plan, we would be propelled into a period of rapid transformation.
We planned our gala event to celebrate and reconnect to our history for the fall of 2008. We engaged a writer to help us produce a document that honored our history. I had known Barbara Ebert, Dr. Ebert’s widow, for many years. She was usually a guest of honor at our annual awards celebration where “Ebert Awards” were presented to exceptional members of our staff. I contacted Mrs. Ebert to talk with her about those “gestational” years of HCHP between 1964 and 1969. She was gracious and after a conversation suggested that I might find it useful to look at Dr. Ebert’s papers that were in the archives of the Countway Library at Harvard Medical School.
I was surprised that you could not just show up and be admitted to the archives. An appointment was scheduled and on the appointed day Barbara and I rode the Countway elevator down to a sub-basement that I had never entered before. When we emerged from the elevator we entered a world that was like a bank vault that was heavy in protocols for protection. After we had put on gloves and were seated at a large table large, boxes full of letters and documents were produced for us to examine. I was fascinated as I read the many letters that Dr.Ebert had written to other like-minded clinical leaders across the country. There were documents that revealed how he had searched for funding. One letter written in 1965 to the president of the Commonwealth Fund caught my eye. As I read his description of his plans and the need for funding for his pilot I realized how what I had lived had been so meticulously planned. Near the end of the letter where he was summarizing his request, I found the statement that was to become the guiding concept of my strategic thinking. It is a very tight statement that says it all:
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.
Let’s unpack it. To start, the context is 1965. Medicare and Medicaid have just passed and what will happen with the implementation is an unknown and a huge challenge for the existing delivery system. During the previous thirty years, the AMA had predicted a disaster if America adopted “socialized medicine.” Now Lyndon Johnson had achieved “socialized medicine” for the elderly and the very poor. Would the hospitals and practice sites of the nation be overwhelmed? Dr. Ebert had different concerns. It was his opinion that the problem was not Medicare and Medicaid but rather a system of care that worked poorly for everyone, and was especially difficult for the urban and rural poor. Even before he had come to the MGH in Boston he was trying to address his concerns by attempting to launch an innovative practice in Cleveland. Dr. Ebert realized that it would take “seed” money to test his ideas and launch a new type of medical practice. I think he had come to realize that he wanted to make a “green” start and that a “brownfield” project in a practice with bad habits that were long-established would be even more difficult. He wanted to demonstrate a better way. I think that he knew that he needed to surround himself with young clinicians who did not have a big investment in the status quo and would be excited about the opportunity to explore new frontiers.
His crisp statement declared that there was a better way that did not require more resources. The implication was that we could be more efficient in our use of our personnel, our buildings, and our money. He knew that there was enormous waste in the existing method of practice. That was quite an assertion. He immediately states what is necessary to achieve better care with the same personnel, the same hard resources, and for less money. A different approach to the finance and methodology of practice is required. It is not easy to establish a different finance methodology, a different deployment of resources, and a different approach to practice. The status quo will always resist That was his experience in Cleveland and at the MGH. Transformation to a new method of practice would not be a simple solution. Transformation demands a steep learning curve for those who think that what they are doing is just fine for them and seem willing to accept the outcome of their performance without paying much attention to its costs or outcomes. Transformation is an exercise in the difficult process of “adaptive change.” But a discussion of adaptive change will be another post.
I have discovered over the years just how hard it is to institute a change, or transformation, in how care is delivered. There were two core changes in Dr. Ebert’s pilot. First, there was an emphasis on the importance of health maintenance, collaborative ambulatory practice, and continuously progressive focus on systems issues. Second, he realized that fee-for-service payment was antithetical to the evolution of more efficient practice and team-based care. It has always resulted in very expensive care with inconsistent quality. It has been my belief that Dr. Ebert believed in these realities as axiomatic facts, and for him, they were not just hypothetical possibilities. Doctors and hospital systems quickly learn how to optimize their income in any financial system. “Gaming” the system seems to be an instinct. Even though HCHP finally was launched in October 1969, it still met with great resistance from many doctors in the Brigham and BI and very vocal criticism from the larger medical community. People were threatened.
The issue that worried me most in 2008 was falling resources. We were in the Great Recession and we had already barely survived a near-death experience when Harvard Pilgrim had been forced into receivership in 2000. The only “positive” reality was that our practice, like all of healthcare, wasted at least 30% of our resources. We could fund our progress even in an environment of falling payment for several years by eliminating waste. By returning to a more focused approach to the care of the underserved we could expand our market share. To live on the funds available through Medicare and Medicaid we would need to be much more efficient. We needed to return to our roots and rediscover the wisdom of Dr. Ebert. The conclusion to our celebratory document was the use of T.S.Eliot’s famous lines of poetry.
We shall not cease from exploration
And the end of all our exploring
Will be to arrive where we started
And know the place for the first time.
That is the end of one story and the beginning of another. I will explore how we tried to mine our waste in the next post.
Return of the Loons
Last Friday I wrote that I was spending a lot of time on my deck because of the warm spring weather. I said that I was on the lookout for the return of our loons. I had not seen loons, but I had seen Mr. and Mrs. Merganser. It turned out that about the time Friday’s letter “went live,” the loons returned.
We heard them before we saw them. My wife loves photographing the loons. Today’s header is her first loon picture of the year. I am certain that there will be many more.
Loons are not like robins, chickadees, and nuthatches, or even mallards. We have lots of songbirds that provide me great joy, but we don’t really have many loons. They are endangered. As of 2019, New Hampshire had 319 breeding pairs of loons. Vermont had about 120. Minnesota and Alaska had the most. The total loon population for the country was less than 16,000 breeding pairs. The population in New Hampshire has doubled since the 70s primarily because people have been studying them as a population and trying to remove some of the hazards that were killing them. The research revealed that lead poisoning was a common cause of death. Loons would swallow lead fishing tackle along with the sand and pebbles that were necessary for food digestion. All the loons that have died that can be recovered are autopsied. One of our loons died of lead poisoning about three years ago. Lead fishing tackle is now illegal in New Hampshire. The state will replace lead sinkers and other tackle with steel tackle for free.
New London enjoyed the presence of its own special “loon lady” before she died of a rapidly fatal cancer in 2018. Kittie Wilson was a much-acclaimed teacher in the area who photographed, studied, and protected loons as a passion. Because of Kittie Wilson’s advocacy, our loons now nest on a floating island. It is a raft that is their permanent nesting site year in and year out. Since it rises and falls with the water level, the nest is protected from flooding. Since it is offshore, the eggs are protected from many would-be predators. Buoys and signs warn people to give the loons the safety and room they deserve. Even with those precautions, we are always on pins and needles until we see the “loon babies,” and then we worry about the eagles snatching a baby for lunch before the summer is over and they are large enough to protect themselves.
Through the summer the loons will be with us. Sometimes we can detect a cry that sounds like they are distressed or that there is a nearby danger. At those times we hope for the best. Most evenings we will thrill to their calls. Sometimes when we are out on the lake in our kayaks they will come as close as 10 yards or perhaps even less. It is amazing to watch them dive and then come up a hundred yards away in just a few seconds. I once had the experience of one dashing under my kayak. It was like a torpedo. Their red eyes are piercing. These birds have a special beauty, but it is their behavior and their calls that make them an even greater joy than the pleasure we get when we just watch them floating along on the surface.
Our loons “winter” nearby. Kittie Wilson and her husband documented that when the lakes freeze our loons travel due east to the coast in Maine near Wells just a little south of Portland where there is water that is not frozen. To get to Wells by car one travels south to Manchester then east to I 95 and then goes north to Wells. The trip is about 120 miles by the highway, but the loons fly direct which is probably no more than 75 miles.
The Red Sox won nine games in a row before they lost a close one 4-3 in the ninth to the Twins yesterday. We have had pretty nice spring weather this week although it snowed last night and continued into this morning. As you can see below, today is not a typical spring day since we are covered with heavy wet, “gloppy” snow. Between the loons and the Sox, I am hoping for a great spring and summer. The snow reminds me that progress is always the sum of several steps forward and an occasional step back. We are anticipating the visit of friends from Massachusetts who are dropping by on Monday as one more step toward the new normal. We are now two weeks past our second Phizer vaccine shot. In another step forward, I am scheduled for my first haircut since March of 2020 on Thursday. I hope to be back to walking in a few weeks. Things are looking up for me, and I hope that the same is true for you as well.
Be well. I hope that where you are reading this note the sun is shining and that you are enjoying warm spring breezes. Take good care of yourself. Enjoy the glory of spring. While you are working for transformational change don’t let anything keep you from doing the good that you can do every day,
Gene
