December 15, 2023
Dear Interested Readers,
Utopian Ideas Versus The Status Quo In Healthcare
Less than twenty miles north up Interstate 89 from my home is the Enfield Shaker Museum. I have visited the enclave by Lake Mascoma with its magnificent main granite building several times and have had a sense of sadness each time. The Shakers were remarkably productive, peaceful, innovative, community-oriented, and doomed from the start by their commitment to celibacy and the impossibility of utopian societies. There has never been an attempt to create a utopian society that has succeeded since Sir Thomas More launched the idea in a work of fiction in 1516 which he entitled Utopia.
As you may remember, ultimately, things did not go well for Sir Thomas. When he refused to sign the “Oath of Supremacy” that put Henry VIII above the Pope in worldly power, he was thrown into the Tower of London with the expectation of being drawn and quartered, but eventually, Henry consented to commute More’s sentence to a more merciful decapitation.
The effort to create perfect societies whether secular or religious peaked in the nineteenth century. While I was in medical school my home was very near one of the most famous secular attempts at a utopian community, Brook Farm. Brook Farm did not require its participants to be celibate, but it too failed even though it had some impressive Brahmin participants including Nathaniel Hawthorne. Brook Farm was a brave idea, but it ended in disease, lawsuits, flames, and debt. Good ideas don’t guarantee good outcomes.
As I have been writing about my experience of practice in Dr. Ebert’s Harvard Community Health Plan and its descendants —Harvard Pilgrim Health Care, Harvard Vanguard Medical Associates, and Atrius Health, it has occurred to me that there are some parallels to the failed efforts at creating utopian communities. I guess that most attempts to create utopias were responses to dissatisfaction with the status quo, and Harvard Community Health Plan was Dr. Ebert’s response to his dissatisfaction with the status quo of healthcare in America in the mid-twentieth century.
Ever since I made the journey in 2008 to the Countway Library archives with Barbara Ebert to read Dr. Ebert’s papers and discovered how succinctly he had described his plan for a better system of care in a letter to the president of the Commonwealth Fund which was written to request financial support, I have been impressed by the boldness of his idea, and how it was a response to the failures he saw in American healthcare. He expanded that description in The Kate McMahon Lecture which he delivered at Simmons College in the fall of 1967 as I was beginning medical school. If somehow you have missed the succinct statement he wrote to the Commonwealth Fund president, here it is again:
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.
If you have not looked at the document in the reference section of this website entitled TRANSFORMING PATIENT CARE: QUALITY, INNOVATION, SOCIAL RESPONSIBILITY, let me encourage you again to take a look. Near the beginning of Roanne Weisman’s narrative, she writes:
The impetus for change was rooted in fundamental problems confronting American medicine during the 1960s: Medical costs were rising at an alarming rate, the neighborhood general practitioner was becoming extinct and there was increased demand for a dwindling supply of primary care physicians. Medical schools and their affiliated hospitals, along with payers and policymakers, were struggling to develop more efficient and accessible models for teaching and delivering primary health services.
Dr. Ebert had considered the frustrating realities of healthcare in the 1960s and tried to launch a utopian response to the problems that plagued American healthcare. HCHP was finally ready for launch in October 1969. Neil Armstrong had walked on the moon on July 20, 1969. It should not be a surprise for you to learn that the launch of HCHP in October 1969 was referred to by its participants as a “Medical Moonshot.” From the perspective of over fifty years, it was also an attempt at creating a medical utopia for patients and practitioners.
Like other attempts at utopian responses to a problem, internal and external forces eventually derailed Dr. Ebert’s dream, but I contend that he was right about the fundamental problems that he sought to solve. They persist today. His error was that he underestimated the power of the forces then and now that are profiting from the status quo and are powerfully resistant to meaningful change.
I was fortunate to have had a few conversations with Dr. Ebert over the years and was a colleague and lieutenant to his principal apostle, Dr. Joseph Dorsey. There is no question in my mind that HCHP was born as a fully developed vision and pilot of a system of care that was an [organization of] the personnel, facilities, and financing into [a] conceptual framework and operating system that [would] provide optimally for the health needs of the population.
If we were not a utopian experiment, we were a “beta site” for a better future for healthcare. Ebert and his colleagues had spent over five years thinking and planning. There was nothing left to do but “launch” and then discover through following the course of the trajectory what was right and what needed further tweaking.
It takes an amazing amount of courage to proclaim that there are deep structural problems in a critical profession and industry that should be a reliable essential advanced utility but still functions in a way that has not fundamentally changed its attitude in over two thousand years. It takes even more courage to announce and then try to implement change that tries to retain the professional positives that do exist and eradicate what isn’t working. Beneficial change is harder yet when the necessary changes threaten the large financial returns enjoyed by the controlling interests in a very profitable complex industry that desperately needs improvement in the necessary services it should provide for those who depend upon it.
It is no surprise that the “utopian” reforms that threaten the profits, comfort, and familiarity of the dysfunctional status quo will be met by resistance. HCHP was a curiosity as it started. As it gained momentum, it became a threat to the status quo, but that was not its only problem. As I have tried to describe in notes over the past few months, there were the inevitable internal disagreements that always plague utopian exercises. The idea may be perfect, but implementation in the real world depends on imperfect people.
Dr. Ebert was right in his assessment that deep changes were needed in American healthcare. Based on his vast experience and commitment to improvement, his having a vision of what might work is not a surprise. That he could organize those thoughts for others to understand and accept, gather necessary resources, organize a team, and launch the experiment is what makes the story remarkable even though over a half-century later what remains is much different from what was launched. What persists for many is the commitment to the idea that we are still far from providing optimally for the health of the nation. What we have learned is that besides the finance and operating system of the practice, we must also pay great attention to the social determinants of health that vary substantially as a function of economics, location, education, environmental exposure to toxins, race, and other factors that impact people and can compromise their health even when they theoretically have access to care.
Dr. Ebert was going for immediate dramatic change. Others prefer incremental change. It is interesting for me to think about theories of change. The Austrian economist, Joseph Schumpeter launched the concept of “creative destruction” in the 1940s. Schumpeter expanded Marxist thought to hypothesize that new ideas emerged from the failures of old ideas and the result was the destruction of the old and the emergence of the new. He was focused on capitalism and imagined that its evolution would eventually lead to its replacement. He wasn’t talking about healthcare, but it is easy to see some similarities. Care has moved from the office of an individual practitioner to group practices, and from house calls to a primary focus in the hospital, and now, as Dr. Ebert advocated, care is rapidly moving again toward the ambulatory environment. I think Dr. Ebert would be pleased. But the organization of care delivery was only part of his vision. The other part of Dr. Ebert’s vision was the change in finance. We keep making efforts to move away from fee-for-service finance toward value-based reimbursement, but even most of those newer models of organizational payment retain a chassis of fee-for-service payment in the “pay for performance” of individual physicians.
Not to be confused with Schumpert’s “Creative Destruction” is the concept of “Disruptive Innovation” introduced by Harvard Business School guru, Dr. Clay Christensen that evolved in the 90s. A simple example of Christensen’s disruptive innovation is the replacement of LPs by CDs, and of CDs by Spotify and other forms of streaming. A good example in medicine would be the replacement of the old-time chest X-ray and KUB by CT scans and MRIs. Dr. Merrill Sosman, a famous radiologist at the Peter Bent Brigham Hospital in the 30s, 40s, and 50s, is said to have predicted that the chest X-ray would replace the need for a stethoscope. Disruptive innovation has been going on throughout history. In 2008, Christensen published The Innovator’s Prescription: A Disruptive Solution for Health Care which he co-authored with Jerome Grossman and Jason Hwang.
Disruptive innovators in health care aim to shape a new system that provides a continuum of care focused on each individual patient’s needs, instead of focusing on crises. Mr. Christensen and his co-authors argue that by putting the financial interests of hospitals and doctors at the center, the current system gives routine illnesses with proven therapies the same intensive and costly specialized care that more complicated cases require.
“Health care hasn’t become affordable,” he said in an interview, “because it hasn’t yet gone through disruptive decentralization.”
A year or so after the ACA was passed Professor Christensen invited me along with four or five other CEOs of healthcare institutions in Massachusetts to spend an afternoon with him at the Harvard Business School discussing disruptive innovation in healthcare and how we were experiencing it. It was a pleasant afternoon, but I was left with the feeling that there was still a long road ahead of us before we would have a transformed healthcare system without its current flaws and failures.
Christensen was right in seeing bits and pieces of the system being improved by disruptive innovation. Still, time has shown that something more powerful than Dr. Ebert’s utopian idea or Christensen’s reliance on disruptive innovation will be required to transform our healthcare system into something that delivers on the opportunities described in Crossing the Quality Chasm (2001), or expressed in the Triple Aim (2008), or approached by the ACA (2010). The interests of the status quo seem much more powerful than the need to improve the experience of individuals or the necessity to address the cost and quality of our system of care. We have had plenty of utopian dreams, but a medical utopia that includes improvement in the social determinants of health is still a long way off and over the current horizon far past our deep cultural and political divides that lie between this moment and the complete manifestation of Dr. Ebert’s dream.
The Next Chapter Of The Story
At the end of last week’s offering of the continuing story of the experiences that helped shape my moral sensibilities in medicine, Harvard Pilgrim Health Care was in receivership, and Harvard Vanguard Medical Associates was deemed “not to be a going concern” by its auditors, but each organization had a huge asset. Harvard Pilgrim had Charlie Baker as its CEO, and Vanguard had Ken Paulus who took the job of CEO with his eyes open to the expectation of oceans of red ink.
I will offer you a Boston Globe column during Baker’s run for governor in 2014 that affirms the miraculous work he did to carry Harvard Pilgrim from receivership in 2000 to recognition as one of the nation’s best healthcare insurers by 2008. Boston Globe columnist Shirley Leung wrote:
After serving in the Weld and Cellucci administrations, Baker went off to work in health care, and in 1999, he was brought in to fix a company in deep trouble. He did so with a plan, a firm hand on the rudder, and grit. He pulled out of Rhode Island. He cut jobs, even outsourced them. He invested in technology to improve customer satisfaction.
By the time he left, Harvard Pilgrim was rated the best health insurer in America in annual rankings conducted by a respected nonprofit. So give the guy credit where credit is due.
“Facts are important, even in politics,” said Tom Reilly, the attorney general who worked closely with Baker when Harvard Pilgrim was put into state receivership so members wouldn’t lose coverage. “The bottom line is that he did a very good job in the turnaround and restoring it to financial health.”
During his eight years at Harvard Pilgrim my relationship with Charlie was mostly through continuing participation in the physician advisory group that Walther Murphey and I had negotiated during the merger back in 1995. The forum morphed from being an advisory group to being advised by Charlie and his management team about what to expect. It remained a good experience until I had a falling out with Charlie over an ad campaign that Harvard Pilgrim was running. The ads suggested that Harvard Pilgrim customers could see any doctor they wanted to see who had a contract with Harvard Pilgrim. Many of our patients were capitated and many of our patients were required to remain in our network of specialists unless we referred them out. That may sound oppressive, but it had always been the reality and the “managed” part of managed care. I was particularly concerned about the disruption the ad would cause and the administrative and professional time it would require from our employees to explain the reality to patients who would otherwise have been happy to continue to get their care within Harvard Vanguard. We had always allowed outside referrals if we felt that it would contribute to better care, but we had never allowed a patient who had heard from a neighbor about a specialist they liked to “go out of network” when there was no potential benefit. A perfect example of this was when we sent one of my patients who needed a heart-lung transplant to Stanford long before heart-lung transplants were done in Boston. We even paid for her living expenses while she waited for her turn in Palo Alto.
Within Harvard Vanguard there was plenty of work for Ken Paulus. He began by convincing our suppliers, the hospitals we used, and the insurers that it would be a shame and a loss to the community if we were to go out of business. He won financial concessions from the hospitals and suppliers we used. Some even gave us loans or grants. He brought in a management team that optimized our ability to do fee-for-service business, and he made deep cuts to management systems that were inefficient.
As we lost over 100,000 patients, we took millions in loans so that we could offer decent severance packages as we downsized. Many valued colleagues wanted to retire or take positions elsewhere in organizations that were not fighting to survive like we were. I have frequently said, “We burned the furniture to make it through the winter.” One regrettable reality was that we could not afford to keep up the proper maintenance of our Epic electronic medical record. Those delays would create huge problems that I would face when I became CEO in 2008. We had to reinstall Epic in 2009. The process cost us millions of dollars.
In the midst of all that was happening internally, it was clear that we had quality systems and a medical record that we could not afford to maintain. Atrius Health was the answer to that problem. Ken convinced Dedham Medical Associates, South Shore Medical Associates, Southborough Medical Group, and Granite Medical Group in Quincy to come together with Harvard Vanguard in a confederation that would spread the cost of contracting, legal, public relations, quality management, some lab expenses, and the medical record system over a much larger population.
Most of these groups had been contracting with Harvard Community Health Plan and then Harvard Pilgrim after the Multigroup merger in 1986 and the Pilgrim merger in 1995. We shared many professional and cultural values with these groups, but on occasions did vary in our sense of physician ownership and willingness to invest in the practice. To join Atrius they all had to convert to 501c3 non-profit organizations. Before joining Atrius only Granite Medical had been using an electronic medical record. The Granite EMR was very primitive even compared to our out-of-date Epic system.
Ken did a lot of work pulling Atrius together. I learned a lot from him in our weekly breakfast meetings at a local dive in Wellesley where we both lived and near our corporate offices in an office park nearby in Newton. You can imagine my surprise when in the summer of 2005, just as things were getting better, at one of those breakfast meetings Ken informed me that he was taking the position of COO with Allina Health Care in Minneapolis. It was time to call Carol Emmott again. We needed a new CEO.
A Walk in the Woods
I live in a hiker’s paradise. Sadly, since my fall in February of 2021 on “black ice” on the downslope of a hill on my usual walk on the road that follows the shoreline of my lake, I have not ventured onto any forest trails. The immediate result of the fall which contused my right sciatic nerve was intense neurogenic pain that made me miserable for about two months.
The pain was worse at night, and sleeping was difficult. I had steroid injections, PT, tons of NSAIDs, and occasional opioids. Nothing seemed to help for some time. As the pain finally receded, I discovered that I had a left foot drop which made walking difficult. The damage to the peroneal nerve was confirmed by nerve conduction studies. My exam revealed a positive Tinel’s sign, and my lower leg down to my toes felt like I had received a novocaine injection that was wearing off.
I tried foot drop braces which I found on Amazon which helped a little, and finally, a large molded support was made for me that allowed me to return to some walking. I tried a nerve stimulator which didn’t do much and then resigned myself to praying for recovery expecting that the time would be measured in years since nerves regrow, if at all, at rates from a millimeter a day to a centimeter a month. It is many millimeters from somewhere in my lower spine to my peroneal nerve.
Since the injury, I have been careful where I walked. I have stayed out of the woods since even before my foot drop, I would often stumble over roots and rocks. I am either better or I am adapting to my injury since I am now walking much better. I have given up my brace for good boots which when laced tightly around my ankle provide effective support. During the warmer months, I supplemented my shorter walks with biking and swimming. I have a lifelong addiction to exercise and need at least 90 minutes of sweat-producing exercise a day to remain happy and functional.
One interesting thing about acquiring a disability is that you begin to pay more attention to other people with disabilities. My wife and I are fans of British television. We watch a lot of English police shows like “Morse,” “Lewis,” “Endeavor,” and “Vera,” on “Brit-Box.” “Morse has been a long-time favorite going back to its original broadcast in the nineties. A benefit of being elderly is that we often rewatch a show without remembering “who done it.” Some authorities regard John Thaw, the actor who played Morse, as the finest British screen actor of his era. He died in 2002 of esophageal cancer at age sixty. Since my injury, I had noticed that Thaw had a subtle but observable gait abnormality that looked like a foot drop. When I researched him on IMDB, the website that tells you about actors, I discovered that indeed he did have a limp which to me looked like a footdrop from an injury as an adolescent—no big deal, but interesting.
I am getting better. I still have a positive Tinel sign, but I can weakly lift my foot. That makes me optimistic. With new boots, I am walking better, and when last Sunday an old hiking buddy asked me if I wanted to try a walk in the woods, I said yes. One of my favorite trails is the “Great Brook Trail” Click here to read about it. Today’s header was taken just below “the lower cascades” on the Great Brook Trail. We didn’t climb all the way to the beaver pond at the top of the trail, but we did a three-mile round trip, and I was very pleased that I did not fall! What I have learned is to never take your ability to exercise for granted. Each time you can get out is a gift, and it is great to have a buddy who will push you.
The weather has been erratic ranging from very cold with a little snow to quite warm with a lot of rain. I still have hopes for a white Christmas, but we take whatever comes. I hope that you have great plans for the Holidays that might include some brisk exercise in the great outdoors.
Be well,
Gene
