Healthcare Musings For November 3, 2023

November 3, 2023

Dear Interested Readers,

 

After Comments on Recent Events, My Story Continues 

 

I have been amazed by how long it has taken me to tell my story. The truth is, I am grateful that I have had something to write about other than the deteriorating state of American healthcare and the distressing domestic and international events of the past few weeks. We live in strange times. I don’t have a MAGA philosophy. It is ridiculous to pine about what we lost in the 60s, 70s, 80s, 90s, and over the first twenty years of the new century. Perhaps, for some of us, those years were great, but they were a major stress and misery for many. I have no desire to return to the America of those days. The best thing that can be said of them is that there were always people who had the dream that America could be better, and there were always some who were committed to making that dream come true.

 

I would refuse to get into a time machine for a trip back to any time I can think of since I was born in 1945. Sometimes, especially since the reversal of Roe v. Wade it feels like we are threatened with that trip, I would not want to take. The same is true for most minorities because it seems to me that MAGA is code for putting angry straight white men from a Christian heritage back in charge. If you lived through the last seventy-five years, there are several moments in history where events occurred that resulted in a loss of progress toward universal peace and prosperity. It seems paradoxical that we have made progress on so many fronts, especially in technology and even in our understanding of human psychology while simultaneously we are rapidly moving toward autocracy and an even more illiberal and inequitable society than we had in those celebrated fifties when everybody went to church, and we were lynching fourteen-year-old Black boys. 

 

Let me be specific about a few things. Those of us who profess to be progressive complain now about our very deeply divided government where a few can block the intent of a supermajority, but things could get even worse. We just took another step in the wrong direction with the election of Congressman Mike Johnson of Louisiana to be the Speaker of the House. Speaker Johnson looks and talks like the poster boy for “Christian Nationalism.”  He was at the center of the efforts to prevent President Biden from being confirmed by Congress as president. We are on a course that puts us at risk of reversing even more of the domestic and international progress that was made over the past 75 years.

 

If you are one of the minority of Americans who like to say “Heaven is My Home,” why would you want to protect the environment here or spend any money on people who are “wallowing in sin”?  If you add the undermining of Congress by the far right which wants to dismantle most of the government and rejects the progress on social issues of the last 75 years to the possible election of a president who led an insurrection against the outcome of an election, and you are not worried about the future of our democracy, you may be in need of mental health counseling. 

 

Speaking of mental health counseling, I had lunch recently with a friend who has a management position with a very large provider of inpatient and outpatient mental health services in my state. He told me that this institution which employs five hundred healthcare professionals was booking routine requests for counseling in late 2024. The lack of routine access to mental health expertise makes the idea of treating gun violence as a mental health problem an exercise in magical thinking. The recent tragic event in Lewiston, Maine suggests to me that eliminating all guns, or at least military-grade assault weapons, is more likely to be an effective strategy for protecting the public from the mentally ill or pathologically angry people in our society than depending on mental health management and the complicated processes of taking guns away from people with emotional problems. Getting rid of guns works to improve public safety everywhere else in the world that doesn’t have a cowboy mentality. Why would it not work here? Getting help to those who really need it before the fact of a mass shooting seems to be beyond our capacity, but grief counseling must be a rapidly growing mental health specialty. 

 

It is hard to know what is happening in the war in Ukraine. The ubiquitous reports in the newspapers, on the Internet, and on the broadcast news about the suffering and bravery of the Ukrainian people have virtually vanished. In the wake of the horrendous attack against civilians by the monsters of Hamas, it seems that many of us, and some in Congress, have forgotten the conflict in Ukraine and the threat that Putin is to all of us.  We are ready to move on. Are we incapable of recognizing that in a world as complex as ours it is possible to be faced with more than one threat at a time? Do we have a short attention span or has the threat to the future of Israel, and the losses of life on both sides of the conflict in Gaza left most of us either so irate or depressed and confused that we can’t hold both conflicts in our minds at the same time? 

 

I don’t want to live in a world where terrorist organizations like Hamas, ISIS, and Al Qaeda and rogue governments like Iran and the Taliban in Afghanistan can plot and carry out heinous crimes while oppressing their citizens and threatening their neighbors. I also can’t imagine us coexisting with Putin after he defeats the people of Ukraine. We can’t agree on how to solve the problems arising from cultural animosities and disputes over territories that are centuries long and have created problems that seem to have no solutions and result in recurrent conflicts.

 

As we learned in Iraq, the problem does not end when the despots are defeated. The movement toward democracies that might replace these agents of death is not a certainty. Tribalism is a force that we (all humans) can’t seem to manage at home or abroad. Moving toward a pluralist society with the opportunity for a full life without poverty and disease in a world that is safe from autocrats and free from carbon-based global warming is hard work. Putting on MAGA hats and retreating into safe white suburban enclaves where we shield our children from learning about the mistakes of past generations is not a strategy that will free us from a world of conflict. It will be hard and may seem to be impossible, but we must find a better way.  

 

This morning while doing the final edits on this letter, I took a break to check out the New York Times. There were updates on the fighting in Gaza. I learned that Sam Bankman-Fried was convicted and will probably spend much of his life in jail. Job growth is down, but the market is up. The Trump children are testifying in the civil trial about the family’s fraudulent business practices. Over on page A5, there was a little article about Ukraine which essentially said things are stuck in a stalemate.

 

After looking at the day’s front page news and unearthing a little mention of Ukraine, I moved on to my favorite section: “Opinion,” and my favorite opinion writer, David Brooks. He almost always expands my understanding of the moment. He looks at the motivations and the emotions that explain the moment, and he rarely fails to offer advice that he extracts from a knowledge of history and literature. He did not disappoint me today. He offered me a way to process the frustrations revealed in the rant that you have read from me so far. His piece is entitled “How to Stay Sane in Brutalizing Times.” At the end of the piece which I hope you will read, he writes:

 

I’m trying to describe a dual sensibility — becoming a person who learns humility and prudence from the Athenian tradition, but also audacity, emotional openness and care from the Jerusalem tradition. Can a single person possess both traits? This was the question Max Weber asked in his classic essay “Politics as a Vocation”: “How can warm passion and a cool sense of proportion be forged together in one and the same soul?”

It’s a hard challenge that most of us will fail at most of the time. But I think it’s the only practical and effective way to proceed in times like these.

 

Given the fact that I have no answers to our current domestic political uncertainties, the current depressing international conflicts, our slide toward the sixth extinction, and am still trying to adopt the attitude that Brooks advocates, I will return to writing about the development of my professional and moral sensibilities and struggles in healthcare. Since it seems unlikely that there is currently any political energy available to do much to improve healthcare or the social determinants of health through improved public policy or programs, perhaps a better healthcare future must arise from the actions of concerned healthcare professionals who rise to the challenge. We are never without options or opportunities to make things a little better. We just need to recognize and believe that working together can make a positive difference. 

 

The hero of last week’s installment was one of my many mentors, Dr. Paul Solomon. I had prejudged and totally misjudged who Paul was until I began to listen to him and observe him as the chair of the Physician Council. I was obnoxious enough that he would have been totally justified in dismissing me as someone who was a problem for himself and others. He didn’t. He used humor and persistence to try to mold me into a more effective spokesman for the important things that he recognized I cared about but was pretty ineffective in articulating. He did not achieve immediate success, but I will always be grateful that he did not give up. I received a multiyear training program from Paul. As I wrote last week, the biggest expression of his eventual confidence in me was when he gave me his job of negotiating the financial relationship between the doctors and Harvard Community Health Plan. That responsibility put me into private conversations with the CEO, Tom Pyle, and the Corporate Medical Director, Dr. John Ludden. 

 

The Harvard Community Health Plan in the mid-80s when I began my experience on the Physician Council was quite different from the organization that Dr. Ebert launched in 1969 and even different from the organization I joined in 1975. Despite its rapid growth and the development of its own insurance function, HCHP was in a market battle. Its chief competitor was Blue Cross, but there was also competition from a host of IPAs as well as other commercial insurers. Many employers offered their employees multiple insurance options. Most insurance companies contracted with most of the hospitals and physicians in the area. HCHP was a closed system. All of the patients I had were insured by HCHP. We had no fee-for-service patients and no patients who were insured by other insurance providers. We did not have the machinery to generate a bill “for services rendered.”

 

We offered prepaid medical coverage in a closed network, and that was a novelty that most patients did not understand. To make matters worse many employers were beginning to see financial and administrative benefits from dealing with only one insurer. We did best when employers offered only us along with other choices, but that was happening less often. At best, we were a choice that employees could make from a list of insurers which meant that to attract a patient we had to make a two-tiered sale.  We had to get the employer to add us to the choices that were offered, and then we had to convince the potential patient that we were the best choice among the several options his/her employer offered. It was always interesting for me to think about why a patient had chosen us. I would frequently ask a new patient why they had chosen to get their care at HCHP. 

 

Sometimes we were chosen because we were a good value. We had thousands of public employees who chose us just to save money on their payroll deductions. Even Governor Mike Dukakis who has just turned 90 famously chose us. (Click on the link for an inspiring review of Dukakis’s life.) The Governor was famous for riding the “Green Line” trolley from his home in Brookline to his office at the State House. Our Kenmore Center was located next to a Green Line stop, and it was easy for him to hop off for his health care, and then hop back on the train as soon as his visit was completed. He was also a great friend of Dr.Joe Dorsey. Both men had impressive credentials in the effort to bring healthcare equity to Massachusetts.

 

Many patients were attracted to us because they had a friend who had tried us and liked the convenience of most of their care under one roof or because of our progressive attention to cost control and quality. By choosing us they avoided frustrating approval processes while they saved money and time. There are many colleges and universities in Eastern Massachusetts and their faculty members loved us. Some of my favorite patients were professors at Harvard, Boston University, Wellesley Colege, the University of Massachusetts, and MIT.

 

Another interesting source of patients was the law firms located in downtown Boston. I reasoned that many of the lawyers in those firms were “left-leaning” or forward-looking and wanted to be a part of our preventative approach to medical management. For a long time, we grew, but then growth slowed as we approached about ten percent of the market. 

 

To grow further we needed to be able to expand our market. In 1986, Tom Pyle and the HCHP board succeeded in acquiring a suburban IPA named Multigroup. As the name implied, its physicians were primarily in well-established suburban medical groups like the Dedham Medical Associates and the Acton Medical Associates. This acquisition was particularly important if HCHP was to retain the business of the high-tech firms along Route 128 like Digital Equipment, Polaroid, and Wang Computers since the majority of their employees lived in the suburbs. Ironically, all those once-powerful firms no longer exist. In 1990, HCHP acquired the Rhode Island Group Health Association (RIGHA) which had many patients who were employed by Texas Instruments in southeastern Massachusetts. Ironically, my wife is from Rhode Island, and her parents were loyal RIGHA members. My father-in-law who spent his working life as a machinist putting threads on screws was a “shop steward” who had helped get RIGHA offered by his employer. RIGHA had much of the same philosophy of care delivery that HCHP had and that acquisition felt better even though any merger creates huge administrative and cultural challenges. 

 

I was not happy with the acquisition of Multigroup. Management decided to create two divisions, The Medical Groups Division–essentially the old Multigroup, and the Health Centers Division.  It operated RIGHA as a stand-alone entity. The fourteen health centers in the old HCHP were the product of the growth of Dr. Ebert’s vision once we ceased to be a self-governing medical group and became employees in a “staff-model” HMO in 1977. I sensed that our attempt to practice high-quality innovative medicine was compromised by the opening of each new center. Some were “seeded” with doctors from our first two sites, Kenmore and Cambridge, but the institutional memory of those doctors, nurses, and administrators was diluted by the majority of new providers and administrative staff that needed to be hired. If the growth of the health centers was a cultural problem, you can imagine the impact of adding hundreds of new doctors from Multigrop for whom capitated medical practice was only a partially acquired skill and for whom fee-for-service patients and patients from other insurers had been the majority of their experience. I understood the business problem that suggested that we needed to offer more variety, but I did not like the solution. That was the environment of HCHP when I assumed my role as chair of the Physician Council and a member of the board of HCHP.

 

About the time I became council chair, I was rushing to one of our meetings at our administrative offices in a commercial building in Brookline Village which was a few blocks from the Brigham and a little less than a mile from my office on Brookline Avenue near Fenway Park and Kenmore Square. Traffic was heavy and I was late. I boarded the elevator and hoped for an express trip to the fourth floor where the board room was located and where the Physician Council met. The elevator was always slow and I was anxious that I would be late when it stopped on the second floor. As the doors opened slowly, I saw Don Berwick, my colleague, and our Vice President for Quality who was waiting to get on. He looked anxious. He said that he was headed to the fourth floor also. Not only the board room but also the offices of the CEO and the CMO were there. I assumed that Don was headed to a meeting with someone who was important. I understood Don’s anxious appearance when he said, “Gene, I have bad news.” I have got data that suggests that it’s not safe to get medical care at Kenmore. That was the only time I ever heard that said. I have always imagined that Don’s presentation was not well received because not long after that encounter with me on the elevator, he left HCHP to become a founder of the Institute for Health Care Improvement. 

 

I was very disappointed when Don left us. A few years later, long before Crossing the Quality Chasm was published in 2001, or the Triple Aim was enunciated in 2008, I invited him to be the speaker at our annual awards dinner. I wish I had a copy of that speech because it was both a presentation of the problems of America’s system of healthcare and a challenge to be part of the solution to those problems. If you have never had the experience of listening to Don I would suggest that you click here and listen to an interview where he describes how his career developed and how his values evolved. 

 

I have been slowly moving toward the turbulence of the nineties. As a preview, I can tell you that we eventually used those fourteen powers we, the physicians of the Health Centers,  were granted through the creation of the Physician Council including the ability to review the CEO and CMO to create substantial change within the organization.  Eventually, we decided that we should create our own professional organization, and Harvard Vanguard was launched in 1998 with the blessings of Joe Dorsey, and even Dr. Ebert not long before he died. It’s a good story. I hope that I will be able to do it justice.

 

Winter Begins

 

The picture that is the header for the post may have been taken on the last warm day of the fall. The temperature was in the seventies and the sun was out when the picture was taken last Saturday morning. You can’t see me in the picture, but I am there with a host of volunteers from Kearsarge Neighborhood Partners (KNP) who were stacking wood at the “transfer station” in Warner, New Hampshire. “Transfer station” is a euphemism for “town dump.” In small towns, there is no pick up of rubbish. Everyone takes their trash and recyclables to the “transfer station.” from there our detritus is hauled away to landfills. Most of the traffic is on weekends. Second only to the post office, the transfer station is the place where you are most likely to meet your friends and neighbors. The transfer station is also a great place to store “free firewood” for later delivery and for pickup as needed in emergencies. 

 

As I have mentioned before, providing wood, heating oil, and propane for people who are financially stressed is one of the activities of KNP. Warner has a population of about 3,000. It is about fourteen miles south of my town, New London, which has 4,500. Economically there is a world of difference between my town and Warner. There are many more economically stressed families in Warner than in my town which has expensive lakefront properties where retirees with excellent benefits are shielded from the stresses that plague many Americans. Halfway between Warner at exits 8 and 9 on I 89 and New London at exits 11 and 12 is Sutton at exit 10. The Kearsarge Regional High School and Junior High that serve most of the towns of the Kearsarge Region is at exit 10. I think that the economic diversity of this beautiful region is one of its most interesting and challenging realities. 

 

For several years KNP has had one large wood lot located in New London. It is a central location, but a review of our records would reveal that at least a third of the people we serve are in Warner. It made sense for us to partner with a group in Warner to make wood delivery more efficient. They had already been storing some wood for delivery at the Warner transfer station so we had more wood delivered directly to the transfer station by our supplier. The supplier just dumps the wood in a pile. For efficiency after the snow comes and to facilitate keeping the wood as dry as possible, it needs to be stacked. Stacking wood is boring, back-breaking work when you do it alone, and it’s almost a party when about 20 people do it together. The stack in the picture was created in about one hour.

 

Well, it was good that we got the job done last Saturday because the temperature dropped forty degrees, and we had soaking rain by Sunday. It was as if someone shut the front door on fall and opened the back door to winter. By Wednesday we had temps in the 20s and our first snow of the winter. It was not much as you can see in the picture. It’s just little clumps of snow in the grass, but it is a harbinger of things to come. There will soon be two feet or more of snow where now there is just dusting.

 

 

Thanks to my wife’s focus, all of our preparations for winter are complete. I have three cords of my own wood that are neatly stacked and ready to keep me cheery as the weather worsens. The dock is out. The kayaks and sailboats are snug on trailers and racks. The lawn furniture that is vulnerable has been stored. Plants have been moved indoors. 

 

I’ve been writing about the less-than-spectacular fall foliage, but that is past history now because most of the leaves are moving toward brown or are already down now. It is time to embrace winter. I can hardly wait for the lake to freeze, and I hope that we have a ton of snow before Christmas when my grandsons are arriving with their parents from California. I am told that they already have new snow gear.

 

If you have a little fall color and sweater weather left where you are, I hope that you get to enjoy it as we change our clocks this weekend. If, as I have experienced, winter has already arrived where you are, lean into it and enjoy it! In six or seven months it will be 70 again.

Be well,

Gene