Looking At the Future Together One More Time

October 25, 2013
Dear Atrius Health colleagues and other interested readers,

Looking At the Future Together One More Time

When I began to write these weekly letters in February 2008, I was trying to respond to a frequent request that leaders focus more on communicating. Corporate announcements are often just declarations of what has or will happen. The best communications go farther and attempt to connect “what” with “why”.
Often, however, “why” is difficult to explain without providing sufficient context and some understanding of a market that is constantly changing. It seemed reasonable to attempt a weekly conversation that gave everyone a similar exposure to market issues, healthcare policy, evolving principles in the conceptualization of how healthcare could improve, and a more complete understanding of our evolving strategy to fulfill our mission.

I hoped this conversation would also be an opportunity to create and encourage alignment among the Atrius Health affiliates by providing a common weekly experience where ideas and issues that should be shared concerns could be discussed. Along the way we have celebrated our collective and individual successes and examined many issues. The letters that I have received back from you confirm to me that the subjects that have been discussed are of concern to you. Most of your letters have been affirmative, but frequently responses have supported another point of view. By developing a dialog with me through this forum, you have provided me with new insights to the complexity of our challenges.

I want to thank every one of you who has been a faithful reader of these letters. I am especially appreciative to those who have written to me to join in the dialog or who have flagged me down as I walked through your site on a gemba walk to comment about some point in a recent letter or on occasion to say that you were a regular reader and looked forward to each edition. My goal has been to answer every response, but I am sure that I have failed to achieve that good intention. I want to apologize to anyone who did not get a response from me and also apologize to anyone who struggled finding the information that they thought would be helpful among my descriptions of my personal experiences, musical interests and reading preferences. I have tried to share what was meaningful to me and what has helped me connect the dots in a complicated world. It is how personal communication usually occurs. The hope was that you would read my letters as a personal note to you as a unique individual who was my colleague with whom I felt it was important to share my feelings and concerns about something that we both love and care deeply about as a responsibility.

One of my favorite subjects in junior high school was plane geometry. I liked it because you could solve problems with principles or axioms. The axioms were statements of truth that had been proven. There was then a logic to how you used what was known to be true to answer questions and solve problems. The ten concerns for the future that I identified last week are problems that will need to be solved by all of us in healthcare whether we work at Atrius Health, Steward Healthcare, Partners Healthcare, and Kaiser­Permanente or anywhere in healthcare across this country. We are connected and we draw from the same resources of finance, from the same pharmaceutical and medical device industry, and from the same system for healthcare education. A few of the “predictions” on the list are likely to be inevitable

outcomes of processes that will be difficult to change. The workforce shortages of the future are an example of that category. Every problem on the list is hard to think about without some orienting “axioms” to assist us. The problems are much less daunting if they are approached with a set of principles and a few tools.

As a reminder, here is the summary of the ten problems I described last week:

1. We need to get to universal coverage or an unhealthy population will cause greater problems in our economy.
2. We need a better financing mechanism, probably some form of global payment.
3.  We need to promote transparency and cost control at the national level.
4.  There will be a rationalization of compensation between the various clinical disciplines.
5.  Inadequate numbers of professional staff to populate current models of care will cause new roles to be conceptualized and old roles to be redesigned.
6.  Primary Care as currently practiced will be challenged by disruptive innovators in lower cost environments.
7.  Behavioral Health, social services, geriatric medicine, survivorship programs in oncology, musculoskeletal medicine, and physical/occupational therapy all will become increasingly important parts of the ambulatory practice.
8.  Hospitals will become smaller as more of the chronic disease complications are managed either in ambulatory environment or in the home.
9.  Those that pay for the care will control the conversation and provider organizations will receive less reimbursement.
10.  Eventually regulators will approve new affiliations and mergers only for higher quality more efficient care that uses resources more wisely.

So where do we find the axioms and the tools to fix these problems and others that you might add? Dr. Ebert’s wisdom, the Institute of Medicine’s six domains of quality, and the triple aim rise to the level of axioms for me. Lean and other forms of continuous improvement are a combination of axioms and tools. Other important tools are our data capabilities, human resources capabilities, project management skills, understanding of traditional and behavioral economics, and finance and contracting skills.

I often hear people approach difficult problems by saying that they must “think out of the box”. This competency within an organization is very important and clearly is required for creative solutions to complex problems and for true innovation. For me, thinking out of the box means not being trapped by conventional thinking like “the world is flat and has an edge from which you can fall”. A flat world concept makes it difficult to venture far from sight of land. The “world is round like a ball” opens up possibilities and frees you from the fear of falling off the edge of the world. Discovering how the current organization of practice and our current practice rules are limited by conventional wisdom may create new degrees of freedom for creative solutions to vexing problems. Physician compensation and concepts of productivity, the role of the physician on the clinical team, and the optimal relationship between the ambulatory practice and hospitals are all areas where conventional thinking may need to be replaced by

new wisdom if our intent is to manage the future for the benefit of our patients and the survival of our mission.

If I could ask you to remember one thing to consider as you approach your problems in the future, it would be to go back again and again to the work and thoughts of Dr. Robert Ebert. In many of my letters the pivotal idea has been Dr. Ebert’s core philosophy expressed by the statement:

“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.”

Dr. Robert Ebert, October 1967

It seems only right for me to offer Dr. Ebert’s profound statement one last time for you to use as an axiom and strategic tool in imagining solutions for a future that will be a continuing challenge to every individual who works in healthcare and to every organization in the healthcare industry. The issues will be challenging for large well­capitalized organizations with large amounts of fixed overhead and for small financially vulnerable practices in need of capital. The challenges of our common future are problems that are like global warming and air pollution. Everyone is vulnerable not only to their own decisions, but also to the decisions of others. No single institution, no matter how well positioned by the metrics of conventional wisdom, can be certain that what they think is an asset today will not be a liability tomorrow. I mentioned Malcolm Gladwell’s latest book last week; its title, David and Goliath: Underdogs, Misfits, and the Art of Battling Giants, gives a hint that conventional wisdom about advantage and what constitutes strength frequently turns out to be wrong. It’s a great read for anyone or any organization that feels disadvantaged.

Dr. Ebert’s statement is most useful because his description of the problem remains accurate today. Furthermore, his sense that understanding the misconceptions we have from our common wisdom about which assets will be valuable is a huge advantage to those who listen. Finally he describes what will constitute a good starting place for a solution. What is surprising is that no one has yet used his description effectively even though in 2001 the landmark book from the IOM, Crossing the Quality Chasm, expanded his cryptic formula and put real meat on the outline that he had provided.

What were Dr. Ebert’s points?

1. There were deficiencies in healthcare in 1967. There are still deficiencies. The greatest deficiency remains the lack of a workable mechanism for universal coverage. The ACA is a step in the right direction, but there will still be huge variations in coverage and the populations that are covered from state to state. At its best it is a “Rube Goldberg” partial solution that is more the child of politics than a logical plan, but it is a great leap forward and should be protected and improved.
2.  Dr. Ebert understood that raw assets consisting of more doctors, more nurses, more support staff, better technical systems, bigger and better buildings and the money to fuel it all would not result in something that would improve care and extend it to everyone. The Dartmouth Atlas proved years ago that outcomes and quality were not necessarily better as a function of either location or expense. Don Berwick has presented evidence that the care provided very inexpensively to some Native Americans in Alaska may actually produce outcomes that are as good as or better than the care provided at great expense.
3.  Dr. Ebert’s solution space is challenging. His diagnosis was that fee­for­service financing was at least part of the problem that produced expensive and poorly integrated care. Dr. Ebert’s statement also suggests that the concept of population health is important in the evolution of an enduring solution. We know from what he tried to do at Harvard Community Health Plan that the solution was more than just a better finance mechanism; he also called for sweeping innovation and redesign of the delivery process.

Unlike Porter and Lee whose article in the Harvard Business Review made specific suggestions to “fix” healthcare, both Dr. Ebert and Crossing The Quality Chasm recognized that there are many routes to the “solution”. Instead of offering a solution, they make the goals clear. The six domains of quality from IOM are profound in their wisdom and a simple description of a destination for healthcare. Care that is equitable, patient centered, safe, timely, efficient and effective is the goal. In 2007 Nolan and others at IHI reasoned that care that met the Crossing The Quality Chasm definition would be care that would improve the health of individuals, the health of the community, and would be economically sustainable. Crossing The Quality Chasm also gave us ten descriptors of an effective system. They advised that an innovative system should be sure to include the following attributes:

1.  Care based on continuous healing relationships: Care should be given in many forms, not just in face­to­face encounters. The system should be responsive 24 hours a day.
2.  Customization based on patient’s needs and values.
3.  The patient as the source of control. Encourage shared decision making.
4.  Shared knowledge and the free flow of information: Unfettered access to medical records with effective communication between patients and clinicians
5.  Evidence based decision making. Practice should not vary illogically from clinician to clinician.
6.  Safety as a system property.
7.  The need for transparency.
8.  Anticipation of need. [For me this is an exciting challenge. We say that we practice “preventative medicine”. Is that the same as “anticipatory medicine”?]
9.  Continuous decrease in waste. [Compliance with minimal standards of accreditation in the future will require demonstration of some form of continuous improvement as an active and effective process. It will not be enough for an organization to say that it does Lean or Six Sigma; demonstration of effective waste reduction will be necessary for accreditation as well as financial viability.]
10.  Cooperation among clinicians. [“I to we” within practices, across practices, across systems and throughout the community.]

The axiomatic statements of Dr. Ebert, the IOM, and IHI are necessary as is a deep commitment to mission. Additionally, successful healthcare organizations will also need continued progress toward a broader spread of new attitudes and competencies if we are to be successful.
Since I am thinking in lists of ten, here is my list of the new attitudes and competencies that organizations will need:

1.  Leadership from motivated individuals in every part of the organization,
2.  A culture of teamwork and respect that weathers internal controversy while working through the tough issues,
3.  A culture of service that is deeply rooted in mission and functions as a natural reflex,
4.  Widespread competency in a methodology for continuous improvement and innovation like Lean that becomes a basic business system and a common language,
5.  Data literacy that empowers everyone ­ Just as there was a time when few could read, we now live in an emerging time when only a part of the practice understands the importance of measurement and is facile in the use of data for improvement.
6.  Courage and commitment to the task that can endure short term failures and market surprises,
7.  The ability to avoid the traps of conventional thinking in the search for solution,
8.  The ability to put the interest of patients, the community, and the practice ahead of personal interest,
9.  The ability to learn together through experience and reflection and to accept the discoveries of others who are trustworthy as sufficient for the adoption of a better practice, and
10.  The ability to sell the importance to our business partners of the necessity of collaborating along the objectives of the triple aim if indeed they are to be our partners.

As I look at Atrius Health I see that you are making progress in every one of these 10 areas. You are strong. You are experienced. You are capable. You will find the solutions.

The Credits

For the last eighteen years my wife and I have seen most of the films we see at “The Nugget” which is the cinema in downtown Hanover, New Hampshire. The cinematic “megaplexes” of the suburbs just don’t feel right for me. We are often the last couple out of the small theater because we love to read the credits. Did you ever wonder what the “best boy” or “key grip” does? To the credit of movie producers, the credits for most films seem to list everyone who contributed to the project right down to the kitchen crew who fed everybody on the set. You can also learn some pretty interesting things. For example, “What About Bob?” starring Bill Murray was set on Lake Winnipesaukee but it was actually filmed on Smith Mountain Lake in Virginia. You would not know that unless you read the credits. For some reason this information is interesting to me, and I think knowing it honors the teamwork and the process that makes filmmaking an important part of our culture.

It would take pages and pages to give proper credit to everyone who contributed to these notes. Most of the ideas and content were a distillation of the fascinating conversations that occur daily within Atrius Health. I owe great thanks to my colleagues in management and on the boards of Atrius Health and its affiliates who are constantly debating the issues that are so critical. In particular I want to thank Jack Kasten, former Harvard School of Public Health professor and a pioneer in managed care, and Annie Stevens of ClearRock for hours of mentoring. I owe a tremendous debt to Barbara Ebert for sharing her memories and the papers of Dr. Ebert with me. I am grateful to Joe Dorsey and Paul Solomon who saw within an angry young man something that he could not see in himself and had the patience to try to help someone who would not listen.

Consultants are favorite targets of efficiency critics, but I am eternally grateful for the support that I have received from Nathaniel Foote and Kathy McDonald of TruePoint, Ethan Arnold of Chartis, Chris Jedrey of McDermott, Will & Emery, the creative geniuses at Solomon McCown, our public relations firm, and the wonderful team from Simpler that includes but is not limited to Marc Hafer and John Gallagher. Each of these people gives much more value than appears on an invoice for services, and I know that they all care deeply about the future of healthcare and the future of Atrius Health.

One of the phrases that I hate in the conventional thinking of “Sloan Management” is the phrase “my direct reports”. It is a backward phrase that at a minimum should be restated as “the people who support me”. Over the last five years I have had the privilege of working closely with an outstanding team of people who were on call to me in my anxieties of leadership 24/7 for over 5 years. I frequently violated their private time and called often when they were on “vacation”. I must list them here because their work has been important to showcase your work in a way that has the rest of the world thinking that something important is going on at Atrius Health. Tom Congoran, Marci Sindell, Kim Nelson, Rick Lopez, Michael Pinnolis, Mary Dawley, Kathy Gardner, Dan Moriarty, Dan Michaud, Tim McMurrich, Beth Honan, Deb Morsi, Bud Stacy, Steve Lampert, Jo­Anne Foley, Emily Brower, and Cheryl Livoli and all of the administrative assistants are the finest and most dedicated professionals I have ever known. Over the years I have met many people in healthcare and none exceed the skill and commitment of these Riverside pros who directly helped me carry my business and leadership responsibilities. To all of my CEO colleagues past and present in the Atrius Health affiliates, I owe you not only gratitude for your tolerance of a leader without a traditional management background but also for the thousands of hours (literally, I added them up) of shared experience and your wisdom in our weekly meetings. I will always smile when I think about walking into Dedham Medical Associates most Wednesday mornings at 7AM for our weekly meeting.

Finally, I want to set the record straight about these letters. I did not do them by myself. I usually wrote a very rough draft late on a Thursday night after absorbing the wisdom of the others listed above over the previous week. On most weeks sometime after midnight I would send the letters to Marci Sindell who would transform them into something that could be read. One of my all­time favorite writers is Thomas Wolfe whose powerful novels like Look Homeward, Angel were delivered to his editor Maxwell Perkins at Scribner’s as disorganized manuscripts that were not much more than scribbled notes in a pasteboard box. Marci has been the Maxwell Perkins of these notes. Usually by 9 AM on Friday my musings were edited and ready for discussion and debate. That was when the real fun began because Marci has a sense of healthcare and healthcare policy that is recognized by insiders across our industry and she has the courage to say what she thinks even if what she thinks is not what I think.. When Marci said, “Do you really want to say that?” or “I can’t follow your point,” the right answer from me was, “You’re right, that does sound off the mark.” I knew that I could say, “What do you think would work?” Let me just say there are a lot of “outtakes” on the cutting room floor.

On the weeks when Marci was away, the job of managing the prose fell to Donna Tolley who came in like a relief pitcher to get me out of a bad inning. Donna has her own unique style and method and the outcome was always an improved letter for you to read.

The final step in the process was the proofreading and assessment of Cheryl Livoli. Cheryl has a feel and love for our organization that she cannot hide. On many occasions her proofreading became an additional editorial exercise. Cheryl, and Carole Martin when Cheryl was away, got the letter out to Atrius Health and to the growing distribution to the “other interested readers” outside of Atrius Health.

I hope that you can see that “team” has not been a concept for the practice alone. Team has been the essence of management and how it did its work. I have been the beneficiary of the efforts these people and of so many more who have supported me from a distance. To all of the people named and to hundreds of others unnamed who supported my efforts to lead, to all of you in every corner of Atrius Health who do the work that makes Atrius Health the hope and success that it has been and will be, and to the people who will continue the journey, I can only say thank you for everything you do. I will never forget the joy of knowing you and working with you toward a distant dream. I will watch from afar and glow with pride as you continue to make a difference in a difficult world.

Bless Be the Tie That Binds

I was raised in a tradition that valued community and mutual support centered in religion. As an adult I have spent much of my time trying to rationalize the inconsistencies between that community of my childhood and the world that I discovered as an adult. As an older adult I have realized that nothing is perfect or stands up to every test and that there is value embedded in many things that we might find imperfect or convenient to discard.

The hymns that I heard and sang as a child have had an enduring comfort for me in moments of difficulty and pain. Separations and departures are often such moments. John Fawcett was a minister in a small Yorkshire Village in 1772 when he wrote the hymn “Bless Be The Tie That Binds” at a time when he was considering moving on to a new responsibility. I think that there are ties that will make me always feel a part of the great practices that form Atrius Health no matter where I am and no matter how you evolve. I believe that those things that constitute the core of why we strive and what we are trying to do for real people in our real community will not change. We are seeking health and opportunity for everyone. How to make it work gets confusing and complicated at times, but we know that we can never let go of the responsibility to try and that is the tie that binds us.

Bless be the tie that binds Our hearts…
We share each other’s woes, our mutual burdens bear;
and often for each other flows the sympathizing tear.

When we asunder part, it gives us inward pain;
but we shall still be joined in heart, and hope to meet again.

It has been a wonderful year for the Sox (never fear, they will rebound yet again) and a wonderful experience for me working with you for more than 38 years. I thank you each and every one.

Be well and carry on,

Gene