Are you wondering what you and your practice or hospital should be doing while living in the ambiguity of “repeal and replace?” Focus on getting better. That is the short answer. With or without the ACA the challenge to create

 Care better than we’ve seen, health better than we’ve ever known, cost we can afford,…for every person, every time…in settings that support caregiver wellness

 …does not go away. The Triple Aim long predated the ACA, and the Quadruple Aim will stand as our continuing and even more important objective after the ACA has been repealed no matter what replaces it

One of my first insights in my medical practice as I moved from the protective environment of the robust Harvard training programs into practice was that I needed to know what to do until I knew what to do. Ambiguity is the constant companion of the physician who is presented with clinical problems to solve every day. It is not a problem that “procedural” physicians or physicians who read diagnostic tests and images encounter quite as often.

My opinion arises from having lived in all of those worlds. My work as a cardiologist doing cath was oriented around completing a specific task just as the work of an orthopedic surgeon repairing an ACL is a specific task. Difficulties do arise in surprising ways, but it is not quite the same as trying to decide what to do based on the significance of an atypical chest pain in a forty year old woman. I loved reading echos. What you see is what is there. The test itself is done to reduce ambiguity. In contrast, there is nothing more challenging than sitting in a primary care practice and listening to dozens of stories every day about various symptoms and trying to decide which ones are best managed with reassurance and observation, and which ones require immediate intervention.

Now as an industry and as individual professionals we must decide what to do in very uncertain times. Many of us will be just fine if we work in well established internationally known academic medical centers. The President Elect met with the CEOs of the Mayo Clinic, Partners Healthcare, Johns Hopkins and the Cleveland Clinics. The main agenda was to ask their advice about the VA system of care but journalist suggest that there were other subjects of mutual concern. I would have preferred him to meet with the CEOs of New York Health and Hospitals, the Boston Medical Center, San Francisco General, and Cook County, or perhaps Dartmouth Hitchcock or Maine Medical. I wonder what the CEOs of Geisinger, UPMC, Swedish, Georgetown and Stanford are thinking.

As a board member of Guthrie Health in the twin tiers of Pennsylvania and New York and the Whittier Street Health Center of Roxbury, Massachusetts, I wish that the President Elect had met with Dr. Joseph Scopelliti and Ms. Frederica Williams, the CEOs of those organizations. Mayo, Partners, Hopkins, and the Cleveland Clinics are fabulous institutions that are famous for the work they do, but their CEOs live in a rarified world that may or may not inform them of the challenges that confront patients and caregivers in many of those “red states” that gave President Elect Trump his majority in the electoral college. My wife worked for many years as an NP at the West Roxbury VA Hospital taking care of veterans with cardiac problems. She may have a better feel for the real issues that face the VA system than Dr. Torchiana who was an able cardiac surgeon at the MGH and now can  demand virtually unlimited resources for his organization from the insurers doing business in Massachusetts.

There is one thing that is not uncertain about the future. There will be continuing downward pressure on revenue for practices, hospitals and health systems. This is as it should be. Medical care is too expensive and wastes resources. There should never be more revenue per patient relative to the GDP than there is now. This is a reality for Partners and Guthrie. I am not so sure it should be true for many of the systems that serve the underserved.

If you need to ask why, the answer is simple. Employers need to have the ability to shift funds now required for healthcare coverage to salaries, or le those funds should be available to reduce their prices to be more competitive. Taxpayers need to be investing more in infrastructure and other services like education and social programs for the disadvantaged. Consumers need to retain money to make other purchases, save for retirement, buy homes, and educate their children.

For the last decade and longer we have been transferring financial risk to patients in terms of higher insurance rates, higher deductibles, and higher drug prices and copays. They really can not take on much more expense. Now we are transferring risk from insurers and public funders of care to care providers. Care providers are theoretically capable of managing costs down but in the moment lack the desire, the competencies, or the insight that they can and should accept this risk. Like it or not that risk is increasing and the rate of change has been accelerated by MACRA.

Nothing that Donald Trump, Paul Ryan or Tom Price has proposed makes the reality of the pressures of finance on patients, employers, taxpayers or providers less. Actually most healthcare economists would suggest that their proposals will make the pressure on patients to contribute more for their care and on the operating budgets of practices, hospitals and health systems to be even greater than they are now. If many of the twenty million plus newly insured under the ACA lose coverage, the pressure on institutions and practices with marginal operating surpluses will be enormous. Many critical systems, like Dartmouth Hitchcock near me, are already in trouble and fighting a rising tide of red ink.

The effective answer to downward pressure on revenue is efficiency and waste elimination through process improvement. Lean and the other system of continuous improvement are agnostic to public and political realities. They work to improve the experience of care and the finance of care in any environment. For most of the history of the practice of medicine physicians have accommodated to the financial realities of those in need. It is not a good system of care for care to be dependent on “the kindness of others”. “Charity care” and pro bono practice are antiquated concepts, though circumstances may force us to revisit them.

A system of universal access in a society that values the health of everyone of its members is a much better concept, and a system that most developed countries prefer and expect, but during a Trump administration we may lose ground to that objective. Our most potent strategy to promote the possibility of universal care is to improve the efficiency and effectiveness of care delivery so that the expense of care will come down while we improve the experience of providing care.

One interested reader who is well grounded in the fundamentals of Lean and continuous improvement and has been a “guru” for me, responded to the discussion of a few weeks ago that was initiated by Dr. Paul DeChant’s advocacy for a more eloquent expression of the Quadruple Aim. He wrote:

The two fundamental principles of Lean are “continuous improvement” and “respect for people.”  The latter is often interpreted as respecting / putting the customer first, or as is often heard “the customer defines value.”  That interpretation is correct.  But our Toyota coaches also taught us that the concept of driving out waste or non-value adding work, when coupled with respect for people, means that we as leaders should never ask our people to perform non-value adding work.

Hence our responsibility is to put people first, and most importantly the “workers” who deliver value to our customers, as it is understood in a Lean culture that this is what the pillar “respect for people” really means.  Thus “… in settings that support caregiver wellness” would be applauded loudly by those of us who work at enabling Lean in healthcare (while our Toyota mentors would probably just smile and say that’s a given in their culture … and clearly we have a long way to go before that’s ingrained in ours.)

And there you have it.

Care better than we’ve seen, health better than we’ve ever known, cost we can afford,…for every person, every time…in settings that support caregiver wellness.

The strategy that we should adopt no matter who is leading now, and at anytime in the future, is a strategy that derives its power from the respect for people. We must always focus on providing value, not expense for patients, and supporting those that do the work of improving care. That is an endorsement for a strategy that is not dependent on finance and need not vary when there is a change in political philosophy or control.

Whether you are the CEO of an internationally prominent academic medical center or a medical assistant in an ambulatory practice serving the underserved, it would be best to start each of these days over the next few years until the way ahead is certain, by personally committing to creatively contributing to the work of continuous improvement that is driven by a respect for the people who need the care, who provide the care, and for those that support the delivery of better care. I am certain that this is the most productive way to make progress in times that are volatile, uncertain, complex and ambiguous. The finance and the politics may change but the human needs and the professional responsibilities are constant, and our need to rise to the challenge is inherent in our roles as professionals.