January 26, 2024
Dear Interested Readers,
Some Recent Articles of Interest
Finally, the New Hampshire Presidential Primary is over. I am relieved. Perhaps through the rest of the winter, as well as spring and summer, we will be free from the robocalls and continual political ads on television. I am sure that the obnoxious ads will return in the fall during the run-up to the election in November.
I never thought that I would welcome the return of ads for drugs, but compared to the lies and misleading hyperbole of the political ads I would rather see ads for drugs for diabetes, inflamatory bowel diseases, COPD, and eczema. Short of divine intervention it seems likely that the 2024 election will be a redo of 2020. If the redo produces the same result, being tormented by all the political ads will have been worth it.
For years I have enjoyed the perspectives on healthcare delivery and public health coming from The Commonwealth Fund. On their website, they proclaim: “Affordable, quality healthcare. For everyone.” If you don’t subscribe to their free output, I would recommend that you get on their mailing list. For several years, Dr. David Blumenthal has been the president of the Commonwealth Fund, and I was apprehensive when he retired last year and was replaced by Dr.Joseph R. Betancourt. I have never met or heard Dr. Betancourt speak, but his background as described in the previous link was reassuring.
…Betancourt formerly served as the senior vice president for Equity and Community Health at Massachusetts General Hospital (MGH), and as founding director of the Disparities Solutions Center. He has devoted his career to improving the quality and value of health care for diverse populations.
This week Dr.Bettancourt published “Message from the President: Navigating a Sea of Change in Healthcare;” a brief letter that I appreciated as a heads-up for what to expect from him and the Fund during this election year.
Dr. Bettencourt begins by describing 2023 as a year of “incremental progress paired with loss and anxiety.” Examples of incremental progress were the acceptance by North Carolina of the Medicaid extension of the ACA after refusing to do so for a decade and the drug price negotiation for Medicare recipients that will eventually lower the cost of drugs for millions. Examples of loss were the facts that after the pandemic millions of Medicaid recipients lost coverage, even patients with “coverage” have a hard time accessing care, and drug prices for many Americans continue to climb. That is not all. Primary care, Behavioral Health, and the environment are failing:
Primary care, once the stable foundation of our health care system, found itself in a precarious position, like a worsening patient moving from the hospital bed to the ICU. Declining access to primary care, coupled with workforce shortages, has made the condition — and prognosis — critical.
… And New York City, like much of the U.S., experienced a day straight out of an apocalyptic sci-fi movie when wildfire smoke drifted in from Canada, providing a stark reminder that climate change is real and worsening.
Perhaps the most embarrassing fact of all is the reality that Black mothers and infants fare worse here than in some third-world countries. Dr, Bettencourt’s summary statement for 2023 is grim:
Despite spending the most on health care of any wealthy nation, Americans continue to get shortchanged when it comes to the return on that investment.
2023 was Dr. Bettencourt’s year of introduction to the Commonwealth Fund. He enters 2024 with a sense of purpose and clarity about their long-term mission. I wish that all of the candidates for public office would listen to the messages coming from the Commonwealth Fund. We need national leaders who aggressively support policies that would address the issues that the Commonwealth Fund so effectively describes. Near the end of his letter, Dr. Bettencourt describes objectives that are highly aligned with my concerns about the healthcare challenges we will face this election year.
In many ways, 2023 was just the tip of the iceberg, given how contentious and unpredictable the 2024 election year promises to be…our teams will focus on primary care, the health care workforce, and the commercial drivers of health care, and we are exploring what our role might be in the rapidly evolving field of artificial intelligence. We will stay the course with our important work on coverage — including Medicare, Medicaid, and commercial insurance — as well as climate change and behavioral health. Health equity will continue to be at the core of all our work…
I bolded that last sentence. I share Dr. Bettencourt’s concern that the election will make 2024 a more difficult year than 2023. Addressing the issues of primary care, behavioral health, the global climate, and AI would be a good start, but making progress will require electing members of Congress and a president willing to recognize the jeopardy we are facing as a nation with an increasingly inefficient system of care on a rapidly warming planet. At a more fundamental level, I know that all of the social determinants of health and healthcare disparities must be addressed more effectively than we have up till now. We talk a lot about the social determinants of health, but talking and doing nothing is frustrating and puts the future of the nation at great risk. Without effectively addressing the social determinants of health improvements in primary care and behavioral health will not be enough to improve the health of the nation.
I have enjoyed the remarkable series of articles that Nicholas Kristoff has been writing in The New York Times since last May entitled “How America Heals.” It is a remarkable series in which Kristof presents the real-life stories of Americans who are suffering from inequalities in the social determinants of health with the hope that more and more of us will support the work and the policies that are necessary if we are to see meaningful improvements and move toward healthcare equity. One of Kristof’s objectives is to show how the social problems of working-class Americans are interwoven in ways that are “creating crises” that are “devastating parts of America.” As he has done in his writing about gun violence, Kristof suggests “exploring paths to recovery.”
One thing that the 2024 election has underlined is that there are still at least two Americas. This week an article, The Looming Contest Between Two Presidents and Two Americas, by Peter Baker of The New York Times gives us a good picture with great depth of our two Americas. Red America is primarily rural and/or blue-collar. It has a macho culture and disdains intellectuals and government as sources of oppression. Extreme self-reliance and self-defence are cultural hallmarks. Church is valued as a concept even if not attended. A defining liability is a sense that life as they imagine it should be and personal freedom is under attack from the left. Donald Trump speaks to Red Americans and his promise to defend them is enough to allow them to recast most of his flaws as the lies of the left or evidence that he is one of them.
Blue America believes that a well-functioning government can improve the lives of everyone. Its inhabitants value education and enjoy living in cities where there are cultural opportunities, challenging jobs and professional opportunities. Individual competency and accomplishments are valued but so are efforts to improve the community for the benefit of all. A defining liability can be a lack of tolerance for those who do not appreciate the wisdom of their political and social preferences.
Most of our states are “red” or “blue,” and there is little chance of color change in the foreseeable future. Baker describes the balance between the less populated and rural red states in the electoral college, and the more populated and urban blue states:
Mr. Biden starts the general election with 226 likely votes in the Electoral College and Mr. Trump with 235. To get to the 270 needed for victory, one of them will have to harvest some of the 77 votes up for grab in half a dozen states: Arizona, Georgia, Michigan, Nevada, Pennsylvania and Wisconsin.
Biden won all of those “swing” states in 2020 by narrow margins, and he must do so again if we are to avoid a second Trump presidency. Hillary Clinton did not win all of them in 2016 and that was why we had the first Trump presidency even though she won the popular vote. It is scary to contemplate the fact that if there is to be any progress in repairing the deficiencies in the social determinants of healthcare before 2029, it will require Biden to win most of those states again. If you care about the health of the nation, or if you want to live in a more equitable America where politicians try to follow the rule of law, this election may be the most important election in the rest of your life.
It seems ironic to me that when we need politicians who are committed to developing effective healthcare policies thoughtful people like Nicholas Kristof are sometimes excluded from office while others who display dishonesty, self-interest, and a willingness to disregard norms and the rule of law seem hard to prevent from pursuing office. Kristof tried to run for governor of Oregon in 2022 but was excluded from the ballot based on having not spent enough time in Oregon in recent years to be considered a citizen of the state.
You may remember that Kristof grew up on a farm near Yamhill, a small town of about 1500 in Oregon. He was not a typical farm boy. His parents were professors at a university in Portland, but as a child, he rode the school bus with children from his rural neighborhood. He maintained relationships with many of his classmates over the years. In 2020, Kristof and his wife described those relationships and what happened to many of the kids on the bus in a book they wrote, TIGHTROPE: Americans Reaching for Hope. The book described the plight, including diseases of despair, and the downward trajectory that plague so many working-class Americans. In her review of the book Sarah Smarsh writes:
Yamhill, which thrived with blue-collar industry just a few generations ago, serves as a microcosm for a nation in which life expectancy has alarmingly declined. One in four of Kristof’s former peers died in adulthood from substance-abuse disorders, suicide, accidents or treatable health conditions such as obesity and diabetes. “Tightrope” suggests why: a corrupt and uniquely cruel economy in which millions of underpaid or underemployed Americans cannot afford education, health care or housing. Familiar statistics on these dismal trends take on fresh urgency when juxtaposed with photos of Kristof’s schoolmates who are now homeless or dead.
The series that Kristof has been publishing recently expands on some of the points made in Tightrope. The most recent article, the sixth in the series, is entitled “Bill Beard Was a Good Man. Then He Committed a Terrible Crime.” in it Kristof writes:
When we were boys, Bill tried to teach me how to fix cars; he wasn’t so successful at that. But with the bumpy course of his life, he taught me how Americans can better support those left behind.
I’m not sure Bill would have much patience for the way I’m telling his story, though. He didn’t make excuses. “I made bad choices,” he told me. “A lot of them.”
But I think there’s more to it than that, as I contemplate a very decent man who did very bad things. And in his story there are perhaps larger lessons that can help us prevent other young people from following his path. So, Bill, if you’re looking down at me, rolling your eyes, just hear me out.
Bill did not succeed in school. After “graduating” and failing to get a job with a future in an economy where good paying “blue collar” jobs were becoming scarce, Bill got into drugs. While high on meth, cocaine, and alcohol, he robbed a convenience store and assaulted the cashier. For his crime, he was sentenced to twenty years in prison but was released after five. Kristof is careful to explain that he is not trying to justify what Bill did. Bill held himself accountable and regretted what happened until the day he died of rectal cancer in his early 60s, but Bill’s story is not unique. He continues:
When Betty Friedan called attention in the 1960s to the lack of women’s rights, she described it as “the problem that has no name.” In a similar way, there isn’t a good term for the bundle of pathologies that have afflicted working-class Americans like Bill.
My “How America Heals” series has explored how to overcome these afflictions, which include stagnant incomes, addiction, homelessness, suicide, chronic pain, loneliness and early death. We still don’t fully understand how they are correlated or why most of them affect men more than women. I do believe that, as with Friedan’s probing of gender inequity, our explorations of these problems will help us chip away at them. That’s the reason for this series: A nation cannot thrive when so many have been left behind…
…The Princeton economists Anne Case and Angus Deaton popularized the term “deaths of despair” for the tumbling life expectancy among working-class Americans since 2010, but the tragedy goes far beyond the staggering mortality. For each person who dies from drugs, alcohol and suicide, many others are mired in addiction and heap pain on their families…
The challenges are particularly acute for Black and Native American men. Native American males have a life expectancy of only 61.5 years, shorter than men in India, Egypt and Venezuela. And the median wage of Black men in 2020 was only 55 percent of that of white men, a smaller share than it had been in the late 1960s.
The burden of the inequities, for people of all races, is compounded for America’s less educated — like Bill.
Kristof suggests that Bill’s death was hastened by the stresses in his life and difficulty getting care. Difficulty getting appropriate care is a problem for many of us even if we have health insurance. When we think of “access” to care we need to consider more than whether a person has some form of health insurance. We need to consider the barriers that exist from the fractured nature of our delivery system which avoids providing care when the volume of patients undermines fee-for-service profits.
After years of rough living, Bill developed health problems and suffered three heart attacks. Then, when he felt abdominal pain a couple of years ago, he found it difficult to locate a specialist willing to accept his insurance. Finally, when the pain became unbearable, he went to the emergency room — and was diagnosed with late-stage rectal cancer.
Kristof emphasizes that even on his deathbed Bill wasn’t looking for excuses. Like many earnest citizens of Red America Bill accepted personal responsibility for what he did in life. Kristof suggests that Bill would have pushed back against the philosophies of Blue Americans who might want to change the world in a way that would have offered Bill more opportunity in life. The conundrum is encapsulated in a conversation that Kristof reports that he had with Bill while Bill was dying. Bill speaks first:
“As long as you have the mental capacity to know right from wrong, it’s your own damn fault” if you get into trouble, he said. “You can’t blame anyone else. It’s ludicrous. Who is there to blame?”
I pushed back. Didn’t the addiction crisis have something to do with larger forces like lost jobs, declining earning power and failed education and mental health policies?
Yes, he acknowledged that there was something to that, but he wouldn’t budge from his embrace of 100 percent personal responsibility, including when it came to his assault on Betty Gerhardt. “I was high; I was angry,” he said, about his mental state at the time. “Nobody else made me do it. How can you blame anybody else?”
While I admire Bill’s acceptance of responsibility, it’s also true that none of this unfolded in a vacuum. He made appalling decisions — but why was it that tens of millions of Americans were suddenly making bad decisions?
The previous generation of working-class Americans had thrived with a booming economy, rising education levels and union jobs. But in blue-collar neighborhoods, the generation that Bill and I belonged to imploded…
I’ve struggled to process all this in a community that I love, but I don’t believe this was a spontaneous collapse of morals. Nor do I think it can be separated from the context: a poorly educated work force that had few options when good blue-collar jobs went away; the proliferation of hard drugs and a lack of treatment programs; and an atomization of society following the unraveling of the social fabric and the collapse of churches, clubs and other local institutions.
The no-excuses personal responsibility narrative has been absorbed by many working-class Americans, and it can be highly motivating; it’s often a pillar of efforts to overcome addiction. Yet this narrative can also be dispiriting when people fall short of their aspirations, amplifying their sense that they are hopeless screw-ups — and that in turn can mean one more reason to reach for narcotics to numb the pain.
I wonder: What killed my buddy Bill Beard?
There is much more to ponder in the contrast between two childhood neighbors. One went to jail and died an early, possibly preventable death. The other went to Harvard, was a Rhodes Scholar, studied law, speaks Arabic, and has won numerous awards as a thoughtful author and journalist. I don’t think Kristof became who he is entirely through his own efforts, and I don’t think Bill was totally responsible for the awful mistakes he made.
As is usually his style, Kristof uses the story to make suggestions that might make a difference in the lives of many who are disadvantaged by how they were impacted by the social determinants of health. I don’t know if Kristof’s suggestions if implemented would reduce the diseases of despair, lessen the use of drugs, or transform both Red and Blue America into an America with less tension and more opportunity for universal improvement, but I do expect that the election this year will make a difference in the collective future of all Americans whether they are Red, Blue, or that intermediate state we call Purple.
Enthusiasm For Lean
Between February and June of 2008, I was a traveling man. As I have said before Atrius land from north to south was nearly fifty miles. Chelmsford, just a few miles below the New Hampshire border was our most northern site. South Shore Medical Center in Weymouth as well as Harvard Vanguard’s Braintree site drew patients up from Cape Cod. We stretched east to west from our downtown Post Office Square office in Boston’s financial district west to Southboro Medical Center where there were patients who lived in Central Massachusetts. There were some days when “my rounds” would require driving almost two hundred miles. I listened to a lot of NPR and sat in the snarl of a lot of Boston traffic.
As I traveled around, and as I was exposed to other healthcare leaders in the LEAD program who believed in the need for transformative change, I was thinking about strategies that might help us be more efficient in ways that might improve the quality of the care we offered while lowering the cost of care and improving life for our employees. I knew we needed to prepare for what I anticipated would be an ever more challenging future. A huge barrier to transformation was the very legitimate work-life concerns of our doctors, nurses, and support staff. Everywhere I went what I heard most was concern about the work-life challenges that our staff experienced. People were unhappy with their work, and they saw little possibility for improvement in the future.
What evolved working closely with Marci Sindel, Tom Congoran, and Zeev Neuwirth and from conversations with the management team and the board was a strategic plan. While getting into the job with my travels and with the work on a believable strategic plan almost written, I decided that I wanted to move from being an interim CEO who was a placeholder to being CEO. Interims can make a difference, but it is hard to set a new direction as an interim. Most people are reluctant to make meaningful and difficult changes when it is possible that in the very near future someone with different ideas will be changing the direction of the organization. In early June 2008, shortly before the strategic plan was ready for introduction and the first steps of implementation, the board took the “Interim” from my title.
The strategic plan recognized that we needed tens of millions of dollars to reinstall and upgrade our medical records system, refurbish our offices, expand our laboratory capacities, and institute new programs of chronic disease management. All of this change needed to be accomplished while improving the lives of all of our employees. Theoretically, I had control over Harvard Vanguard and the management services that it “sold” to its partners in the Atrius confederation. Each Atrius partner had the ability to succeed or to fail without obligation to the other Atrius members. I could influence, as Ken Paulus had done, the other Atrius CEOs, but they reported to their boards and not to me even though I had the title of CEO of Atrius when we jointly faced the outside world. In a way, Atrius was a bit like America where there is sometimes confusion about what gets decided locally versus collectively.
As my thought partners and I talked about our opportunities, we kept coming back to the startling assertion from authorities like Don Berwick that about 35 to 40% of healthcare spending was waste. The annual budget of Harvard Vanguard was over a billion dollars. Could it be true that we were wasting 350 to 400 million dollars every year? I hoped that was true because if it was then there was plenty of capital to be used for the improvement in care delivery and workforce experience that we wanted to make. What evolved was a simple strategy, “rescue and reallocate.” We would eliminate waste, the “rescue,” and then invest the savings, the “reallocate,” to improve our future.
“Rescue and reallocate” sounds great but the “rescue” part was much easier to say than to do. There is a momentum to the status quo that is hard to redirect. “Rescuing” waste meant changing a lot of things from contracts to workflows. Some clinicians would consider the introduction of “best practices” as an encroachment on their clinical autonomy. To make the job even harder, we also promised that we would not use workforce reductions, or layoffs, to achieve savings. If a job were to come open, we would see if the workflows could be reconfigured to make a replacement unnecessary. Conversely, if a new workflow eliminated the need for a position the person in that job would be given another responsibility.
Selling the plan was a little like getting acceptance of “cold fusion” as an energy source. It was clear that if we wanted different results, we would need “a new way of walking.” The 1963 tune, “Walk Right In” by the Rooftop Singers kept rumbling through my head because we did need a new way of “walking” and a new way of approaching our responsibilities.
Walk right in, sit right down
Daddy, let your mind roll on
Everybody’s talkin’ ’bout a new way of walkin’
Do you want to lose your mind?
As the song implies, change does involve losing or maybe changing your current mindset and adopting something new. The need for change is something that is easy to recognize in others and often even easier to avoid yourself. “Don’t rock the boat,” is a good example of conventional wisdom.
The “how to do it” part of the plan called for developing organizational-wide expertise in some form of continuous improvement. In the LEAD program, we had shown our rudimentary Lean skills, while others had used “microsystems” thinking, Six Sigma, or TQM methodologies. They were all systems of “continuous improvement,” and all of them had been employed in healthcare with some successes and frequent failures.
We had tried TQM in the 90s, but the initiative lost momentum. Zeev favored Lean. His arguments won me over because I had seen what Lean could do when he had introduced it at Kenmore and then again at Chelmsford and Medford where he was leading our activities for the Blue Cross LEAD program.
Zeev suggested that we reach out to other organizations that were successfully using Lean and verify that the scope of change we wanted to introduce across the practice using Lean was possible. It was his idea that we call John Toussaint at ThedaCare in Appleton, Wisconsin. Working with a Lean consultancy, Simpler, Toussaint, and his colleagues had achieved amazing results. John generously spent over an hour with us on that initial phone call. Much of what he told us would be published in his 2010 classic, On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry. He invited us to visit Appleton, and that sounded like a great idea so several members of the management team made the trip. What we saw was impressive.
ThedaCare had been initially guided by Simpler. We wondered if we too should hire Simpler to help us. I learned that Simpler had worked with Don Berwick at IHI and supported Dr. Patty Grabow in the amazing transformation that she had led at Denver Health.
We decided to make more visits before finally deciding on our path forward. One of the most noted examples of Lean’s success in Healthcare was the work of Dr. Gary Kaplan at Virginia Mason Medical Center in Seattle. Group Health of Puget Sound, now a part of Kaiser, was also introducing Lean to its clinical and business processes. We headed to Seattle. I remember talking with an internist at Virginia Mason who told me that before becoming involved with Lean he was burned out and ready to retire. Lean had revitalized him and now he hoped to continue to work for several more years because he felt that he was doing something exciting and important. He believed that if Lean and its philosophy could become a standard business practice across America we could achieve the Triple Aim. His enthusiasm was infectious.
After we had completed our visits we contacted Simpler and asked them to come and talk with us. It was the beginning of a very fruitful relationship. The only downside to what I learned was the realization that a Lean transformation was a multiyear journey. We had to learn “a new way of walking” and a new language. The first lesson for me was that I had a lot of personal learning and change ahead. In the new Lean environment my role as CEO was to change from solving problems and giving instructions to others to enabling others, those closest to the work, to bring forth their ideas. Our strategic plan would be translated into Lean initiatives. There would be many who had enjoyed their authority over others who would not easily accept their new roles of teaching and supporting those whom they once could command.
Welcome To Forest
Today’s header which is the scene looking west toward Mount Sunapee from the highest point on Burpee Hill Road suggests that we are in the middle of winter. Indeed we are, but I am not interested in the weather. I have other things on my mind.
Forest Casler Horton-Lindsey arrived six weeks ahead of schedule at 7 AM on Saturday, January 20 at the Maine Medical Center in Portland. He was in a hurry beating his ETA by almost six weeks, but at five pounds 13 ounces and foot and a half, he was big enough. He pulled the same trick as his father, uncle, and cousin. They all arrived four to seven weeks early.
My granddaughter who is both an academic and athletic star at Bowdoin College holds the family record for earliest arrival at 33 weeks. Unfortunately, since my granddaughter was born in Miami, I did not see her until after she had come home from the hospital. So, my most recent visit to a NICU was in 1985 when Forest’s father arrived almost six weeks early but not quite as hefty as Forest. Maine Medical has a very high-tech NICU that encourages parents to stay with their babies and allows two other visitors to stay as long as they want to stay. Things do change. When my first son was born back in the sixties I had to look at him through a window where his bassinet was lined up with about twenty other squealers. At Maine Medical they encourage having the parents participate in the baby’s care, and they have no problem with elderly grandparents holding the swaddled baby for as long as they want! What a treat!
Forest is getting a crash course in sucking. His mantra is “suck, swallow, breathe, and repeat,” As soon as the little Twig learns the drill and can repeat it reflexly he will be heading to his home on the edge of the forest. He may pass his test within the next week. He has already graduated from the NICU to the “continuing care” unit.
Forest’s parents are outdoor people who like living in the woods in Maine where they can enjoy nature. His father explained Forest’s name to us in a long text when we asked how the name was chosen:
Thanks for asking this question. It was a good opportunity to write down some thoughts that have informed our conversations about this. I think we wanted a name that would evoke some value or impression or idea. Before we knew his sex, we had a lot more ideas for girls’ names, and we noticed that what a lot of those had in common was that they evoked the natural world. Lots of plant and flower names (for example) are available for girls and we had a lot of those on our list. When we realized that the natural world was a value/idea that resonated with us, we tried to apply that same idea to a boy and we found there weren’t as many great options out there — the girls kind of own a lot of them for some reason. That made it pretty easy to locate the nature names we felt were good for a boy. I think evoking a forest is a way of encouraging him to spend time there, feel at home there, honor it, and learn from it. It’s what he will see when he looks out his window, and wherever he goes it will be where he comes from. It’s the setting we chose for him to grow up in, and it’s a place we both feel connected to. It felt like a good fit for our family, our values, and our aspirations for him to grow and thrive.
Since our first visit last Sunday, we have gotten a stream of pictures and videos that have convinced me that we should return for a second visit this weekend, weather permitting. I hope that you are also looking forward to something special this weekend.
Be well,
Gene
