March 15, 2024

Dear Interested Readers,

 

Income From Quality

 

In the early years of this century after the near failure of Harvard Pilgrim Healthcare, there were very active conversations in Massachusetts about the cost, quality, and access to healthcare in the state. Attention to quality and safety had crescendoed through the eighties and nineties. The NCQA was created in 1990.  Don Berwick left Harvard Community Health Plan, and with a few visionaries, he launched the Institute for Healthcare Improvement (IHI) in 1991. In November 1999, To Err Is Human: Building a Safer Health System was published by the Institute for Medicine (IOM). In 2001, the IOM published Crossing the Quality Chasm: A New Health System for the 21st Century. The central truth in all of this work was that quality in its six domains was the key to eliminating waste, containing the cost, and improving the outcomes of care. Those six domains of quality are patient-centered care, safe care, timely care, efficient care, effective care, and equity in access and quality of care. The challenge was to develop an operating system built on the priorities of quality, and the simultaneous shift to a finance mechanism that favored the production of quality over the tendency of fee-for-service practice to generate “billable” encounters. 

 

Healthcare access, quality, safety, and costs had been a very active conversation in Massachusetts long before Senator Ted Kennedy undermined Jimmy Carter’s attempt to pass a national healthcare bill in 1980. In 1969 Dr. Ebert launched Harvard Community Health Plan driven by the sixties version of “quality” wisdom. During the governorship of Michael Dukakis, in the build-up to his run for the presidency, a comprehensive healthcare bill was passed, the 1988 Massachusetts Universal Health Insurance Law, but the bill was never implemented.  

 

When the status quo is changing things move slowly, even when a majority of the population agrees with the new concept. The result of that “conversation” in Massachusetts that had been going on for over thirty years was the passage of “Romneycare” in 2006. The actual name of the bill was Chapter 58 of the Acts of 2006 of the Massachusetts General Court, An Act Providing Access to Affordable, Quality, Accountable Health Care. I usually just called it “Chapter 58.” There was a new healthcare law almost every year through 2012 with a series of “new chapters.”  The bill in 2012 was “Chapter 224” of the Acts of 2012. Its major provisions were the creation of a cost control council that could review all proposed mergers and acquisitions to determine whether cost or quality would be negatively impacted by the deal. The bill also set the target of holding the annual increase in insurance costs to 3%.

 

It always felt to me like a significant portion of the population of Massachusetts cared enough about healthcare to make it a top political issue in the state. Perhaps that was because we had the most expensive healthcare in the country. The lay press frequently published articles about how expensive healthcare was and the efforts being proposed to improve access and contain costs.

 

I would facetiously say to my colleagues that in Massachusetts the public was speaking to the medical profession using the legislature as a bullhorn. I implied that we needed to take healthcare reform seriously and assume a leadership position in the transformation. The last thing anyone wanted was for the state legislature to be the sole designer of our system of care.

 

When I became CEO of Atrius and Harvard Vanguard the conversation about healthcare was peaking locally and Barack Obama was announcing his candidacy for president. In Massachusetts, Blue Cross was talking about a new “Alternative Quality Contract.” How to prepare for the coming demands from insurers and the state and federal governments was among my top concerns. The question was whether or not we could leverage what we did internally to help stimulate positive changes in the wider Massachusetts healthcare community.

 

Concurrent with the debates that led to Chapter 58 in 2006 (Romneycare), Blue Cross of Massachusetts was beginning to work on the challenge of implementing a contract that would foster the kind of changes that would promote quality as described in Crossing the Quality Chasm. You might remember that Atrius received a large grant from Blue Cross for “innovation” as part of a study (LEAD) that also involved The Beth Israel, The New England Baptist Hospital, The Mount Auburn Hospital in Cambridge, Cooley Dickenson Hospital in Northampton, and Atrius. At the same time, they were collaborating with Charles Kenney to produce The Best Practice: How The New Quality Movement Is Transforming Medicine (2008). The  review that is accessed by the link above calls the book “strictly for the already converted.” Perhaps, that is why I like the book so much. 

 

Kenney was a consultant to Blue Cross for many years and the Forward to the book was written by Cleve Killingsworth who was then Chairman and CEO of Blue Cross. Killingsworth’s Forward puts their objectives into perspective. At the end of his Forward, he wrote:

 

We should demand:

• A system with a goal of “zero preventable harm” for each and every patient.

• All patients receive appropriate and evidence based care, whether preventative or for acute or chronic conditions.

• A system that eliminates racial and cultural disparities in access to and delivery of, health care.

• Those who deliver care are rewarded on the basis of objective performance measures related to the quality of clinical outcomes.

• Patients receive what they need to make informed choices.

• Health system leaders, especially trustees and board members of hospitals and health care companies, become strong and consistent advocates of quality on behalf of those they serve.

• New technologies and treatments are evaluated and compared to existing alternatives prior to their adoption.

• The public and health care providers are fully informed about opportunities for improving care.

• Savings from a safer, more evidence-based and cost-effective health care system are reinvested in a way that slows the spiraling cost of health care and improves the health of the community.

 

 

When I began as CEO in February 2008, I had not seen Kenney’s book or read Killingsworth’s Forward, but I agreed with every point. I was “already converted.” My challenge at the time was to have my team develop a strategic plan that would help us “harvest” waste and reinvest what we harvested into further improvement that would push us closer to the goals of the Triple Aim which had recently been announced. 

 

One problem with selling “transformation” to doctors is that they automatically imagine being asked to do more with less. What is hard to convince them is that a focus on quality could make their work lives easier and more professionally satisfying without reducing their compensation. It is the best strategy for avoiding moral injury. It’s not alchemy. When 40% of the expense is from wasteful or unnecessary processes, or from failing to deliver care in an efficient, effective, equitable, and timely way, then it is possible to imagine “harvesting” that waste while charging less to lower the cost of care, improving work-life balance by doing less unnecessary work in more efficient systems, both while maintaining or increasing pay to the medical professionals. To many the ideas coming out of Blue Cross seemed too good to be true. 

 

In 2009, Blue Cross created a “new contract” option for the institutions and physicians with which it worked. The old contract was still an option, but the new “Alternative Quality Contract” satisfied all “system demands” listed by Killingsworth. I think that there were some who worked at Blue Cross who were not so sure if the new contract would work. Some members of my team were also apprehensive about assuming performance risk. We had many long discussions about the “downside” risk of not meeting quality objectives. Some argued that we were still in a “recovery” mode from the collateral damage we incurred from the near collapse of Harvard Pilgrim. One significant concern was that much of the infrastructure that we had used to play a leading role in the quality movement of the nineties had been lost or abandoned as unnecessary overhead as we sought to survive by doing more and more fee-for-service work. 

 

In a value-based reimbursement system, a solid IT platform is an absolute must. Our Epic medical record was out of date, and there was very little that could be easily extracted from it to guide our attempts to eliminate waste and improve quality. Investments in improving our quality infrastructure were necessary if we were going to succeed. I was eager to sign the contract. Others on the team were hoping for more guarantees of protection. Some changes were negotiated that waylaid some of the fears on both sides, and we did sign. We were the first group to accept the contract. 

 

We did reinvest in our quality infrastructure, and we did succeed. External analysis of the whole program done in 2012 and published in HealthAffairs showed that it was a success as have subsequent studies. When I consider the investments we made to succeed, including Lean,  I realize that our transformation was being driven by and largely funded through the AQC. What I did not know at the time was that we were also preparing ourselves to succeed in the Pioneer ACO. 

 

It has been fifteen years since we signed the AQC. I have always wondered why more organizations did not see it as a path to transformation. There is one bit of irony in the story that is worth presenting as a lesson for others. I mentioned that there were negotiations before signing. Many of our financial types were terrified that we would lose our shirt so they demanded that after a few years the contract be reopened and the original terms adjusted to reflect the experience. When that time came our experience did not lead to an increase in the terms. We had been so successful that the contract called for a reduction in our revenue. If we had not pressed for the “safety valve” we would have done even better. 

 

The change in the contract led me to the conclusion that it was time for me to call the CEOs of the Beth Israel Deaconess Medical Center and The Lahey Clinic to suggest that we get together to discuss the creation of an affiliation that could compete effectively with Partners Health Care and bring more balance to the Massachusetts healthcare market. I will tell that story in a few weeks. 

 

Twiddling My Thumbs Till Monday

 

I have no “Ides of March” fears.  Beyond some corned beef and cabbage with potatoes and carrots made expertly by my wife which I will wash down with a New Hampshire stout that is better than the Guinness that gets to these shores, I plan to have a very quiet St. Patrick’s Day.

 

My eyes are on Monday when I will have the back surgery that I hope will give me relief from the neuropathic pain, difficulty sleeping, difficulty walking, and the general sense of exhaustion and frustration that has laid me low since the middle of January. I hope that I will be writing again next Friday, but we will see how things go.

 

My recent troubles have been a learning experience, and my pain has given me great empathy for those who live with chronic pain and don’t have the hope that I have of being revitalized by an operation. In the eighties and until early in this century, physicians were made to feel guilty for denying those with chronic pain adequate treatment. What began as a loosening of opioid availability for patients with cancer became an argument for more compassionate management of all patients with chronic pain. Oxycontin was aggressively marketed as having an extremely low risk for addiction. Opioid use skyrocketed, and we know the painful outcome of an epidemic of overdoses that is the ultimate indicator of the fact that we have not evolved a standard of care for acute and chronic pain that works without the risk of some people becoming addicted.

 

Since mid-January, I have taken less than 5mg of oxycodone every three days. Until ten days before my surgery, I could take ibuprofen, and I took 600 mg doses as often as every four hours. Since I will be having bone grafts, I am not supposed to take aspirin or any NSAID for at least ten days before the operation. The switch to acetaminophen has left a lot to be desired so an occasional 5 mg oxycodone tablet at night has allowed me to get some sleep. 

 

Summing up the experience so far, I have a few observations. First, and I feel bad about saying this because I know that I got pushed ahead in line, but access to care is an issue. I am “privileged” so if the process of getting care is slow for me, I wonder what it would be like for someone who couldn’t play “the doctor card.” My second observation is connected to the first. I wonder if the delay in waiting for surgery may compromise my outcome. 

 

I fear that I may have residual problems once the surgery is done that I would not have had if it could have been done three weeks earlier. I have dysaesthesia or numbness in my lower leg and foot that I did not have three weeks ago. I have lost strength and have difficulty getting up from the floor or rising from a chair, and I can’t walk without a cane for fear of falling. Things have progressed. I am hoping that all of this gets better immediately once the nerve root, (L5), which is described as “crushed” on my MRI done five weeks ago, is released.  There are problems on both sides from L3 down, and the vertebral body at the L3 level is crushed from a previous fall. I am surprised by all the pathology that I have lived with. I think my experience underlines the reality that many of our “acute” problems are just the final manifestation of neglected chronic problems. I guess that a third “learning” is that I should have been open to surgery sooner. 

 

Last week, I predicted an early “ice-out” on my little lake. I think that prediction will come true. What I didn’t predict was that the rain we were scheduled to get last weekend would come as two overnight snowstorms that delivered more than six inches of wet snow. You can see the result in today’s header. It was very pretty here on Sunday and Monday, but also very cold with gusts of wind that made it “feel” like the low 20s. I am sure that the melt of the ice was delayed by that sudden change in the weather. By mid-week, winter’s little encore was over, and we were back in the fifties with a lot of melting snow and ice. 

 

Wherever you are, and whether you are Irish or just love them, I hope that you have a terrific Saint Patrick’s weekend!

Be well,

Gene