One thing that I am learning about first hand these days is ageism. I have experienced having young clerks walk right past me as if I was invisible to serve a younger customer who has just appeared. There is a wider gulf between generations than just familiarity with popular music or the ability to use Snapchat or Twitter. When I eavesdrop on the conversations of younger people I realize that I own part of the problem. What interests them does not always interest me. I have no interest in experiencing many of the things that they are eager to do. One thing that I know for sure is that it is rare for a younger leader to solicit the advice of a predecessor. In most areas my interests and experience are losing applicability to the issues that concern them. Much of the expertise that assured success in 1990 is fading and being replaced by a new set of required skills that enable progress now and in the proximate future. I can remember the energy and excitement of being a proponent of “a new way of walking.” I can also remember my desire for those that were in control to get with what was evolving or get out of the way. In time it was appropriate for me to get out of the way.
“Old soldiers never die; they just fade away.” General Douglas MacArthur famously ended his public life with those lines lifted from an old military song in a farewell speech to a joint session of Congress in April 1951 after President Truman fired him from his command in Korea. Truman was trying to limit the Korean conflict to a small military action. He feared that MacArthur would expand it to a much larger Asian conflict. If you are interested, Vaughn Monroe put out a popular recording of the “old soldiers” song that same year. I presume it was a tribute to MacArthur. What MacArthur did after 1951 did not make much difference. He did make a brief attempt at becoming president in 1952, but there was no stopping the more politically popular Eisenhower.
Old doctors fade away also. More specifically I feel that those who were served by old doctors, taught by them, or lead by them gradually forget them. Their revolutionary ideas move from being daring “moonshots” to mundane daily activities of the status quo. I really sound old when I complain that there are very few people who care much about the portraits that they see hanging in the hallways and auditoriums of our medical institutions. I doubt that there are many Brigham residents who know or care about the fact that Lewis Dexter performed one of the first right heart catheterizations on himself, or that Richard Gorlin went on from Dexter’s work to use the data that Dexter uncovered to come up with a calculation for the functional size of the mitral valve, and that he did it in an armchair conversation with his father who was an engineer. New knowledge and new invention rest on yesterday’s breakthrough concepts that are now taken for granted. Sometimes new knowledge is recycled old knowledge.
These thoughts were passing through my head as I listened to the excellent conversation between Zeev Neuwirth and Sachin Jain on a recent edition of Zeev’s podcast, Creating a New Healthcare. It was a sparkling, insightful conversation between two men of great wit, knowledge, and insight. More importantly, their dialog reveals that they care about the principles of the Triple Aim and are trying to contribute to a “new healthcare” designed to respond to the needs of a nation that is struggling with inequalities and poor population metrics despite a willingness to spend enormous amounts of money on cutting edge technology. It occurred to me that Drs. Neuwirth and Jain are trying to come up with solutions that are inline with Dr. Ebert’s 1965 analysis of the challenges that faced healthcare then. I am reluctant to state Dr. Ebert’s formulation again, but I will risk boring you because it is so important.
“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.”
I have “riffed” on the wisdom of this statement until perhaps it is ignored out of familiarity, but I have not described how Dr. Ebert acted on his own wisdom. By 2008 I had been the Chairman of the Board of Harvard Vanguard Medical Associates for the first decade of its existence. I became the CEO as we were approaching our tenth anniversary since “spinning off “of Harvard Pilgrim Health Plan as an independent medical group. We were the legacy practice of the old Harvard Community Health Plan which Dr Ebert had created in 1969 as a pilot to test his own hypothesis and ideas. In 2008 it felt appropriate to revisit our roots. So we put together a celebration that included a very nice document that is still available as a “glossy” downloadable PDF from the Internet. Take a look at the document because it describes the “moonshot” that Ebert and colleagues were attempting in 1969. I joined the practice when the work was getting traction. The methods and ideas we had then were not that different from the story of CareMore, a subsidiary of Anthem Health, that Dr. Jain described in Zeev’s podcast, Creating a New Healthcare, Episode #56 – Customized Care for an Aging Population with Sachin Jain MD.
As it says in the section of the 2008 PDF entitled “A Medical Moonshot”:
…The impetus for change was rooted in fundamental problems confronting American medicine during the 1960s: Medical costs were rising at an alarming rate, the neighborhood general practitioner was becoming extinct and there was increased demand for a dwindling supply of primary care physicians. Medical schools and their affiliated hospitals, along with payers and policymakers, were struggling to develop more efficient and accessible models for teaching and delivering primary health services. Solutions ranged from reorganizing outpatient clinics to developing neighborhood health centers in urban areas.
Ebert and his team had a different idea: their plan was to replace fee-for-service care with a prepaid group practice that would provide high quality ambulatory health care within the community, serving the sick while also providing preventive care to healthy members of the community. Comprehensive care services would be available under one roof, delivered by a group practice staffed by salaried physicians, working with clinician teams. Affiliation with Harvard Medical School would provide training for future physicians, and the program would provide care to patients from all sectors of society, including low-income, underserved populations. Most significantly, it would be the first medical school sponsored managed care organization in the nation. Despite the enthusiasm of the planners, the idea was met with skepticism and even scorn in the Boston medical community. Some called the idea “a medical moon shot” that smacked of “socialized medicine” and would never succeed.
Ebert and his colleagues were persistent, having spent years in careful and conscientious planning. they secured the support of Harvard Medical School, received initial funding for the not-for-profit corporation, established relationships with the two Harvard teaching hospitals, and acquired space on the first two floors of an apartment building at 690 Beacon Street in Brookline. They developed the medical care programs and arranged for Blue Cross/ Blue Shield to market the Plan, and even to provide a guaranteed number of members. They staffed for a predicted 10,000 members, and then hastily modified that estimate to 1,000 just weeks before the opening. As it turned out, the day that Harvard Community Health Plan opened its doors—October 1, 1969, there were only 88 members, most of whom were said to be employees of its affiliated hospitals.
From that rocky start of 88 patients HCHP grew to 30,000 patients in two years. There were about 70,000 in two sites when I joined in 1975. There were over 400,000 patients in 14 sites in 2008. Dr Ebert’s formula was to provide a “medical home like environment” before that was a well understood concept although it first appears in the literature in the late 60s. We had an EMR. We had team based care. We practiced population health with programs that evolved for specific populations. We focused on preventative care and the care of chronic disease. We evolved many of the concepts of the quality movement. We were capitated. We were salaried. We were diverse and welcomed women as colleagues and allowed clinicians to modify their hours to accommodate other interests like teaching, research, or caring for their families. We had everything but hospital beds under one roof. Mental health resources were integrated into the practice, and our total cost of care was double digits below the cost of other providers. Dr. Ebert had proven that:
Many of the existing deficiencies in health care can be corrected 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.
As I listened to Dr. Jain describe the growth of CareMore I became quite excited by the results that they are getting with a Medicare Advantage population that is capitated. The physicians are salaried and given further incentives through bonuses for measured quality and improved outcomes. CareMore has forty sites and has 150,000 patients. Like the old HCHP the pilot has delivered reproducible results and they are now scaling up. I liked Jain’s version of the type of physician they are trying to hire. They want doctors who love giving care and exercise social responsibility in their approach to their work. “Will, skill, and organization” are the ingredients for organizational success.
As great as the experience of practice was at HCHP and at Harvard Vanguard were, we were often faced with external challenges that left us feeling like we were desperately bailing a sinking ship. I always look West to Kaiser as the best example of how Dr. Ebert’s ideas appear when in full bloom. HVMA, Kaiser, Group Health in Washington (now a part of Kaiser) should be studied because they have been some of our best attempts at reaching for the Triple Aim.
As I look back on what I learned working in Dr. Ebert’s world I might say that in his succinct expression of how to improve healthcare he left out the third ingredient. We do need efficient operating principles, we do need financial systems that are aligned with the best care, but we also need healthcare professionals with a great sense of social responsibility. He knew that, too. He spent a lot of time and energy recruiting people with a great sense of social responsibility into his project. He explicitly said that a primary objective of his tenure as Dean of Harvard Medical School was to train physicians to have a great sense of social purpose. There is a description in the 2008 document that makes my point:
One day late in Dr. Ebert’s life, he was in the Kenmore Center seeing Joe Dorsey as a patient, “Dr. Ebert drew me back out into the waiting room where an ethnically diverse group of patients were preparing to be seen,” Dorsey recalled. “He observed that the Dean of Harvard Medical School, the wealthy from Wellesley, and the patients in the waiting room representing such diverse racial, economic and ethnic backgrounds could now all have the same physicians, the same facilities and receive the same respect. He was proud of the fact that this was no longer just an academic theory and/or idealistic vision of his, but a reality that he was witnessing right before his eyes.”
The is no question in my mind that Dr. Ebert’s ideas and efforts were the greatest influence in my professional life. As we search for answers to today’s problems, yesterday’s thinkers still have relevant things to say to us long after they have faded away.
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