27 December 2019
Dear Interested Readers,
Looking Back At 2019 As We Think About 2020
I am a maker of New Year’s resolutions. It’s that time of year again. Looking back on 2019 I did a pretty good job. I had some partial successes, and some of my failures were not my fault.
After forty years of randomly plucking on guitars, I currently have nine guitars in my living room, I decided to get a teacher. I was determined to become proficient for my own pleasure, and as a hedge against a declining capacity to learn, if not for the entertainment of others. I had read enough of NYU psychologist and neuroscientist Gary Marcus’ book Guitar Zero: The New Musician and The Science of Learning to know that getting anywhere with a musical instrument, or for that matter to learn a new language like Spanish, at my age would be a challenge.
It was not long before I abandoned my attempts to learn Spanish using the ap, Babel. I was so disappointed in myself that I have not yet cancelled the subscription which is automatically charged against my credit card. I still harbor the faint hope that I may try again and yet succeed, which means that I must tolerate the embarrassing questions that my wife asks me each month when see scans the American Express bill and comments that I am paying for something that I am not using. Those of us who fail need humiliation.
I was doing really well with my guitar playing resolution because I found the perfect teacher for me. Richard was a dream come true that I met when I inquired about lessons at Blue Mountain Guitar (originally a Lebanon, NH enterprise) which recently moved its retail store to my town. I love poking around in music stores, and was delighted when Blue Mountain moved into a vacant space in the rear of an old building located just across Main Street from the police station. Richard worked part time at Blue Mountain as a luthier, manager/ salesman, and teacher, but that was only part of his life. He was into construction as well as performing.
When I first saw Richard at the guitar store, I knew that I had seen him before playing and singing at a local eatery. He is an unforgettable figure, who is about the same age as Bruce Springsteen, and has the same appearance with a tight athletic body that just looks like its about to explode from too much contained energy. Richard has two things on Bruce, he is a better guitar player, and he looks like a handsome “Colonel Sanders” with his snow white hair pulled back in a ponytail. Richard has been performing since he was 14, and can play from memory more than five hundred songs from the 50’s, 60’s, 70’s and 80’s.
I confessed my guitar inadequacies to Richard, and he offered his help. At the first lesson, I showed him what I could do with some of the pieces I had been trying to play, and he give me pointers. Every lesson followed the same format. I would bring in some music that I wanted to play, and we would go from there. What was great was that we would play and sing together. We were definitely not the Everly Brothers, but I loved it. We were singing many of my favorites like “Your Cheatin Heart,” “Bobby McGee,” and “Sweet Dreams.” I enthusiastically drug my wife and sometimes visiting friends to hear Richard play. His better students sometimes took the stage with him. I could only dream of that day. His wife was always present, perhaps because he had a following of elderly fans that I got to know. We were groupies! We adored him, and he responded with a good show.
My lessons were at 9 AM every Saturday, and I was faithfully living up to my resolution to practice, practice, practice, until I was surprised by an unexpected event when I walked in for my lesson on a Saturday morning in late July. I found Richard busily putting things into boxes. He appeared to be a little upset. He looked up without his usual smile and said, “Didn’t you get my text?” I said, “No,” as I looked at my phone just to be sure I had not missed his attempt to contact me. There was no text. He continued, “I am leaving.” That was obvious to me. It looked like he should have said, “I am in the middle of my getaway, get out of my way!” I did get him to tell me that he was going to a new job more than an hour away. I got no lesson that day and haven’t had one since. I still don’t know what precipitated his sudden departure.
So, did I fail with my New Year’s guitar resolution? Sort of yes, and sort of no. I am a little better guitar player than I was thanks to six months of Richard’s help, and after a few days of grieving the loss of my experience with Richard, I did get back to the sort of lame and infrequent efforts I have always made to become “self taught.” The down side of Marcus’ book is that he says that no significantly successful guitar player ever took up the instrument after the age of 17. The upside of his message is that if “great” is not your objective, and if your willing to put in a lot of time, some success is possible. I’m still trying to get up the energy to try another teacher. I keep hoping Richard will come back to town.
While most of us are making resolutions, many organizations are still formalizing their strategic plans, managerial objectives, or organizational goals for FY 2020. I have always favored a financial year that conforms to the calendar, but there are some organizations that start their new financial cycles on the first of July, and others that follow the example of the federal government and kick off a new cycle on the first of October. I have always thought of the budget, whenever the cycle starts, as the mathematical expression of the organization’s tactical approach to its longer term strategic intent. In some healthcare enterprises, as in many other businesses where change is occurring at an accelerating rate, the old concept of an annual budget cycle is becoming an increasingly frustrating exercise.
When I became “accountable” for organizational success, I felt extremely vulnerable to all of the dysfunctions of the budget process. Objectives and realities in January would often have little relationship to the challenges that were encountered in August. Like my experience with Richard, things can change in ways you can’t control. Expectations could always be modified, but the process of redefining clinical goals and manipulating clinical programs to meet financial and organizational objectives was always an uncomfortable process. The lowest points of my leadership career were management meetings and board discussions that were driven by the tyranny of the budget cycle.
It should be no surprise that after I saw how ThedaCare was becoming facile with the use of the quarterly “rolling budget” that I saw a lot of merit in the idea. Ideas to improve the management of our finances are perhaps the most difficult of all “improvements” to implement. One hears pushback in the form of clichés like, “It’s not right to change the rules in the middle of the game.” Suffice it to say that a failure to institute a rolling budget was only one of many preferences that I was unable to add to the list of “accomplished.” I am extremely pleased that Guthrie Clinic, where I am on the board, has adopted a rolling budget process.
No matter what your budget cycle is, and whether you are managing by objectives or have adopted Lean thinking and are managing by processes, your strategic thinking needs to include frequent assessment of the environment in the context of your organizational objectives. If you have been successful in constructing and realizing any New Year’s resolutions, you probably assessed your personal objectives, considered your potential resources, considered your previous failures, gave some consideration to the environment, established “intermediate” milestone objectives, and then took a deep breath before jumping into the challenge.
Whether we recognize it or not, most of us are trying to be in a process of continuous improvement, and any success that is not grounded in pure luck, and some are, is the outcome of “continuous improvement.” I still can’t play guitar well enough to bore friends and relatives, but I am better than I was before my last attempt at getting better which my teacher with the silver ponytail brought to an end. External events do have an impact on organizational success.
I have heard the presentation of many strategic plans and their derivative budgets over the years, and have come to appreciate the fact that the first steps should be a critical assessment of the last cycle and a refreshed look at the environment. My favorite part of the Lean A3 process is “box 9,” the last step. In the reference that is the last link, the ninth step is described a little differently than the process I use. They describe the last step as:
Evaluate results
In far too many situations, the A3 process ends with implementation. It’s critical to measure the actual results and compare them to your predictions in order to learn. If your actual results vary greatly from what was expected, do research to figure out why. Alter the process as necessary, and repeat implementation and follow-up until the goal is met.
The version of “box 9” that I learned to use at the end of a cycle of improvement, which I think is also applicable at the end of a financial year, is a simple set of questions. What went well? What did not go well? What should we continue to do? What should we stop doing? What are we not doing that we should consider doing? To answer those questions is is also helpful to ask one more question. What is happening in our environment?
One of my favorite sources of balanced assessment of the external environment is the Commonwealth Fund. If you don’t receive their articles and opinion pieces I would suggest going to their website and signing up. I recently received notice from them of an issue of their podcast, “The Dose,” which is hosted by Shanoor Seervai, entitled “Everything You Need To Know About Healthcare 2019.” That sounded like just the sort of analysis or assessment that might be a jumping off point for 2020. I had to listen. What follows are my comments about the podcast along with some abridged text of the conversation between Seervai and Dr. David Blumenthal, the President of the Commonwealth Fund.
The podcast begins with a sense of “here we do again and a toned down introduction of Dr Blumenthal:
SHANOOR SEERVAI: And it’s time once again to look back at the past year and everything that’s happened in the health care universe. And then what that means for 2020. My guest today is David Blumenthal, president of the Commonwealth Fund. David worked as the national coordinator for health IT in the Obama administration. In the past, he’s also worked as a physician, a health system leader, and a professor.
Among Dr. Blumenthal’s credentials is that with the publication of The Heart of Power: Health and Politics in the Oval Office co authored with political scientist James Morone of Brown University, he was established as a scholar of the role of the presidency in the long history of efforts to establish meaningful healthcare reform. Dr. Blumenthal’s credentials suggest that much of what follows will be a political review of 2019.
DAVID BLUMENTHAL: Well, this has been a big year for health care. In the run-up to the 2020 election, health care has turned out to be one of the most important issues for the American public. And it’s also an important issue for the Democrats, in general.
And any serious candidate for president in the Democratic Party has to have a position on health care. It’s always been true, but it’s true now more than ever. There are a range of such positions now. And they span the spectrum from the small modifications of the Affordable Care Act all the way toward the often discussed Medicare for All single-payer proposals.
That’s not news for the readers of this post, but Blumenthal is elegantly succinct, and goes on to add further explanations or reminders of facts that many people may have forgotten in the cacophony of the last three years.
DAVID BLUMENTHAL: The small modifications are usually intended to make the Affordable Care Act somewhat more generous and cover more people. For example, to increase the subsidies that are available to help people buy private insurance. And also, to introduce a provision of the Affordable Care Act that was removed, and that was something called reinsurance, which is a way to provide insurers special protection against the high cost of care associated with very sick people. And that usually requires some federal subsidy or some governmental subsidy to do, because these people have very, very high costs of care and their premiums don’t cover the costs.
SHANOOR SEERVAI: …Medicare For All is the other end of the spectrum.
DAVID BLUMENTHAL: That would be a single payer program, the federal government would become the insurer for everybody. It’s called Medicare for All, but it’s really not Medicare as proposed by several candidates. It’s really more generous than the existing Medicare program.
It would not only cover everybody, but give them much more, complete coverage than Medicare provides, more generous coverage without copayments, deductibles, and coinsurance that now exist under Medicare. More generous coverage of things like mental health services. And it would also involve more restrictions on payment to hospitals and doctors and other providers of care that would reduce the prices paid to them, and thereby reduce the cost of care, or at least so it’s projected to do. And it would, in the process, eliminate all private insurance, which is, of course, a huge change for this country.
At this point in the podcast I am thinking that what I am hearing is great, but we are already talking about what might be, and not what is, other than ideas.
SHANOOR SEERVAI: Do you have a sense of what the public wants or where sentiments are when it comes to this very wide range, as you described, at the one end, modest fixes to make the Affordable Care Act work better, and then at the other end, a full overhaul of our system?
DAVID BLUMENTHAL: The public is divided. About a third in our surveys would favor Medicare for All. About a third would favor building on the Affordable Care Act. And about a third would like something very different that would be neither the Affordable Care Act nor Medicare for All. There is not majority support for Medicare for All when people are given the choice between options.
We’ve all heard that there is no majority opinion about what to do to achieve universal coverage, but we also know that if we do not know yet, the “how,” there is a significant consensus around the “what.” The majority of Americans want healthcare to be a right and access to be an entitlement. Dr. Blumenthal emphasizes that fact. I emphasized his words with bolding. He also notes the reality, and the confusing fact, that most people still want their employer based insurance even though the cost is increasing rapidly, sometimes with double digit jumps, as benefits are decreasing for most people.
The American public does believe that the federal government should take care of people and that nobody should go without coverage. Substantial majorities of Americans believe that. But they tend to get anxious when the federal government is given responsibility for insuring everybody.
There is a high level of satisfaction, whether it’s deserved or not, there is a high level of satisfaction in polls that ask people whether they like their current insurance. And most people do, even people who have pretty high deductibles. So, it’s a pretty tough thing in politics to take something away that people say they’re satisfied with. And when that is posed as a possibility, people get concerned.
The answer to the next question draws on Blumenthal’s experience as a historian. What follows is in essence a summary of the message of the book that he wrote with James Morone. To summarize the concept: To improve healthcare, healthcare must be a president’s first priority. If he/she doesn’t get it done in the first six months the possibilities diminish rapidly.
Ms. Seervai picks up the conversation and takes us back to the present. Blumenthal answers with a description of how the Trump administration has undermined the ACA.
SHANOOR SEERVAI: And if we look at the last person who did that, that was President Obama. And brought us the Affordable Care Act. But the current administration has taken a lot of actions to change the way that the Affordable Care Act works. So, what’s happened in 2019 that’s impacted the Affordable Care Act?
DAVID BLUMENTHAL: In 2019 we’ve been seeing some backsliding in the numbers of insured Americans and some deliberate efforts on the part of the current administration to undermine, change key provisions of the law.
For example, they have — the current administration has changed regulations that now make it acceptable to sell very short-term plans, lasting three or six months, and also different kinds of plans called association health plans, neither of which have the same benefits that are required under the Affordable Care Act for private insurers to provide. They tend to be cheaper, but they tend to be skimpier. So, more people are buying those plans. And those plans, in some cases, are very limited in their coverage…So, this combination of things has resulted in about a million and a half to two million more people without insurance over the last couple of years.
There is more, if you want to read it, but the bottom line is that we have lost ground on what was originally achieved by the ACA. Blumenthal adds information that most of us don’t consider in the desecration of the ACA by bringing in the complexities of how immigration issues impact the ACA. The administration’s aggressive policies frighten some immigrants who are eligible for through the ACA so much that they don’t take advantage of the opportunity to get coverage. Some who are here legally fear someone in their household, or in their circle of friends who is not a legal resident, will be caught because of them. Then Ms. Seervai changes the subject to the cost of healthcare. Again, Blumenthal sums things up in a few words.
SHANOOR SEERVAI: Okay. Well, let’s shift gears a little bit and talk about another issue, which is the cost of health care. Now this isn’t a new problem in 2019. I think that Americans have been worried about how much health care costs for a long time. But it has been getting a lot of attention this past year. Why is that?
Blumenthal’s answer is a reiteration and expansion of his earlier comments about the paradox of people loving their employer based care even as it is becoming more expensive.
DAVID BLUMENTHAL: Well, you’re right that health care costs are a long-standing issue.
As costs have gone up though, employers in particular, have felt the pressure of increasing premiums that they’ve been paying on behalf of their employees. And they’ve been passing more of those costs onto their employees in two forms, first asking employees to pay more of the premium. And secondly, selling them less generous plans. Plans that have higher copayments, higher deductibles, and higher coinsurance, that is requiring a payment at — when you see a doctor or when you’re in the emergency room.
It’s the latter, I think, that has affected people’s view of the health care. It’s the amount they have to pay out of pocket that isn’t covered by insurance anymore. And it’s affecting people who previously felt protected.
Another thing that’s contributed to this is the high cost of drugs…
SHANOOR SEERVAI: Right, so the costs of the drugs are going up, but also because employers are cutting back on what they’re spending on their employees’ insurance, people are seeing that they have to actually, as you say, out of pocket pay more, and that’s — that’s alarming.
DAVID BLUMENTHAL: They’re feeling it. It’s coming out of their pocket. It’s cutting into their budgets for entertainment, for food, for rent.
There is more to the cost question which may be why the public has a lot of affect. The complexity of the subject, the difficulty of instituting change, and the inability of the Democrats to present an organized front to the public has made 2019 both interesting and frustrating for many who fear that the debate will in some way inable a Trump victory.
Ms. Seervai continues the conversation by asking Blumenthal to talk about the phenomenon of surprise medical bills. Blumenthal’s answer is an excellent explanation that focuses on what consumers and politicians should know.
DAVID BLUMENTHAL: Sure. When employers and insurers want to reduce the cost of care they go out shopping for doctors and hospitals that charge less…And they construct what’s called a network…What sometimes happens though is that certain groups of doctors or hospitals whose services are needed in a particular area will refuse to negotiate with the insurer. They can get away with that if there are no alternatives… And somebody has a car accident…let’s say that the hospital has a contract, and so if you were planning in advance to get your care at a place that you would be covered for you would go to that hospital. But low and behold the emergency room doctors…don’t have a contract. Well, they’ll stitch you up or they’ll set your broken bone or they will take care of your bleeding —
SHANOOR SEERVAI: It’s an emergency.
DAVID BLUMENTHAL: That’s right. You have no choice. But then they will bill you. The insurance company has no contract with them, so the insurance company won’t pay. And the bill ends up in your mailbox. And those bills can be thousands of dollars...And that is not acceptable to many legislators and to many people. And there’s a big controversy about that now in the United States Congress. And we’re right now in the midst of negotiations in the House and Senate about how to manage that. It’s not clear what’s going to happen.
After the cost discussion, the conversation moves on to a discussion of healthcare as a new venture for large technology companies like Google, Microsoft, Apple, Facebook, and Amazon. Blumenthal sees them moving deeper and deeper into healthcare as a continuing process that will gain momentum. It may be a good thing, but…
DAVID BLUMENTHAL: …it’s causing a lot of people heartburn because people are not sure they trust Google to sit on their data, to keep it private. And the question is, is it even legal to share that data? It probably is legal under current privacy protections, but that doesn’t mean those privacy protections are what people now want because those privacy protections were created before the internet existed and before Google was even a gleam in anybody’s eye.
So, it’s a different world. And even though it may be legal from a privacy perspective, it may not be acceptable from a policy perspective. So, those issues are going to get hashed out. The upside potential is huge, to learn from this data about — how to be a better doctor or a better nurse or a better hospital. And we would all benefit from that. And as somebody who’s practiced medicine with the help of electronic record and with computer assistance to make me a better doctor, I have a lot of respect and hope that that that opportunity will the good for everybody. But it’s going to have to be managed in a way that makes people comfortable.
Initially I was surprised to see how short Blumenthal’s list of 2019 issues turned out to be. But then I remembered that some issues drive other issues, and I think that he was right to focus on a short list of:
- The politics of universal coverage
- Healthcare costs: the soaring expense of drugs, less coverage for more expense, and out of pocket expenses which are sometimes totally unexpected
- Healthcare as a growing opportunity for the big five high tech companies.
The future of healthcare will be largely driven by how we manage these issues that Dr. Blumenthal has discussed. Keeping the list short is good strategic thinking. How you or your organization integrates these issues and realities into your strategic view of the future will probably be a defining factor, like it or not, of your organizational success. More importantly, how we all integrate these observations into our collective pursuit of the Triple Aim may define the future of America.
My Little Town As Seen From Above. It’s Worth A Thousand Words
Peter Bloch, my craftsman neighbor turned drone photographer, has already produced several new pictorial essays for this winter season. I was delighted to discover that in his latest production he has taken his drone “downtown.” I lifted today’s header from a recent post entitled “Merry Christmas, New London, N.H.” The piece was recorded the morning after we were lucky enough yo get a fresh blanket of snow that gave us a “White Christmas.” Most of his pictures show only the natural beauty of the lakes, mountains, and forests of our little corner of the world. If you invest the two and a half minutes it takes to view the video below, you will have an appreciation for “downtown” New London.
If you just look at the header or the picture above without playing the video, you will see that Main Street is running south to north from right to left. You see some of Colby-Sawyer College on the right, or east side of Main. Next as you move north on Main is the First Baptist Church with its tall steeple. Across the side street is Whipple Hall and the Police Station where the flag is flying. You can’t make out the memorial to Union Soldiers from New London who died in the Civil War. You see a little bit of the town green to the left of the flag. The mountain in the middle is Ragged Mountain. You can see the eastern slope of Mount Kearsarge on the far right. To the west and north, out of view, are Mount Sunapee and Croyden Peak. At the bottom and center of the picture, you can see a car parked behind a tight collection of frame buildings. Just to the left of the car is a white door. That door is the entrance to Blue Mountain Guitar. I have a New Year’s resolution to resume guitar lessons there soon. This time around I am looking for a demanding, low key teacher, who will not let me make learning a game of conning him into playing old favorites with me.
The video and picture are peaceful. As the video runs you will see the rest of the town green. after the town green is the building that once was the home of Colby-Sawyer when it was founded in 1837. Past the town office is the New London Inn, circa the 1790s. Main Street continues northwestward past the firehouse and other businesses toward the red barn which is the summer theater. In a little town like mine you quickly relax because there is not much traffic and a slower pace. You get to know your neighbors.
I am looking forward to an interesting 2020. I am trying to put together a list of challenging resolutions. I hope that you will be making and keeping a few resolutions for 2020. This is the one year out of every four when we can participate in a change of direction. Let’s not blow the opportunity to give the majority of Americans what they want, even if we still don’t know just how we are going to do it, excellent healthcare for everybody in the spirit of the Triple Aim.
Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,
Gene
