November 10, 2023
Dear Interested Readers,
Going Strong After 10 YearsÂ
Ten years ago this month I resumed writing these letters. I wrote my last weekly letter to my colleagues at Harvard Vanguard on October 25, 2013, after I announced that I would be retiring at the end of the year. I stopped writing on the recommendation of our Chief of Public Relations and Governmental Affairs, Marci Sindell. She convinced me that during a period of transition, I should not continue to speak to the group. What I did not know was that the real motive behind her advice was to give her the time to have all of my letters bound in leather for presentation to me at our annual awards dinner which was scheduled for late November. It was a wonderful gift with great meaning for me. The book is entitled Be Well, Gene. There are almost three hundred letters, and it is almost eleven hundred pages long. I have never read it. That event and how the next ten years began are described in the letter I wrote on November 22, 2013, which I entitled “Volume II.” In the first two paragraphs of that letter, I described the transition and some of my feelings at the time:
I was amazed and quite shocked when at the recent Harvard Vanguard awards dinner I was presented a bound copy of my letters to “Atrius Health and other interested readers”. The tome looks something like the old library-sized dictionary that sat on its own reading table in my father’s study. It dwarfs the reliable Physicians Desk Reference that once had a place in every practitioner’s office or made a good doorstop. All in all the 298 letters are printed on 1097 pages. Perusing them I sometimes wonder, “Who wrote this?”
Shortly after I had written my farewell letter, John Gallagher my friend, colleague, and mentor in all things Lean asked me if I was done. His question surprised and challenged me since he might as well have asked me if I was dead. To my own surprise I heard myself answer, “No, I don’t think I am done!” (Thinking, “Not dead yet”). John had asked me the right question, and as I reflected on his query over the next several days, I realized that I was not done. I was in transition, and I needed to pause for a few weeks to collect my thoughts and look around. I also realized that the weekly exercise of writing added an important dimension to my life that I did not want to give up. When I write I am forced to be more observant and more reflective about what I hear and observe. Far from being a burden, my weekly exercise sustained and informed me. Writing was as important to me as my daily walk. It had become part of my standard work.
It is obvious in retrospect that not writing was disorienting to me. I had the same sort of feeling that I had experienced as a child when I would be dizzy after riding a merry-go-round. John Gallagher was the “therapist” I needed to put my transition in perspective. During our conversation, John pointed out that the salutation on my letters had morphed to include our employees and “other Interested Readers” as more and more readers outside of Harvard Vanguard and Atirus Health had asked to be included on the distribution list. I had the emails of the “other Interested Readers.” Either John suggested, or from our conversation, I realized that I should continue to write to the “other interested readers.” Near the end of that first letter of “Volume II,” I summed up the situation and what motivated me by writing:
So, here I am now standing outside the comfort of the structure and power of the strong organization that has evolved from Dr. Ebert’s ideas and that has added import to my words and opinions. Now my words must stand unsupported by a corporate infrastructure. My words will have merit in the future if someone finds them helpful. If in the future these words contribute to your vision and understanding of the complexity of healthcare and our mutual journey toward an operating system that might meet the needs of our state and nation then they have achieved their purpose. If they broaden your understanding of quality and the importance of managing our self-interest by becoming patient and community-centered then they will have succeeded. If they in some small way contribute to your understanding of the inextricable way that waste in healthcare denies services to those who need them and makes us all vulnerable to economic distress then these weekly words will have succeeded. If my words motivate you and add energy to your own personal sense of mission and purpose or make you smile as I seek to share the things that contribute to my own holistic worldview, then these words and the effort to record them will have succeeded.
Comparing what I wrote ten years ago to what I am writing now, I realize that my focus has shifted a bit even as my intent has remained much the same. Ten years ago, I was focused on organizational efficiencies and pursuit of the Triple Aim. I am still very concerned with all of the components of patient-centered care and the complexity of business and governmental stresses that shape the healthcare we receive, but I am more focused than ever on the social determinants of health and how external events and public policy have impacted access to care and the cost and quality of care. Ten years ago, I thought that concerned physicians could drive improvements. I am not so sure that is possible now. If care is to improve, concerned physicians will be critical to the improvement, but their efforts must be coordinated across an even wider political gulf and in a more fractious environment. If things are to improve, there will need to be a more effective coupling of concerned physicians with progressive politicians and citizens who are aware of all that is at stake for our healthcare as well as for the health of our democracy.Â
My greatest concern for healthcare at the moment is that it is no longer one of the most pressing concerns that is debated by politicians seeking our votes. A year from now we will vote again for a president, all of the House members, and a third of our senators. I hope that between now and our next election day healthcare will once again motivate voters to elect the officials who will focus on the broader issues that improve the social determinants of health like housing, employment, education, and child care. That would mean looking for politicians who respect individual freedoms and rights but have a scope of vision that takes in the reality that what impacts the most disadvantaged person among us for better or worse will ultimately impact all of us for better or worse.
Healthcare issues are woven through every aspect of our collective concerns. Healthcare is impacted by climate issues. It is impacted by gun violence. It is impacted by international issues like the active conflicts in Gaza and Ukraine and the potential conflict with China. How we use AI will impact the future of healthcare. How we treat the “least of these” and minorities in our society will impact the future of healthcare. I will continue to write about all of these things. To paraphrase what I wrote ten years ago by shifting to the present tense:Â
When I write I am forced to be more observant and more reflective about what I hear and observe. Far from being a burden, my weekly exercise sustains and informs me. Writing is as important to me as my daily walk.Â
Back To The Early Nineties
The last paragraph of last week’s letter read:
I have been slowly moving toward the turbulence of the nineties. As a preview, I can tell you that we eventually used those fourteen powers that we, the physicians of the Health Centers, were granted through the creation of the Physician Council including the ability to review the CEO and CMO to create substantial change within the organization. Eventually, we decided that we should create our own professional organization, and Harvard Vanguard was launched in 1998 with the blessings of Joe Dorsey, and even Dr. Ebert not long before he died. It’s a good story. I hope that I will be able to do it justice.
To understand what happened internally to HCHP in the nineties we must examine what was happening in the external world. The eighties had been a decade of rapid growth that was driven by HCHP’s ability to lower the cost of care while becoming a national leader in objectively measuring medical quality and safety. We offered all the care that could be offered in the ambulatory environment under one roof. If hospitalization was indicated, our patients went to world-famous facilities where we followed them closely with our own clinicians. In the nineties, our competition got better at offering what we offered plus more choice. Our offices were spread all over Eastern Massachusetts so that anyone living there was usually not more than ten miles from one of our sites, but with the change in the market, the doctor that a patient or family had always seen and who was just a mile or so away in their community was often easier for them to see, just as inexpensive, and more familiar. It is not easy to attract a patient away from a satisfactory resource for care that has been a long-term relationship even if it was not perfect.
We lost many patients because their employers stopped offering us as they signed single-source contracts with one Blue Cross or some other commercial insurer. We were dependent on choice and our ability to be the best value or the most convenient provider. By the nineties, distinguishing ourselves for the value we provided was getting harder as others were adopting some of the efficiencies we had developed and also began to focus on quality and patient satisfaction. At a higher level, being a leader should have been satisfying, but at a practical level, having a flat or declining market share is stressful, especially for the administrators and the board.
Some of my most disappointing moments in practice occurred when a patient whom I had known for years would announce that they were seeing me for the last time. When I would ask if they were moving or perhaps if they felt we were not serving them well, the answer was almost always, “No, I wish that I could continue to see you and get my care at HCHP, but my employer is no longer going to offer HCHP as an option. Can you help me pick someone that takes Blue Cross?”
All was not negative. By the nineties, there were several hundred thousand patients and families who were very attached to us. Some were the healthcare “deciders” for their companies and realized just how distinctively good we were. Some of our patients stayed with us because they loved their doctor or one of our nurse practitioners. I heard of a few who changed their employer to one that did offer HCHP so that they could stay with us or their doctor who was one of our clinicians. Some stayed with us because they understood what we were trying to do to improve the delivery and quality of healthcare. Some stayed because we were “just next door.” Some stayed because we were available to them 24 hours a day. Unfortunately, the total of those who loved us and what we were trying to do was never enough to satisfy a nervous administration.
We did a lot of market research. One fact that drove me up a wall was we were perceived to have long waiting times for routine appointments. The waiting time for routine appointments on average was actually only about two weeks. Patients with urgent problems were always seen on the same day. Research that was done with data from one of our largest customers, Digital Equipment, showed that their employees who continued to see their local doctor who had joined an IPA/HMO alternative to us were better satisfied with their access to the doctor than the employees who chose us were satisfied with their access. The objective data showed in fact that the waiting times for an appointment with local doctors were often twice as long as our waiting times. Furthermore, we were available 24 hours a day and on weekends by walk-in to our urgent care sites or by phone consultation, and their local doctor often sent them to an emergency room if they didn’t have an appointment. It galled me that we were better by objective measurement, and it seemed that the effort it took to be better wasn’t appreciated and didn’t make a difference.
When a family begins to have financial problems because of problems in the external economy it often precipitates tension and disagreement within the home. It works the same way within a practice. The biggest expense in most businesses is the “personnel line.” That is not as true in a self-insured or capitated medical practice. In that environment, hospitalizations, medications, and diagnostic testing—medical utilization— are larger factors in the budget. In all my years of negotiating physician compensation or later when I was CEO, the doctor’s pay and benefits were never more than about 12% of the total budget. Again, facts are often overlooked, because the lay management of HCHP felt that the best way to solve the organization’s financial problems was to have the doctor be more productive where they defined productivity only by the number of office visits delivered rather than considering the thought and effort necessary to eliminate wasteful utilization that provided no real healthcare benefit.Â
We were salaried. The theoretical work week for primary care physicians was 55 hours. 32 hours were to be for office appointments, and the remainder of the time was for practice management, night and weekend calls, and hospital management. There was an additional expectation for some unspecified time devoted to teaching, practice improvement, and committee work. We were paid well. We “measured the market” each year. Our compensation philosophy was “lead/lag” which meant that going into any cycle we wanted our pay to be at least seventy-five percent of the best market offerings for new hires. By the end of the cycle, it would be possible that we would be lower and need to increase our wages. The previously hired doctors got salary advancements each year for their first eight years and then got cost of living and market-driven increases. Increases in the hiring salaries automatically were applied to the whole program as well as the programmed steps in the first eight years.Â
As the market became tougher, it is likely that the CEO felt that we were overpaid. An audit was done that suggested that on average doctors were in the office for 32 hours, as was the expectation, but the number of patients seen was calculated to be the equivalent of 27 hours. The CEO thought the workweek data was useful information that explained some of HCHP’s growing financial concerns. Doctors were quick to point out that canceled appointments, “no-shows,” vacation days, and other staff shortages explained the observation. The CEO disagreed and suggested that the explanation was “fraudulent behavior.” The CEO also demanded an accounting of all “non-practice work activities,” and the establishment of explicit “non-practice work expectations.” That demand immediately became labeled as NPWEs, pronounced “nipwie’s.” The pronouncement of fraud and the demand for measured NPWEs created a substantial blowback from the more than 400 physicians in HCHP’s Health Centers.Â
As Chair of the Physicians Council, a member of the management team of HCHP, and a member of the Board of HCHP, I was in the middle of a very large controversy. I had no confusion about the intersections of my roles. Initially, I tried to find a resolution through negotiations based on plausible explanations for the data and a mutually determined solution, but Pandora’s box had been opened. The pronouncement confirmed for many of our physicians that they were not respected. The Physicians Council called for a group meeting at the Museum of Our National Heritage in Lexington which had an auditorium large enough to seat over 400 attendees. It was standing room only. Speeches were made and anger was vented. The most effective speech was delivered by Dr. Jennifer Leaning who was our chief of emergency services and had not been with us for very long. She had not found a seat and spoke from the stairwell at the back of the auditorium where she had been standing. A few months later, the effectiveness of her oration had persisted and she was chosen by the group to be the Chief Medical Officer of the Health Center practices. The “doctor’s revolt” was covered by the Boston Globe and the local NPR affiliates.
When the dust settled the CEO had resigned. The doctors felt vindicated, but we were not sure what the next steps should be. I had the problem of dealing with the board’s anger toward the physician group and the physician group’s anger toward management. It was a stalemate that was not a platform from which progress could be made. The market problems persisted. The board wanted more changes, and pressure was applied to the president of the Health Centers Division of HCHP who was caught between the board and the practice. Some physicians believed that he had not defended them well when they were accused of not doing their jobs. He also resigned a few weeks after his boss, the CEO, had resigned.
Within a very short time, the organization had been radically changed. The question in my mind was whether or not the management of HCHP and its Health Center Division could be rebuilt in a way that would allow it to resume the pursuit of the noble goals that Dr. Ebert had espoused in 1969 when the dream was created. Like it or not, I was on a very steep learning curve and more challenges were ahead than I could have imagined.Â
Late Fall Reflections
In these weekly letters, I have said that winter in New Hampshire starts whenever it wants to start and lingers as long as it wants to pester us. This fall I have complained a lot about the duller foliage which is presumably the outcome of the excessive rain that we endured this summer. The upside of the excessive rain was that we never had to water our grass or gardens. An unexpected outcome of all the rain has been that the birds, squirrels, and even the bears have pretty much abandoned our bird feeders because they have all the food they need in the surrounding woods and fields. We have excessive pine cones and acorns littering our roads which can be treacherous when I take a walk. It’s like trying to walk on a minefield of scattered marbles. Another curiosity in the era of global warming has been that the late summer was cooler than “normal” and the early fall has been warmer.Â
Early fall is over. Many of our leaves are down and those still on the trees are some combination of dark orange and brown that reminds me of a 70s shag rug. I guess that I should be happy that winter delayed its appearance until this week. We had a preview dusting of snow last week. As you can see in the picture below, we got our first “pretty” snow on Wednesday night. My grandsons are visiting at Christmas. They hope that we will have several feet of snow and a frozen lake by then.Â
The temps at night this week have been in the twenties, and on some days we did not see forty. I think that I may have had my last outdoor bike ride until spring. My last swim, in a wet wet suit, was in mid-October. I hope that winter decides to leave early this year. “Ice out” last spring did not come until mid-April. I hope that I will be swimming and sailing again by early May, but that’s a long six months away.
This week’s header is a picture that I took that looks east toward Mount Kearsarge. Most of my pictures of this mountain are taken from the north, my side of the mountain, looking south. Looking from the west to the east it looks very different. The branches in the foreground are bare. There is a little of that orange-to-brown color on the mountain. Sometime soon it will all be white.Â
Today is the “observed” Veterans Day. Maybe you are enjoying a vacation day. I hope that at some moment during the day, you will pause and reflect on the sacrifices made by so many in service to our nation. It is startling to realize that the values that our veterans fought to defend, and many died to preserve, always remain vulnerable to the short-term interests of some. Veterans Day is a good day for those of us who have not served to honor those who did give time, and perhaps their lives, for what it is now up to the rest of us to defend at a ballot box.
I hope that you can take a walk this weekend, and while you are enjoying some brisk weather, you will think about how you will seek to defend our democracy at home and support others in distant lands who are engaged in the struggle for freedom and the right to be themselves. While you are walking and reflecting, watch out for the acorns! There may also be a bumper crop near you.
Be well,
Gene
