President Elect Trump has said what he will do with the ACA. What will you do if he carries through with his intent? I can’t answer that question for you, but I am delighted to give you unsolicited advice. I was recently reminded of how important it is to remind ourselves of things for which we are “fanatical”. Let me digress.
For several years I have been trying to read David Foster Wallace’s Infinite Jest. I thought that Joyce’s Ulysses was a challenge, but it is Dick and Jane next to Wallace’s doorstopper. I have recently had success after adopting a new approach. I downloaded the audiobook of over a thousand dense pages and I listen to about an hour and a half each time I walk alone. Since there are 56 hours it should only take me about 35 to 40 walks or about 200 miles to get it done!
As I was walking and listening this week I was surprised by the dialog between two strange characters who in the book are operatives for radical French Canadians. The exchange was about the importance of identifying what you would die for. The speaker is French Canadian and has no legs. He is challenging his American colleague who is in drag.
“Marathe had settled back on his bottom in the chair. ‘Your U.S.A. word for fanatic, “fanatic,” do they teach you it comes from the Latin for “temple”? It is meaning, literally, “worshipper at the temple.” ’
The American made a comment that Marathe ignored as he continued with his discussion of “fanatic.”
‘Are we not all of us fanatics? I say only what you of the U.S.A. only pretend you do not know. Attachments are of great seriousness. Choose your attachments carefully. Choose your temple of fanaticism with great care. What you wish to sing of as tragic love is an attachment not carefully chosen. Die for one person? This is a craziness. Persons change, leave, die, become ill. They leave, lie, go mad, have sickness, betray you, die. Your nation outlives you. A cause outlives you.’
“You U.S.A.’s do not seem to believe you may each choose what to die for. Love of a woman, the sexual, it bends back in on the self, makes you narrow, maybe crazy. Choose with care. Love of your nation, your country and people, it enlarges the heart. Something bigger than the self.”…“choose with care. You are what you love. No? You are, completely and only, what you would die for without, as you say, the thinking twice. ”… [the bolding is from me, not David Foster Wallace]
Perhaps I am stretching it, but I do think that the first step in the way forward is to remind ourselves of what we believe is important. Those are the things for which we think are important and for which we will sacrifice, or at least work very hard. If you are “fanatical” for the Triple Aim, you will not be easily thrown off course by something as temporal as an election. If we are worshipers in the temple where the message of the gospel is:
Care better than we’ve seen, health better than we’ve ever known, cost we can afford…for every person, every time.
We will recognize that the shift that seems like a loss does perhaps offer us an opportunity. Progress on improving the ACA before the election was precluded by a log jam of political resistance that was likely to have increased had we elected another Democratic president while Congress remained under Republican control. What we have now is an opportunity to negotiate toward something better than the ACA while retaining much of what an unsuspecting electorate never seriously thought that they would lose.
I seriously doubt that many of Trump’s base who were upset about jobs lost overseas and were angry about their economic status really understood what the ACA had given them. If you do not understand what you have, it is hard to be rational about what you are in jeopardy of losing. Once you realize that your anger was used to someone else’s advantage and that it cost you something dear, your take on the reality of what you care about and where you direct your anger may change. If there is any recurrent theme in Trump’s personal history it is the recurrent theme of disappointment in those who once trusted him in a business deal.
President Elect Trump says he will move quickly to repeal the ACA. The most objectionable part of the ACA is its mandate. The conundrum that will face the new administration and the Republicans in Congress will be how to eliminate the mandate while retaining what they like, the guaranteed insurability at community rates without lifetime limits or deniability from pre existing conditions.
There is some variation among the pundits about how the “repeal” process will play out in time, and how the process of putting together the “replace” piece of “repeal and replace” will evolve. Experts who will be involved like Senator Lamar Alexander of Tennessee, chairman of the Senate Health, Education, Labor and Pensions committee where much of the legislative work will be done, expect the “replace” process to take several years. There are some recurrent themes that most commentators mention that are nicely described in a recent New York Times editorial, “The G.O.P. and Health Care Chaos.”
What is evolving is the picture of an interim state during which elements of the ACA may persist for up to a year and a half. As the ACA fades away, the Republicans will not have the sixty votes to move something like Paul Ryan’s plan into legislation. The midterm elections of 2018 may well be the time when the debate about healthcare will get the attention it needs and did not get in 2016. Your plans for the next two years and perhaps longer should probably include the concept of legislative chaos, but I feel that the long view may be more positive than many who are so crushed emotionally by the thought of a Trump presidency may be able to envision.
There several things that the moment should underline for all of us and that will be important in determining the process and outcome:
- Care costs too much and unless the cost comes down fewer people will be covered.
- The cost can never come down unless doctors and other professionals are working in a context that allows them time to think critically and spend more time focusing on the needs of their patients.
- The cost of care can not come down when care is delivered by a growing number clinicians who are burned out and performing inadequately. Their own despair precludes collaboration, effective interaction with patients and the ability to do the critical thinking that leads to efficient, effective care that satisfies their professional expectations and delights their patients.
- Fee for service finance aggravates the problems of cost, patient satisfaction and optimal clinical performance.
- We will never have more financial resources for the population than we have now.
- Unless we can reduce the resources per person necessary to deliver quality care, we will be delivering a lower quality of care to fewer people who will be living in a declining environment of increasingly poorer health per capita.
When we realize that the opportunities to make progress over the next two years lie primarily within organizations and not through legislation, we are fortunate that over the last seventy years we have evolved a body of knowledge that if applied to healthcare can move us toward the Triple Aim. That was the message in John Toussaint’s On the Mend and Management on the Mend. That message was echoed in Patty Gabow’s The Lean Prescription: Powerful Medicine for Our Ailing Healthcare System and Joan Wellman’s Leading the Lean Healthcare Journey: Driving Culture Change to Increase Value. In his description of “Era 3” in healthcare, Don Berwick underlines both the importance of every practitioner’s effort to lower the cost of care and the necessity of using continuous improvement science to do the job.
Lean is not a religion. It is more than a management tool. I believe, based on my own personal experience, that it is much more than those who have not lived and worked inside a Lean organization can realize. Lean is the foundation for a culture that enables people to work together to produce outcomes that delight patients, return joy to professionals and lower the cost of care so there will be access within our system to great care for every person. I am a Lean fanatic. Unlike the impression provided by those who equate Lean with “Taylorism”, I can worship in the temple of Lean and know that none of my cherished principles of practice need be violated. Not only does Lean enable clinicians to more effectively do what they believe they entered medicine to do, it offers patients more than they ever expected. I can think of nothing better for the organizations to do during the confusion that we should expect over the next two years than to “become” Lean.
I am past the time when I will personally benefit from working in a system where my professional efforts are enhanced and supported by workflows that have been made more efficient by Lean engineering. I am thankful that although my days of practice have passed, as my needs increase as a patient, Lean is still working for me. Despite the fact that the Lean engineered Atrius practice where I receive care is 103 miles from my door, I can not let go. The Lean engineered pharmacy programs, the 24 hour phone support, the referral process that was streamlined by Lean, the fact that my PCP answers my questions online within a few hours while practicing at a pace that allows critical thinking in a Lean designed workflow all contribute to a value that I would never give up until some organization nearer can reproduce the quality.
I hope that most healthcare organizations will eventually accept the reality that as the ACA is abolished the urgency to lower costs does not go away. Through MACRA and the value based finance systems offered by commercial insurance the need to lower costs and become more competitive will become more urgent, even as their clinicians become more and more burned out. The successful healthcare organizations post ACA will realize the need to understand the care of populations. As value based reimbursement and population based care delivery become everyone’s daily reality organizations that have prepared for the moment with Lean and improvement science will be able to meet the challenge and answer the needs of both patients and providers.
The alternative to managing processes of care through attention to the teachings of improvement science is to be condemned to the pain of working harder in inefficient systems that seek to survive by continually cutting budgets and asking fewer people to work harder doing less for fewer people. It is a choice for a downward cycle that will result in expensive processes that don’t satisfy patients and continue to burn out clinicians and other healthcare professionals.
It’s nice to have choices. Earlier this year I gave a presentation about what to do if you find yourself working in a system that does not understand or practice the benefits of Lean. Basically it was a discussion about speaking truth to power. Unfortunately there are many organizations who think they “tried Lean” or are now trying Lean in a “do it yourself” fashion that are having a hard time while they are simultaneously hiring consultants to help them make budget cuts. Lean is actually “agnostic” to the revenue source. It is about making progress by eliminating waste and being more efficient and more effective. Call me a “fanatic” about Lean if you will, but worshiping in the “temple of Lean” does not require that you die for the cause.
