7 June 2019
Dear Interested Readers
This and That
Some weeks it is hard for me to decide what the topic of this letter should be. Longtime readers might remember when I would take on three of four different subjects in the same letter. At the time I was conceptualizing this exercise as a newsletter/magazine. When some readers complained about the length of the letter, I added an introduction that I thought would allow readers to pick and choose what to read in much the same way you scan the cover of the New England Journal looking for what interests you. More recently I have discussed two topics a week because I put out a Tuesday note which began as a redo of one of the Friday subjects, but now is a new stand alone subject. With the advent of the Tuesday note I have been able to focus on one subject in the Friday “Healthcare Musings” plus a closing section on the things that I enjoy.
This week has been a different kind of week, and the letter may seem like a throwback to the “old days.” My thinking has been distorted all week by stories about D Day and memories of my uncle who was there which you can read about in the last section. Perhaps that focus has prevented me from coming down on one main subject, but I think not. There have just been several interesting subjects that have popped up that I want to pass on to you. Here is an overview, or menu, of what follows:
- Two interesting articles in this week’s NEJM from writers I know and respect, Tom Lee and Michael Chernow. Both articles are a little “wonky” and if you are focused more on practice than policy, or are a lay reader who does not have a deep understanding of healthcare policy development or the evolution of ACOs, then you might never have given either article much attention. I hope that I can frame their messages for you.
- The announcement from all of the former Health IT Coordinators that they support the new interoperability rules suggested by ONC and CMS.
- The formal unveiling of CVS’s Health Hubs. CVS presented their progress on this potentially transformative and disruptive development to the investment community. Their stock immediately went up. If you are managing a primary care practice in a community that has a strong CVS presence, you may need to sit down and dose yourself with an antacid or your favorite benzodiazepine before reading this update on a subject that I first discussed back in mid April.
- Jamie Dimon, CEO of JP Morgan Chase, has announced at BIO 2019 that Haven Healthcare, of which Atul Gawande is the CEO, will be open to other companies beyond the founding organizations, J.P. Morgan Chase, Amazon, and Berkshire Hathaway.
- Atul Gawande’s keynote speech at the ASOC meeting in Chicago: I think his speech was a logical extension of Being Mortal. It was particularly interesting to me because two dear friends are dealing with the reality of choosing life in the moment versus aggressive management of their metastatic cancers.
That’s the lineup. I am just going to try to make you aware of all the things that are happening and put them into perspective. I hope that what follows will be worth the time you invest in reading the letter and following the links that I offer to more detail.
Check out these NEJM Articles and a Bit From Health Affairs:
The first article by Sherry Glied, Ph.D. and Thomas Lee, M.D. has a provocative title with a hint of humor that I would guess comes from Dr. Lee, “Is CBO Forecasting Good Enough for Government Work?” Their question is critical because the Congressional Budget Office has played, and will continue to play, a critical role in healthcare legislation. The CBO takes proposed healthcare legislation and “scores” it. They are the non partisan authority that is supposed to be “above the fray.” It is critical that the CBO have both the expertise and the integrity to predict the likely outcomes of a piece of healthcare legislation. During Republican attempts to replace the ACA it has been the CBO that has been able to predict the outcomes in terms of cost and lives covered. The CBO pointed out the catastrophic outcomes that these proposal would have caused and that was not appreciated by Republicans. The information and analysis that the CBO provides will continue to be important when Congress returns to healthcare, presumably after the 2020 election. What would Medicare for All cost? If there was a “public option” how many additional lives would be covered? Would employers push their employees into public offerings? These and other questions are important to consider without the bias of politics.
Glied and Lee present data that suggests that the CBO is pretty good at what they do. Not perfect, but then predicting the future is part data and part art. They say:
Our take is that the CBO has been doing a good job, and its methods and record should give us some confidence about its future performance. But accurate predictions are far from guaranteed. Moreover, even policy decisions based on accurate forecasts may turn out not to be wise.
That said, we believe that policymakers should focus less on evaluating the CBO and more on helping it fulfill its difficult role. Such an approach would mean supporting the development of evidence that can be incorporated into the CBO’s models, including evidence that is most likely to prevent the kind of inaccuracies that have been seen in past forecasts and to address the questions that are likely to be pressing in the future.
That sounds right to me. It is refreshing to have the cacophony of the moment interrupted by voices of reason.
The second article, Getting More Savings from ACOs–Can the Pace Be Pushed?, written by McWilliams, Chernew and others, is also a little “wonky,” but it discusses a very significant issue, getting the cost of care down through the introduction of ACOs like The Medicare Shared Savings Program:
“…produced modest savings for Medicare and been popular among providers, with 561 participating accountable care organizations (ACOs) covering nearly a third of the fee-for- service Medicare population in 2018. Yet the pace of savings has not been commensurate with Medicare’s fiscal challenges, prompting calls for reform – to which the Centers for Medicare and Medicaid Services (CMS) responded in December 2018, with “Pathways to Success.”
The authors point out that the core problem is that MSSP is voluntary and organizations drop out when there are attempts to pick up the pace of producing savings by forcing them to assume risk before they have the skill or infrastructure to manage. The paper gets technical as the issues are discussed. Let’s face it, establishing fair goals and criteria for revenue for performance that saves money is complicated. Every market is different and within many markets “expensive” providers have an advantage over providers that have already demonstrated savings. This reality seems unfair and generated my only negative emotion during my experience leading an organization in a Medicare ACO. Pressing the grape the second and third time takes more energy and often yields less than the first squeeze. Organizations that have already attempted to lower the cost of care have a greater challenge than organizations whose revenue has been bloated by years of revenue producing overuse and misuse of procedures.
The authors go through a remarkable discussion of the issues. They ask whether or not CMS should push harder and ask for better results sooner. Along the way they discuss the MIPS program and then make a startling observation. Are some poor performing ACOs in it for the regulatory relief from anticompetitive practices that increase spending? I would hate to think that is true, but we live in a world where behavior can be influenced by any unintended opportunity for a competitive advantage.
Frankly, I appreciated the analysis but was a little disappointed by the conclusion offered by the authors even if they are right. It sounds a little coddling to me and the result may be to perpetuate poor performance. My response would be more like what Massachusetts has done with their Medicaid program and pay for all of Medicare through ACO structures or the risk contracts offered by Medicare Advantage. They write:
It remains unknown whether the MSSP will unravel into a large subsidy for providers with already low spending, but the evidence raises concerns about strategy for accelerating savings by holding ACOs to a specified pace. Efforts to improve the MSSP should build on, rather than jeopardize, its early success. Instead of setting a faster pace for high spending ACOs, CMS should set stronger incentives to elicit a faster, albeit uncertain and and varied pace in ways that wouldn’t compromise participation….if we give ACOs a pace to beat instead of a reason to set their own, we may never know what could have been.
An equally important issue for the future was discussed in the Health Affairs Blog this week in a short statement by all of the former, from both Republican and Democratic administrations, National Health IT Coordinators, David Blumenthal, David Brailer, Karen DeSalvo, Robert Kolodner, Farzad Mostashari and Vindell Washington. They write:
In February 2019, the Office of the National Coordinator for Health Information Technology (ONC) and the Centers for Medicare & Medicaid Services (CMS) proposed new regulations to advance interoperability across key sectors of our nation’s health care system and empower patients and their caregivers with easier access to their personal health information. The proposed regulations would implement part of the 21st Century Cures Act (Cures Act) of 2016.
We, the six people who have served as National Coordinator for Health Information Technology since the ONC was formed in 2004, unanimously believe that these rules have the potential to transform how information flows through our health care system, catalyzing broad innovation and engaging and empowering consumers. We strongly support the proposed proactive measures for the acceleration of information exchange and interoperability, including the promotion of technical standards and the use of hospital conditions of participation. We also applaud the proposed rule’s enforcement mechanisms against the use of pricing to restrict patients’ access to their health information and other types of information blocking.
What rational person would be against such a move? Has not interoperability been the objective all along? The former administrators go on to discuss some of the technicalities. Can you imagine what it would be like if healthcare had systems like banking or the Internet capabilities of the digital marketplace? Would that change things? What would it be like if patients really did own their own, or have access to their medical record and could show it to whomever, wherever, whenever they wanted another opinion or price? The current IT systems “shackle” patients to the provider that controls their information. Would competition change if information could be moved or exchanged more easily? Would safety improve and unnecessary utilization be diminished? I would like to think so.
CVS and Haven Health Are Working Hard to Disrupt Healthcare. Are You Ready?
The stock price of CVS has slipped a bit since their $69 billion dollar purchase of Aetna so they staged a show this week for the investment community. They showed the world what they have been up to with pilot programs in the Houston Area. You can see for yourself if you click here and watch a two and a half minute CNBC video that showcases a “CVS Health Hub” in a suburb of Houston.
CVS plans to launch 1500 Health Hubs like the one you just saw, if you watched the video, over the next two years. They estimate that they can capture, and do better for less, 80% of what is done in the typical primary care practice. Many of the patients coming to them will be double wins because they will be covered by an Aetna plan. The closest CVS stores to me are twenty five miles away, and just down the street from Dartmouth College in Hanover, New Hampshire and in West Lebanon. Their closest Minute Clinic is forty miles away in Concord, so it will take a few years for this innovation to impact care in less populated areas like mine. How close is a CVS Mini Clinic to You? Will it be upgraded to a Health Hub? I would check out those things if I were you while I was asking myself how easy it is for patients to get the service they want and need from you. You may still have a little time to prepare for the competition.
The presentation to investors worked. The CVS stock price went up about $7 a share. CVS has a plan that should be a signal to your organization that it needs a transformational plan. What has worked in the past may soon not work that well. Do you remember going to Blockbuster for videos not that long ago?
About the same time CVS was showing off in Houston, Jamie Dimon the CEO of JP Morgan Chase which along with Amazon, and Berkshire Hathaway launched a bold new company, Haven Healthcare, was in Philadelphia addressing the BIO 2019 conference. Stat Plus reports that he announced that Haven Heathcare will be open to doing business with other employers. In essence they have been developing a product to sell as much as a service for their own employees. But, you probably guessed that fact many months ago. Amazon sells things. If CVS reminds you of the fate of Blockbuster video stores perhaps Haven Healthcare will conjure up memories of Barnes and Nobles and your neighborhood book store.
The CEO of Haven Healthcare is Atul Gawande. While Jamie Dimon was talking like the businessman he is in Philadelphia, Dr. Gawande was in Chicago talking like the thoughtful physician he is. I was delighted to read about the highlights of his keynote speech at the American Society of Clinical Oncology (ASCO) Annual Meeting this week. I hope that it will, like many of his previous speeches, be on YouTube soon. The report I read of his keynote made it sound a bit like a speech that Don Berwick might have given. He asked a straightforward question of the assembled oncologist, “Are your treatment goals what your patients really want?”
This question has pertinence for me because my wife and I have two friends who are dealing with metastatic tumors. They both tell us the same things. They are having trouble with treatment choices. They have ambivalent feelings about the relationship with their oncology providers. They appreciate that they have access to care at the “best oncology programs” with the latest protocols, but their doctors seem as interested or more interested in the “rules” of the studies or pushing the next phase of treatment than they are in the realities of their existence. They respect their providers, but really do not know how to talk with them. One reported to me that an issue of great concern to him was addressed by a caring nurse but that his doctors gave little attention to what worried him. Gawande suggests in his speech that their experience is not unique. According to the report of the meeting and the speech written by Daniel Verdun of Medical Economics, Gawande said:
“It seems like our goal (as physicians) was simple: It was to improve health and independence (for our patients). People are coming with much larger questions. They want to know how we can help optimize the quantity and quality of life. They want to know it can be affordable and not bankrupt them along the way.”
Gawande then shifted to talking about an early role for Palliative Care, Verdun reports the sense of what he said. I did the bolding for emphasis:
“As I talked to the palliative physicians, they said their job was to bring the best of medicine to improve the quality of a patient’s life. And they were doing it successfully by asking simple questions.
- What are your goals for your quality of life?
- What are your priorities?
- What matters most?
- What will you accept and not accept in the course of treatment?
Physicians ask questions like this only 25 percent of the time. “We have learned that when we don’t ask, the care is out of alignment with people’s priorities. The result of that can be suffering.
A better understanding of what patient’s want from their treatment has created common questions physicians can ask patients:
- What is your understanding of your illness?
- How much information would you like about what might be ahead for you?
- What are your goals if your health situation worsens?
- What are your biggest fears and worries?
- What is the minimum quality of life you would find acceptable?
I do not think either of my friends has been asked any of those questions. Perhaps the most efficient, but sad, resolution of their problem is to give them the questions so that they can give their answers to their oncologists with the hope that the conversation will be changed. One additional question that they need answered is, “What will we do when this latest protocol comes to an end or does not work?” Old Dr. Peabody was right when he said:
“. . . For the secret of the care of the patient is in caring for the patient.”
As this week’s harvest of medical events and papers suggests, what is most important about what we do can get lost in the business and politics of what we do. It is understandable that we pay great attention to policy, politics, and the business of healthcare, but if we do not occasionally ask ourselves the sort of centering questions that Dr. Gawande reviewed in his discussion at the ASCO meeting our progress will be slow and our patients will become even more secondary to our concerns about ourselves and our future. We have lost our way if our greatest interest is about ourselves rather than the health and happiness of our patients and the quality of life in our communities and our nation.
Staff Sergeant William Herbert Lindsey and D Day
An op ed piece in the New York Times on Wednesday resonated with me. The title was “‘Saving Private Ryan’ Got My Dad to Finally Talk About the War.” The author was Ben Mankiewicz, the son of Frank Mankiewicz who was a famous journalist, presidential advisor to JFK, Peace Corps executive, press secretary to Robert Kennedy and George McGovern during their campaigns for president, and later the president of NPR. The younger Mankiewicz reported that although he knew that his father had fought in World War II, his dad never talked about it until “Saving Private Ryan” came out in 1998. The younger Mankiewicz wrote:
The dramatic opening sequence of “Saving Private Ryan,” a wrenching 24 minutes long, starkly depicts both the random brutality of combat and how teams of men, despite best laid plans, were forced to think on their feet in order to somehow navigate across beaches and up rocky cliffs, under enemy fire. Its realist approach personalized the war for audiences and hit an old nerve with veterans like my father.
My Uncle Herbert was called “Bill” by his buddies in the 507th Regiment of the 82nd Airborne. It was never clear to me why his parents and family called him by his middle name because, unlike me, he was not a “junior.” Uncle Herbert was one of the 2400 paratroopers in the 507th regiment who were dropped behind the Germans Lines after midnight before the D-Day landing on the beach early on June 6, 1944. I have read that fewer than 800 of those paratroopers survived the battle. I will let Wikipedia describe their mission.
The 507th Parachute Infantry Regiment was initially formed at Camp Toccoa, Georgia on 20 July 1942, under command of Colonel George V. Millett. It would participate in three operations during World War II: D-Day, the Battle of the Bulge and Operation Varsity.
As part of the 2nd Airborne Brigade alongside a sister unit, the 508th Parachute Infantry Regiment, the 507th PIR was assigned to the veteran 82nd “All American” Airborne Division, commanded Major General Matthew Ridgway, to replace the 504th Parachute Infantry Regiment, which had suffered many casualties while serving, with distinction, in the fighting in Italy. The regiment arrived in the United Kingdom in late 1943, and began training and preparing for the invasion of Normandy, scheduled for the spring of 1944. Their D-Day objective during Mission Boston, part of the American airborne landings in Normandy, was to help secure the Merderet River crossings. Although their target was supposed to be in Drop Zone T, north of Amfreville, the confusion caused by clouds and flak resulted in a wide scattering of the unit…
As a child I spent significant time with my uncle in 1952 when he was recovering in a body cast at our home in Oklahoma from a terrible accident in the desert near the Arizona-New Mexico state line which occurred when he was hit by a truck while he was changing a flat tire. His wife and step daughter were in the car and his wife was killed when the car was knocked into a deep ravine. She died in the ambulance on the way to the hospital. The nearest hospital was seventy miles away. I later spent six weeks with him in the summer of 1954 at my grandparents home in South Carolina.
I always knew that Uncle Herbert had been a paratrooper and had fought at the Battle of the Bulge because he was wounded and when I asked him about his scars he told me that he was wounded by a hand grenade at the Battle of the Bulge; end of conversation. After he completely recovered from the injuries sustained by being hit by the truck, he returned to South Carolina to live with my grandparents and go to Furman University to get a graduate degree in psychology. Later, he taught at Oneonta State College and was an administrator in the Oneonta, New York public schools. He was happy there and we visited him once. He was a leader in his church and community. He died in 1969 of metastatic colon cancer at the age of 52, 29 years before “Saving Private Ryan” was produced. In the movie Private Ryan was also in the 507th.
In all the time I knew Uncle Herbert he never talked about his experience in the war, other to answer my question, and my parents and grandparents never talked about it. His picture in his uniform always hung over the Philco radio in my grandmother’s living room. I would look at it while listening to shows like the Lone Ranger on hot summer afternoons. It was years after his death, when on a visit home to see my parents, while I was talking with my father about his brother, that I learned that he had been at D Day, and at Operation Varsity, the last significant battle of the war, as well as the Battle of the Bulge. I learned of his service when my dad pulled out a box of letters his brother had written to their parents when he knew that he had terminal cancer. In the box, along with the letters Dad had wanted me to see, were citations commending Uncle Herbert for his actions, and awarding him a Bronze Star for his valor on D-Day in the battle to capture and defend one of the bridges over the Merderet River. He had exposed himself to enemy fire to retrieve supplies and communication equipment that had been dropped at a distance from them in the stormy weather the night before. After the officer leading his squad or platoon was killed, he had assumed command because he was the highest ranking enlisted man. He had joined the army in the late thirties and was in the process of leaving the service to go to college when Pearl Harbor was bombed. He re enlisted but asked to be transferred from the clerical job he had previously held to a combat unit.
He was a quiet man who was focused on family and work. He was loving and interested in everything that I did, but he never talked about himself. He had a 1953 Mercury convertible that I loved. I spent six weeks with him and my grandparents in 1954, while he was in grad school getting his life back together. We would often go to the “drive in” movies in the convertible with his fiancé, who later became my Aunt Sue, and watch the show sitting under the stars.
He was devout, and the letters that he wrote to my grandparents telling them of his imminent death were full of his reassurances that he was at peace with his illness and that they should not worry about him. He had enjoyed a good life and was not afraid to die. There was dignity in his words, and no hint of concern for himself or anger about his cancer. It has occurred to me that he was 27 in June of 1944, and might have been thankful that unlike the hand dealt to the majority of the men he knew who jumped into the darkness and rain that night before D-Day, fate gave him another 25 years of life and he was thankful for that time. The more I hear about the gallant soldiers who fought on D Day, the more I realize that his service was not exceptional. The young men who fought were most exceptional in their focus on things other than themselves. They did their duty, and it seems that when it was over the outcome did not need much discussion, perhaps the experience and the losses were too painful, but what did happen and why they were willing to sacrifice everything for a cause larger than themselves should never be forgotten.
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
