18 October 2019
Dear Interested Readers,
Morality, Trump, Democratic Debates, and More Thoughts on the Cost of Care
I had some sort of awakening in the late eighties and started reading more nonfiction. History, theology, and business related books–primarily about leadership and organizational behavior–became more interesting as I assumed larger leadership responsibilities. It’s interesting how few of the books that I read in the early 90s I can specifically remember until I start looking through boxes in my basement or look down at the books on my lower bookshelves. Then I see old friends and sources of inspiration. Sometimes a book that I have not thought about in a long time will pop into consciousness. Recently, I had a book from the past suddenly come to mind while I was having a conversation with my minister about norms of behavior. The book that emerged from the past was Robert Wright’s book, The Moral Animal, Why We Are The Way We Are: The New Science of Evolutionary Psychology.
That 1994 best seller changed the way I thought about the world. I related to Wright in part because we had come from somewhat similar backgrounds. He had spent much of his childhood in Texas like I did. His parents were devout Baptists, as were mine. He was trying to rationalize the discoveries of science, especially Darwinian evolution, with the religious training he had received as a child about creation and man’s relationship to God’s eternal plan. Both of us had been taught that we were moral because we were made in the image of God. Wright had concluded, based on his study of Darwin and John Stuart Mill that we were moral for utilitarian reasons because it maximized our happiness. In a later book, The Evolution of God, he argues that it is a good thing that we have evolved or created God in our image as our image became more educated and our world becomes more complicated. All of this may seem on the surface not to make a difference and have no relationship to healthcare, but it does, because it is our desire for goodness and happiness for ourselves, and the practical realization that it is in our best interest to recognize that valid desire in the lives of other people, that is the underpinning of much of our motivation in practice to care for others, and the best argument for the importance of considering healthcare to be a human right that should be extended to everyone.
I told my minister that Wright had argued that religion was not necessary for a sense of morality. I was pretty sure that I owned an extra copy of the book and promised him that I would bring it to him. In my memory the discussion that I wanted him to read was in the appendix. Memory is tricky. There is a discussion of homosexuality in the appendix, but the whole last section of the book was the discussion about the evolutionary origin of morality that I remembered. It is good to revisit old friends, and to revisit books that were once like friends.
As I was reading, trying to find the passages that I wanted him to read, I came across a paragraph that seemed appropriate for this time and got me thinking about how our perspectives change. On page 357 in a chapter entitled “Blaming the Victim” and in a section of that chapter called “Thoroughly Postmodern Morality” Wright writes:
Robert Axelrod, whose computer tournament so nicely supported the theory of reciprocal altruism, has also studied the ebb and flow of norms. He finds that robust moral codes rest not just on norms but on “metanorms”: society disapproves not only of the code’s violators but also of those who tolerate violators by failing to disapprove.
I see this reality operating now in the discussion of what divides us as a nation. All of the books on my bookshelves that have been written about Donald Trump since his election, and I own many, talk about his violation of norms. Much of the anger I feel in the moment is not directed at him. Before this week, I didn’t think I could be more surprised or more outraged by anything that he did, even if he were to test his own hypothesis that he could shoot someone on Fifth Avenue and not lose one voter. He proved me wrong when he exposed the Kurds to the slaughter of the Turks with an impulsive tweet.
The other side of Wright’s description of Axelrod’s findings is certainly true for me. I accepted the fact that I had political differences with most Republicans, but there was an opportunity to manage those differences at the next election. It was not political difference, it was indifference to the president’s disregard and violation of norms that caused me to shake my head and become very sad when I hear the name of Republican leaders like Mitch McConnell, Lindsey Graham, Jim Jordan, Mick Mulvaney, Rudy Guilianni, and even Susan Collins as well as so many other Trump “enablers” and apologists. The president’s blatant disregard for the “norms” of his office is amazing, but not nearly as amazing as his enablers’ willingness to participate by their lack of outrage in the pornograpy of his narcissism in the process of discarding almost anything of value in our norms, including respect for the sacrifices, the labor, the hopes, and the lives of others. Until now they have been willing to go along rather than to speak up and say enough is enough.
For a brief moment it appeared that his lack of respect for our military ethics and his violation of the trust of our allies and “comrades” in the fight against ISIS and other international terrorists would finally cause his enablers to turn on him. Would the horror of the events that were triggered by his tweet finally cross a line that would cause his enablers to turn against him? I have wondered on many occasions what kind of crime would elicit a definitive response from his enablers even when they have resisted acting on the strong evidence that he has tried, and will try again to violate the sanctity of our elections, has no regard for our press, or for our system of judicial and legislative checks and balances. It was a brief consolation that did not justify the mugging of the Kurds. Now that Mike Pence has gone to Turkey, it seems that the president is rationalizing the whole sorry episode as a good thing, and now we are hearing less from “enraged” Republican Senators. I doubt anything has changed.
Time may show that the president has had another winning, remarkable week. The Kurds have been sacrificed to whatever fuels his relationship with despots like Recep Tayyip Erdoğan and Vladimir Putin. He has enabled Russia to have a better foothold on the Middle East, and he will rent a bunch of rooms at a failing golf resort during the off season in Miami next summer when we host the G7. There wasn’t a murder on Fifth Avenue, but he might as well have pulled the trigger himself on the border between Turkey and Syria, and he has probably shown us once again that he can kill people, this time Kurds, and not lose a voter, or an enabler.
History suggests that Andrew Johnson was arguably our worst president before Trump. He fought the fourteenth amendment and was obnoxious, arrogant, and tried to placate the South after the Civil War. His impeachment and the highlight on his failures was his penalty and not removal from office. He won in the Senate by one vote. Richard Nixon earned removal from office, but had the grace not to put the nation through more pain after his fight to cover up Watergate was clearly obstruction of justice. Bill Clinton failed himself and those who believed in his leadership. I remain confused about whether his lies and perjury demanded removal from office, but in retrospect the pain of having his personal failures reviewed in the Senate seems to have been some sort of justice since he did break the law when he committed perjury despite his creative use of language and a remarkable definition of sex.
I do not look forward to the process of the president’s impeachment and trial, but I do not accept the idea that we can settle the issues in an election. The damage to norms, and the damage to people at home and abroad in this generation and likely for generations to come that has flowed from his behavior deserves being underlined by adding his name to those who have been impeached. Whatever happens in the Senate, whether he is removed or not, will not be an exoneration, nor will those who have enabled him be exonerated even if their votes keep him in office. I hope, unrealistically, that someday some of them will attempt to recover their honor by recognizing and admitting the damage to our nation that they have enabled at home and abroad and will apologize.
The Democratic presidential debate last Tuesday proved that it is time for some of the candidates to become supporters of other candidates. Here in New Hampshire you can still see candidates that were not even on the stage in Ohio, like John Delaney and Michael Bennet showing up at restaurants and libraries eager to shake your hand and involve you in their hope that a miracle will occur. The lack of clarity about the benefits of Medicare for all versus a public option persists. It is clear that Elizabeth Warren will never say that taxes will go up for middle class Americans as a way of funding the Medicare expansion. She rightly fears the video of that statement being used against her in a general election.
I was delighted to see an op ed article in the New York Times this that argued that much of the expense of Medicare for all could be funded from military spending. The piece was entitled “We Don’t Need to Raise Taxes to Have ‘Medicare for All’”. The author is Lindsey Koshgarian who is the director of the National Priorities Project at the Institution for Policy Studies. It is an interesting analysis of how we are prioritizing excessive defense spending over human services like healthcare.
Tuesday’s posting, “Let’s Think About Our Waste As An Opportunity And As A Responsibility” was primarily based on a recent JAMA article by William Shrank and colleagues that looked at how healthcare professionals might lower the cost of care coupled with an editorial about the article that was written by Don Berwick. The article was considered by JAMA to be so important that there were several associated editorials. One of the other editorials, “Toward Evidence-Based Policy Making to Reduce Wasteful Health Care Spending,” was co written by Karen E. Joynt Maddox, MD, MPH of Washington University and Mark B. McClellan, MD a former Administrator of CMS under George W. Bush and co creator, along with Elliot Fisher, of the concept of the ACO.
I am very pleased that Maddox and McClellan come to the conclusion that there is much that can be done within our delivery system to lower the total cost of care. They write: [I added the bolding.]
The “clinical” categories of waste identified by Shrank and colleagues (failure of care delivery, failure of care coordination, and overtreatment or low-value care) collectively account for as much as an estimated $345 billion in waste. Together, these categories represent the waste associated with suboptimal quality of care.
The remedies for poor-quality care, outlined by the authors, could be considered as being in 2 interdependent categories. The first is clinical care redesign, which includes approaches such as care pathways, care coordination, and delivering the right primary, secondary, and tertiary preventive care for those who qualify. The second is composed of the policy initiatives that are meant to incent and support those care redesign activities, which include approaches like the Hospital Readmissions Reduction Program, Center of Excellence designations, and bundled payment programs. These policy initiatives entail using financial or recognition incentives to nudge clinicians, hospitals, and health systems to improve care and reduce costs, as well as new payment structures to sustain them.
For sometime now it has been my advice that clinicians, hospitals, and health systems realize that they control healthcare spending even as they are complaining of inadequate financial resources. Developing the ability to live within the available revenue is a self serving strategy that is not quite the same as striving to reduce reduce the cost of care, but it has “survival benefit.” CMS has been “nudging” us to do better. I believe that those clinicians, hospitals, and systems that have responded to that challenge will ultimately do better than those that don’t. As they protect themselves, they are also lowering the cost of care.
In the editorial Maddox and McClellen demonstrate Lean thinking. They admit that “nudges” like the Merit-based Incentive Payment System (MIPS) have not produced impressive results. In Lean, it is true that often the initial solution doesn’t yield the desired result, but it does give evidence of what to try next. Their analysis of what “tweeks” might be tried next is a demonstration of how we make progress if we have the will to be engaged. Their ideas include the reality that there is no uniformity among payers, and that Fee For Service is still the dominant payment modality. But the biggest problem is us:
…,there has been inadequate clinician buy-in to these programs. Congress required CMS (the Centers for Medicare & Medicaid Services) to conduct national programs with standard approaches for a wide range of health care organizations, and, consequently, CMS has implemented performance measures and alternative payment models that many clinicians do not feel reflect their unique circumstances, capabilities, and patients’ needs. Therefore, even if measures are reasonable, pushback from clinicians has likely impeded progress.
Change is hard. They also point out that it costs money to redesign what we do. In the Atirus strategic plan that I mentioned from 2008, we expected to continuously use some of the resources that we “rescued” as investments in the process of further improvement. Metaphorically, we must prime the pump of improvement. They draw hope from their analysis of all that could be done ( the takeaways), if we have the will, and then they strongly advocate for value based reimbursement and dare to use the word “capitation.” I love to bold my favorite points.
Collectively, these takeawent and dareays suggest a path forward. The current piecemeal approach, which imposes complexity and additional implementation costs on clinicians, hospitals, and health systems, should evolve to a simpler and more holistic approach to value-based payment. Primary care should move toward a capitated payment system, with a streamlined set of quality measures and financial supports for keeping people healthy and out of the hospital. Specialty care will likely need a combination of a primary care–like chronic disease management track and add-on “bundles” for procedures, with quality measures relevant to specialized care comprising the core of quality measurement. Hospital care should be structured within such bundles where feasible, with clear quality measures around safety, and the move of accountable care organizations from fee-for-service–based models to organizations paid on a person level should continue…it will require an approach that integrates strategies that have shown promise across payers and programs, with more engagement and leadership from the clinical community so that they can be implemented fully and improved along the way. If so, perhaps the next iteration of measuring waste in the US health care system will find that progress has been made.
I totally agree. A partnership between payers (or a single payer) and the practice will lower the cost of care, and perhaps as we all hope, our patients will be able to afford both their healthcare and their taxes.
This Fall Has Been Durable
We had a big storm in New England this week. I usually just shrug my shoulders when I hear that we are expecting a “nor’easter.” We live in New England and an occasional storm does come our way. I have a very good propane fueled generator because I know that a few times each year we will lose power after a storm comes our way. This time was different. I was afraid that the wind and the rain would be the end of this fall’s color show. It has been the best one I my memory, and I did not want it to end.
I have really enjoyed the colors this fall and the wonderful scenes that keep popping up like the one that you can see in today’s header. My wife captured the shot last weekend. She was just looking out the window at the lake late in the afternoon when the light can be so dramatic. What she saw called to her, and she grabbed her camera.
On Wednesday night, the wind howled, the rain pounded the roof and the windows. It sounded like we were in the middle of a riot. When I awoke yesterday I was very afraid that I would look out of my bedroom window and see nothing but bare limbs against the sky, and windblown brown leaves covering the ground. I was only partially right. There was a little damage. An umbrella on our deck (which I should have put in the garage) had been torn from its weighted stand and thrown like a javelin into a clump of white birches where it was undamaged, but lodged between two of the white trunks. No limbs came down. The generator never came on although I hear that around the state there were tens of thousands of people without electricity. To my great delight at least three quarters of the leaves were still on the trees. Thursday was a grey and drizzly day, but I still took my walk, and the colors were pretty good. The weatherman is now predicting a pretty good weekend with sunshine and temps around 60. I am delighted with the anticipation of another spectacular weekend.
Who knows how long the show will last. I was ready to accept its end and begin my grieving, but then to my delight I discover that there will be at least one encore. My advice to you is to absorb as much fall beauty as you can while it lasts. It will end. Knowing that it will end, makes each day that it does last a sweet gift. To make the moment even better, enjoy it with someone who is special to you.
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
