June 11, 2021

Dear Interested Readers,

 

“Every System Is Perfectly Designed To Get The Results It Gets.”

 

Dr. Paul Batalden was one of the thought leaders in the quality and safety movement of the last thirty-plus years who may not be as well known as Don Berwick, but he was one of the founders of the IHI and a fierce advocate for using processes of continuous improvement in medicine. His concept of “microsystems” was built on a clear vision of how we should be collaborating if we wanted the whole system to produce outcomes consistent with the Triple Aim. I was very fortunate to have spent a day with him and others on his team at Dartmouth in the spring of 2008. Sometime later I was visiting Don Berwick in the offices of IHI in Cambridge, Massachusetts, and I was not surprised to see that “Every System Is Perfectly Designed To Get The Results It Gets.” was painted on the wall in large fancy script letters. 

 

I have always thought that this paraphrase of another great thinker in the field of continuous improvement, W. Edwards Deming, was Batalden’s message to us that we must re-engineer healthcare, like it or not. If we ever want better care for all people, healthier communities, and sustainably affordable healthcare, we must realize that healthcare is a complex system. I think what we have learned as our experience and understanding of healthcare disparities and the social determinants of health has grown over the last fifty years, is that healthcare is embedded in a much larger social system that also must be considered as part of the transformation process if we are ever going to see the results we feel would best serve patients and the nation as a whole. Even that national view is inadequate as we are learning from the pandemic and global warming. In reality, our healthcare system and our nation are embedded in a worldwide system that plays a huge role in our own personal and local health and life experiences. If you judge a system by what it produces our vast system of care seems perfectly designed to produce miracles on occasion, but most reliably has produced medical errors, and an average health experience with metrics that lag most of the developed world. We get these results at enormous expense, and rife with disparities that land most heavily on our most vulnerable populations. Dr. Batalden would suggest that the system needs to be redesigned to produce a better product.

 

Even if you own a copy of Crossing the Quality Chasm: A New Health System for the 21st Century you may have never examined its authorship. The “author” is the “Committee on Quality of Health Care in America” of the Institute for Medicine. You may know all about the IOM, but I would venture that a majority of healthcare professionals don’t give it much thought. They don’t know that it was founded in 1970 by the National Academy of Sciences and that in 2015 NAS changed its name to the National Academy of Medicine. What you may have noticed is that for the last year the New England Journal has been running a series of “Perspectives” articles under the general topic of “The NAM at Fifty.” So far there are thirteen articles. The most recent article, published on June 3rd was “Womens’ Heath.” May’s article was a very important article for all healthcare providers since we are in the midst of culture wars around the subjects of “Critical Race Theory” and “Structural Racism.” Many political observers believe that the Republican party is driving the challenge to these subjects in state legislatures across the country as a prelude to the 2022 midterm elections and their hope to take back control of the House. Loss of the House would put an end to any efforts by President Biden to improve healthcare and extend coverage to the millions of uninsured Americans. The title of the May 6 article was Understanding and Mitigating Health Inequities — Past, Current, and Future Directions. It was written by Risa J. Lavizzo-Mourey, M.D., M.B.A., Richard E. Besser, M.D., and David R. Williams, Ph.D., M.P.H., and its message is worth your attention. They begin by writing:

 

Over the past half-century, understanding of health and health care disparities in the United States — including underlying social, clinical, and system-level contributors — has increased. Yet disparities persist. Eliminating health disparities will require a movement away from disparities as the focus of research and toward a research agenda centered on achieving racial equity by dismantling structural racism.

In the 1970s, the same decade that the Institute of Medicine (IOM), now the National Academy of Medicine (NAM), was founded, researchers began to see a clear pattern of disparities in the health of Black people and other minority groups as compared with White people in the United States. More Black people than White people died from cancer, for example, even as more effective treatments became available, and American Indians had substantially higher rates of diabetes than White people.

 

We have come to expect things to move slowly in healthcare, especially when new ideas challenge common practices and concepts so a clear pattern of disparities may have been recognized by reachers in the 70s, but it was not until 1985 that a noteworthy publication was produced by the government. The authors write:

 

In light of the clear need to understand the drivers of such disparities and to design effective interventions, in 1985, Department of Health and Human Services (HHS) Secretary Margaret Heckler released Black and Minority Health, the first U.S. government report to focus exclusively on the health of racial and ethnic minorities. The report, which documented a higher burden of disease and lower life expectancy among Black and other minority populations than among White populations, called for enhanced data collection to design effective interventions. This report launched a new era of productive research and led to the 1986 formation of the Office of Minority Health, with the goal of improving the health of racial and ethnic minority populations by implementing new health policies and programs.

 

Let me ask you a rhetorical question. When did you begin to think about healthcare disparities? Quite honestly if you had asked me about disparities in the 90s, I might have been vaguely aware of how our system of care did not treat African-Americans quite the same as the White population, but I would have been quite upset if someone had suggested that there was a lack of equity in my practice or in any practice at Harvard Community Health Plan. It had never occurred to me that since we drew most of our patients from an employed suburban population that the issue of equity was de facto not an issue for us. There were several well-known and high-quality Federally Qualified Health Centers (FQHCs) in the greater Boston area which served disadvantaged populations. End of problem.

 

We did “diversity training” in the mid-nineties. I even became a facilitator in the program, but then we moved on to what we thought were the more important issues. We had other concerns. It was long after Crossing The Quality Chasm identified “equity” as a healthcare issue that anyone in our practice began to give the makeup of our patient population much thought and longer still before anyone asked the rhetorical questions about how we might be agents in the reality that outcomes were worse for disadvantaged populations. We were not alone as the authors note:

 

Although data collection on health disparities between Black and White populations began to improve after the Heckler report, data related to other marginalized populations remained scarce. Efforts were soon launched to collect data on health status and health care outcomes based on race, ethnic group, language, and other important characteristics. Beginning in 2003, the Agency for Healthcare Research and Quality reported annually on progress toward eliminating disparities…But disparities were not eliminated, and gaps in data emerged (and persist) regarding disparities faced by Asian and Latinx people; lesbian, gay, bisexual, transgender, and queer people; and people with disabilities.

 

It takes most of us a long time to develop much interest in problems that are important but don’t seem to directly impact our own personal or institutional wellbeing. Our days are filled with efforts to take care of those who have access to us. Speaking for myself, it took a long time to “connect the dots” and longer still to realize that as a physician and even more as an executive and board member, I had a responsibility. I had a responsibility to be part of the solution. As the authors demonstrate with an excellent timeline running for the thirty-five years between Heckler’s 1985 report and 2020, it was many years before the pandemic and the demonstrations following the murder of George Floyd got more people thinking about disparities in healthcare. It is hard to know why it took such a long time for most of us to seriously consider the differences in disease and life expectancy between minorities and White Americans. I did not hear the phrase that your ZIP code had more impact on your life expectancy than your genetic code until at least 2010. Even the Triple Aim is soft on the subject. We believed that if “everyone had access to care” we would make a big dent in the problem. There are now studies that show that even when minorities have “equal access” they do not have equal outcomes. The authors give us insight:

 

In 2000, the Minority Health and Health Disparities Research and Education Act established the National Center on Minority Health and Health Disparities, along with a dedicated research budget to explore strategies for advancing health equity.

Researchers turned next to drivers of health disparities within the health care system — chief among them unequal access. The IOM issued a six-volume series documenting the effects of lack of insurance on access to various types of care, from preventive services to care for chronic or potentially fatal illnesses, such as cancer and renal failure. The reports tied disproportionately low rates of health insurance among minority populations to low availability of community-wide health care services — and, in turn, to health disparities. These reports illuminated the way in which a community’s health status could be linked to its residents’ insurance status.

Congress also tasked the IOM with studying racial and ethnic disparities in quality of care, evaluating potential sources of these disparities, and recommending interventions. The resulting 2003 report, Unequal Treatment, explored the continuum of services from hospital-based care to rehabilitation and long-term, home-based, and outpatient care…Although Unequal Treatment acknowledged the influence of socioeconomic factors on health outcomes, it did not explore specific linkages between socioeconomic status and health care or recommend solutions that integrated social and health care–related factors.

 

The authors note that studying a problem is much easier than fixing one:

 

Twenty-five years after the Heckler report, researchers had made substantial progress in collecting and stratifying data on the basis of demographic dimensions, in understanding the relationship of socioeconomic status and inequitable health care access and quality with health outcomes, and in recognizing the necessity of structural change to achieve health equity. This potential has yet to be realized, however.

The research that emerged after the Heckler report made it clear that health disparities cannot be reduced by targeting individual clinical conditions. Instead, the field has turned toward the exploration of structural factors, such as the role that structural racism plays in segregating society and limiting opportunities for health and well-being, as essential to advancing health equity.

 

“Structural racism?” Is there structural racism in healthcare? Their timing is not so good. Studying structural racism is becoming a political problem, but the authors charge forward identifying that we have plenty of studies that settle the question even though in many parts of the country mentioning structural racism, critical race theory, “The 1619 Study,” or even anti-racism can cause problems, especially if you are a teacher.

 

On the positive side, we have pilot studies that moving people from a minority community to a “higher rent” section of town improves health, motivation, and the education of children. Read the article. The authors lay it all out for your consideration.  The ACA did make a little difference, but there is a long way to go. They sum up our current state near the end of the article. They project their hope that after fifty years based on what we have learned in many studies and pilots, and what the last year has demonstrated, maybe things will get better:

 

In 2020, two events increased public awareness of structural barriers to good health, particularly for racial and ethnic minorities, and could engender new interventions and policies. One of these events, the murder of George Floyd, an unarmed Black man, by police, sparked a massive cultural confrontation of structural racism and the systemic factors that cause Black people and other people of color to be sicker and die earlier than White people in the United States. The other event, the Covid-19 pandemic, sickened, hospitalized, and killed people of color at higher rates than White people because of many factors, including an increased risk of exposure, unequal access to testing and high-quality care, higher rates of medical conditions associated with poor outcomes, and less access to vaccination. These events could increase political will to address the structural racism that drives inequitable health outcomes — thereby creating an unprecedented opportunity for researchers, advocates, and policymakers.

 

I don’t think that they checked with Mitch McConnell or for that matter Joe Manchin when they wrote:

 

These events could increase political will to address the structural racism that drives inequitable health outcomes…

 

I totally agree with their last sentence:

 

Only by addressing underlying structures will we get closer to a day when a person’s health prospects are no longer predicted by the social construct of race.

 

Unfortunately, they didn’t give us a road map to that vision. I guess they left that work to you and me. It is a very long road from insight to action. Dr. Batalden would advise us that if we want a system of care without disparities we are in need of a major redesign effort.

 

I Am Relieved. It’s Loon Watching Time Again, and the Red Sox Are Interesting Again.

 

Loons fascinate me. I think my fascination is a combination of the Loons’ inherent beauty and their predictability. Many people believe the haunting beauty of their variable calls constitutes an intelligent language. 

 

Loons always come back to the same lake. They have a reputation for monogamy although I am told that they are monogamous to place more than a specific mate. Whatever their marital status they arrive soon after the ice melts. Well, maybe he comes first and she follows a few days later or vice versa, but In either case, I can see them tour the lake together almost as soon as the ice melts. 

 

The female loon goes on the nest to lay one or two eggs about the third week in May. They share their parenting duties which include taking turns sitting on the nest. The chicks predictably arrive during the second week in June. My wife keeps a record of the arrivals. Baby chick day last year was June 12.

 

Today’s header features a picture of one of the loons, it could be the mama or the popa, that my wife took last weekend with a long lens. There is a barrier to prevent the curious from getting too close to the nest which is maintained by the same conservationists that designed the permanent floating island that the loons use year in and year out. Islands are great places to protect the nest from predators like foxes that would love a loon egg for breakfast. The nest needs to be very near the water because evolution has moved their legs so far to the stern for better swimming and diving that they are not much use on land. Loons are not that great in the air either. As fall comes on and the leaves begin to change, it is fun to watch the parents try to teach their juvenile offspring how to get airborne. It takes a long runway. I have seen them “running” across the surface of the lake for several hundred yards while wildly flapping their wings before they finally get enough lift to clear the trees along the shore. These birds have evolved to swim fast and dive deep. Flying is reserved for getting to the Maine coast before the lake freezes and returning from the Maine coast once the lake thaws. Once again the whole process is predictable and observable. Flight is practiced in the fall, just in time for the timely departure.

 

Predictability and reliability are not always positive traits. Consider former President Trump. He is both predictable and reliable. He predictably speaks self-serving falsehoods as he attempts to undermine the free press. In his four years in office, he reliably performed to his personal benefit and the benefit of his base while giving a wink and a nod to the fringe organizations that promote the philosophy and activities of an emerging white supremacy movement. He also took care of the financial needs of the very wealthy arguing that if they were OK then eventually there would be more and better jobs for the less affluent. He predictably denied the threat of climate change, the role of carbon-based fuels as the causative agents, and derided the use of science to explain what is obvious to most seventh graders. 

 

Mitch McConnell is another champion of consistency except for that one brief moment after he engineered the failure of the second attempt to remove Trump through impeachment. In an amazing and confusing performance, he gave an emotional speech condemning Trump for doing the crime for which he had just guaranteed Trump’s acquittal. McConnell made absolutely sure that the Republicans blocked every significant attempt at social legislation during President Obama’s terms, and he is predictably and reliably at it again now that another Democrat is in office.

 

Thanks to Mitch, we won’t have a commission to investigate what happened at the Capitol on January 6th. We probably won’t see the passage of either of the pending bills passed by the House to improve the voting process and ensure fair elections. He will see to it that the Republicans will bargain down the infrastructure bill, The American Jobs Plan, and then probably ask Republicans to vote against the bipartisan outcome just like he had them do when the ACA was passed full of amendments in committee by Republicans but without one Republican vote on the final vote. I don’t think there is much reason he will not approach the American Families Plan any differently. It is very hard for me to understand the partisan divide that has grown over the last thirty years. I struggle not to hate the leaders and the followers of ideas and actions that seem to me to be antithetical to all that once defined our better sense of who we are.  In time many have come to recognize where we have failed. Many are trying to bring hope and change in search of the ideals of liberty, equality, and opportunity that we say defines our essence. Not hating and trying to depart from an easy dualism is a daily struggle for me, and the loons help.

 

The loons offer me relief from the frustrations and disappointments of the daily news. The only thing that is unpredictable about loons is where they will come up after their dives. That is always a delightful surprise. I wish Mitch would delightfully surprise me just once. It’s unlikely, but at least I have the consolation that when I get really steamed up about his resistance to legislation that could substantially improve healthcare disparities I can get in my kayak and join the loons on the lake where everything is predictable and beautiful. That is much better than turning up the volume on my anger. I am looking forward to the loons helping me get through another summer of stalemates with no positive surprises in the ongoing Washington culture wars. 

 

There has been one totally unexpected pleasure this summer. How about the Red Sox? The Yankees are loaded with the best talent money can buy, but last weekend the Sox won three straight games from them in the Bronx. I had to turn the game off on Sunday night after their usually reliable closer, Matt Barnes, gave up a run in the ninth inning to put the game into extra innings. I was afraid that if I tried to watch I would have a heart attack. I was thoroughly surprised and delighted when I checked the final score before going to bed and discovered that the Sox had completed the sweep with a 6-5 win. This week they have had a tough time with the Astros. I have seen enough to know that win or lose, they will be interesting to follow this year. I wonder if I turned off what is coming from Washington like I turned off the Yankee game I might discover at the end of the summer that a miracle had occurred and all of the critical legislation had passed. 

 

While waiting for a Washington miracle the loons and the Sox will have to be my steadying source of satisfaction and renewal. I hope that you have your own coping strategies that will give you a satisfying summer. I have several kayaks so if life sends you up I 89 for some reason stop by and I will introduce you to our loons.

Be well,

Gene