There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things. For the reformer has enemies in all those who profit by the old order, and only lukewarm defenders in all those who would profit by the new order, this lukewarmness arising partly from fear of their adversaries … and partly from the incredulity of mankind, who do not truly believe in anything new until they have had actual experience of it.
Machiavelli’s well known quote about the fate of innovators is a very useful piece of wisdom to keep it in mind as I expand on what we might better understand about clinical innovation by reflecting on the early history of Harvard Community Health Plan.
A few weeks ago I wrote:
…in the innovator’s world, integrating what is new with what exists inevitably produces conflicts as “creative destruction” becomes a reality. Years ago I imagined HCHP as an “island economy”. As long as we were an isolated pioneer outpost and there was a spirit of adventure, life was less stressful. We were not concerned with our work load or our compensation. We were happy exploring a better way.
One day we faced the reality that we had to be integrated with the wider world. If we were going to survive, we needed to grow. To grow we needed to attract professionals who wanted “a market compensation for market responsibilities”. It was as if we had built a causeway from our happy little island to the realities of the “mainland”. I sense that Iora is fast approaching some of the same realities that faced HCHP. The number of similarities are astounding, from the fascination with prepayment, to the redesign of the concepts of an optimal practice, and the attempt to create a more clinically useful medical record.
If you read the link from Wikipedia about Schumpeter’s concept of creative destruction you may surmise that it is very similar to Clay Christensen’s “disruptive innovation”.
In Schumpeter’s vision of capitalism, innovative entry by entrepreneurs was the disruptive force that sustained economic growth, even as it destroyed the value of established companies and laborers that enjoyed some degree of monopoly power derived from previous technological, organizational, regulatory, and economic paradigms.
Such conquests always seem to follow a period of struggle and learning for the innovators that are invading the domain of the establishment. Creation requires energy and has its costs both in money and human effort. This concept of natural resistance to creative destruction connects nicely to the statement by Machiavelli warning agents of change or innovators not to expect that their ideas will be immediately embraced, but rather resisted, especially by those who sense that their investments or their professional culture are threatened.
Harvard Community Health Plan was met by resistance from the moment Dr. Ebert began to describe it to his colleagues who clung to the status quo of hospital based practice. There was also a cry of “foul” from community physicians who were graduates of Harvard Medical School. Some wrote letters of complaint to the New England Journal of Medicine and to the Harvard Alumni publications of the day. There surliest manifestation of this resistance was a “joke” that was floating around the Boston medical community in the seventies that HCHP was an acronym for “Horrible Care for Healthy People”.
There are more granular challenges that face innovators than just gaining acceptance by the market if the innovators expect to overcome “the old order” and capture the “lukewarm” members of the status quo “who do not truly believe in anything new until they have had actual experience of it”. I believe that examining the experience of HCHP in the seventies and eighties will inform the understanding of challenges that include:
- Creating and managing a leadership team or guiding coalition that includes business and medical expertise.
- Promoting and managing growth in an era of limited resources.
- Managing the “make/buy” relationships: vendors, hospitals, nursing facilities, specialists, diagnostic resources.
- Maximizing relationships with collaborators who are sometimes competitors, i.e. “coopetition”.
- Understanding and promoting the “game theory” of quality, service and collaboration.
- Acquiring and managing clinical talent. The issues of parallel commitments.
- “Dyads” management and other realities of a “positive” bureaucracy.
- Acquiring competence and learning balance in the ongoing reality of the continuing debate between top down and bottom up decision making in the context of “subsidiarity” in organizational life.
- Remembering and modifying the original intent and mission in the context of oppressive externalities.
- Understanding the interplay of continuous improvement, relational contracts and a complex environment that promotes distrust.
From the inception of the practice in 1969, one barrier to the continuing existence of the pilot was the need to grow. On opening day in October 1969 there were 88 patients. Calculations suggested that at least thirty thousand patients were needed to insure the resources necessary to continue the practice’s existence. Dr. Joseph Dorsey (pictured, later in life, in the header) made it happen. I am told that he was in a mode of continuous evangelism and spread the gospel of the new approach to care with daily visits to civic groups, politicians, labor leaders, state agencies, town managers, city councils, and employers by the hundreds.
It worked. In less than three years they passed the 30,000 mark. Ironically the “sale” to professional corporations, academic institutions, hospital employees, and civil service employees of the cities and towns greatly exceeded the membership that came from trade unions and manufacturing. When I joined the practice I was warned by colleagues at the Brigham that my practice would be populated by “well secretaries”. My very first patient was a fifty five year old engineer. He was an urgent “add on” to my first day’s schedule. His problem was an idiopathic cardiomyopathy complicated by complete heart block. I was off and running to a continuous banquet of challenging clinical problems that kept me learning for over thirty five years.
Dr. Ebert had leadership problems to manage from the get go. He had assembled a late sixties “dream team” of economists, experienced clinicians, rising clinical superstars, healthcare theorists, policy wonks, and systems engineers. Within the group there were creative disagreements about how to organize and deliver care. Given the support of both the Beth Israel and the Brigham, there were initially two Chief Medical Officers. Joseph Dorsey led the part of the practice that utilized the Brigham as its hospital home, and Richard Nesson led the Beth Israel practice. Within two years Nesson had left to assume leadership of the Brigham’s outpatient clinic on his way to becoming the President of the Brigham and the founder of Partners in 1993.
Eventually stability was achieved when Robert Biblo became CEO in 1970. By the time he left to go to New York City in 1977 to be CEO of HIP, we had grown to 80,000 patients getting care in two sites, Kenmore Square and Cambridge. He was succeeded by a dynamic young business man,Tom Pyle, who grew the organization from two sites serving 80,000 patients to over 400,000 patients with more than 14 sites. By 1988 there was a “staff model HMO” location convenient to almost everyone in the greater Boston area. I had patients who were coming from as far away as Cape Cod, New Hampshire and the Berkshires. In 1985 HCHP created a second division which was a network of group practices in the surrounding suburbs. That was a strategic move that left many of us in the original practice confused.
The necessity to grow undermined the original pioneer spirit that was so attractive to me. The need to hire over 500 doctors in a relatively brief time will by necessity change the hiring criteria. It was the need to grow that built the “causeway to the mainland”. As we began to grow rapidly in the eighties, I jokingly observed that we were willing to hire anyone who could be credentialed with the hope that they would fit.
Dr. Dorsey was forced out of his role as Medical Director in 1977. Some said he was forced out because of his enthusiasm and legendary ability to do more, and ask others to do more. Whatever the cause, it was upsetting to me. His leadership had inspired me. His response to the change was the greatest example of professional commitment to purpose that I have ever witnessed. What he did was to devote himself to practice and improving our utilization of the hospital.
Joe forged bonds with Dick Nesson and Eugene Braunwald at the Brigham which greatly enabled our specialists and surgeons to function more efficiently and effectively. He helped to establish a strong primary care residency program at the Brigham. Joe’s work and efforts were largely responsible for the completion of a major part of Dr. Ebert’s vision with the creation of a department of ambulatory and preventive care for HMS based our practice. That gave every Harvard Medical student a primary care experience at HCHP.
During the early eighties Joe lead me and others in an effort to improve the care given at a small community hospital on Mission Hill. It was the greatest six years of my practice experience. We introduced many “innovations” that better leveraged the interface between the hospital and the ambulatory practice. Sadly the experience also taught me that success does not always guarantee survival in a complex and competitive world. By 1986 success had created the need to expand. The analysis done at that time revealed that expansion of the little hospital would be impractical and prohibitively expensive. A plan emerged to move all admissions, both from the community hospital and the BI, to the Brigham. I was devastated by the loss of my creative opportunity at our little hospital. That was when my career changed and I began to get involved with the governance of HCHP, a path that eventually would result in becoming CEO more than twenty years later.
Finance and the need to grow were obsessions in the eighties while HMOs thrived and employers were offered “sole source” relationships by insurers. HCHP became a self insured practice after Ted Kennedy pushed the passage of the HMO Act through Congress and Richard Nixon signed it into law in late 1973. By the time of Helen Hunt’s Oscar winning rant about her HMO in the movie As Good as It Gets in 1997, our organization had abandoned most of our innovative efforts and transferred our focus to the effort to survive.
Many events complicated Dr. Ebert’s dream and the work done by the pioneers at HCHP in the early days. One was a marketing study that suggested that patients did not want to see nurse practitioners and physician assistants. As a result new sites were not opened with the same partnerships that enhanced my ability to care for my patients. I always felt that the result would have been just the opposite if the study had looked at the satisfaction of patients who were receiving care from an experienced clinical partnership between a physician and a nurse practitioner or physician assistant.
Another mistake was the misapplication of hospitalists and the relegation of the PCP to the office for efficiency. I am not against the use of hospitalists. They can be wonderful. It’s just that in thirty years we have not adequately backfilled the advantages that we lost when we made it difficult for PCPs to get to the hospital..
There are more more stories and lessons learned. Others who were there with me may have a different take on the same scene. I appreciate the prod to memory and reflection that my exposure to Iora Health has stimulated. If you would like to know more, you can download a PDF that was produced by Harvard Vanguard in 2009 to celebrate the fortieth anniversary of the practice.
