16 November 2018
Dear Interested Readers,
Things To Ponder
I have recently finished reading Jill Lapore’s These Truths: a History of the United States. Lepore finishes the book with a forward looking question:
Barack Obama had urged Americans “to choose our better history,” a longer, more demanding, messier, and, finally, more uplifting story. But a nation can not choose its past; it can only choose its future. And in the twenty-first century, it was no longer clear that choice, in the sense that Alexander Hamilton meant, had much to do with the decisions made by an electorate that had been cast adrift on the ocean of the Internet. Can a people govern themselves by reflection and choice? Hamilton had wanted to know, or are they fated to be ruled, forever, by accident and force, lashed by the violence of each wave of a surging sea?
Some reviewers think that Lepore’s prose gets overly dramatic at times, but I found that it helped me to have a better grasp on both the complexity of the moment and the reality that despite all of the fake news, the recent Supreme Court decisions that seem to undermine protections of voters rights, and the current administration’s genius for using fear to manipulate large portions of the electorate, there is still hope for us to get back on track to moving our reality closer to the founding ideals that launched our experiment in self government.
The passage is a couple of paragraphs from the end of the epilogue and the book. A few pages before those words Lepore’s begins the epilogue with a quote from the great mid twentieth century theologian and proponent of the “social gospel,” Reinhold Niebuhr.
If we should perish, the ruthlessness of the foe would be only the secondary cause of the disaster. The primary cause would be that the strength of a giant nation was directed by eyes too blind to see all the hazards of the struggle; and the blindness would be induced not by some accident of nature or history but by hatred and vainglory.
Reinhold Niebuhr,
The Irony of American History, 1952
As I read and re read the epilogue to avoid letting go of the book, I was was struck by the fact that the quote from Niebuhr and the questions that Lepore is still asking suggest that the situation has not changed much in the intervening sixty six years. I do not mean to imply that no progress has been made, but we are still struggling with economic inequality. Racism and bigotry seem to be flourishing. We are still divided by attitudes about guns and abortion. Women, non whites, and the LGBTQ community all are still denied equal rights with white men. We are still at some distance from achieving “We hold these truths to be self-evident that all men [all humans?] are created equal.” Much has happened since Thomas Jefferson wrote those words, but much still remains to be done. In some areas, and perhaps healthcare is one, we may have recently regressed.
I agree with Lepore’s uncertainty about the future and how we are still looking for complete answers to the big questions that existed in the summer of 1787 when the Constitution was written. The ACA was a beachhead in the struggle for equity in the distribution of healthcare. The issue is not whether we are making progress in our search to understand disease or whether we are advancing our understanding of how to treat things effectively that just a few years ago were death sentences. Atul Gawande says that we are no longer ignorant. He points out that we have learned a lot about disease and treatment in the last 70 years, but he adds that we are inept when it comes to the equitable distribution of the benefits of what we know. At this moment, despite the recent capture of the House by the Democrats in the midterm elections, we are at risk of being thrown from that beachhead on equity and all of the other domains of quality that we had taken in 2010 with the passage of the ACA.
When I finally put Lepore’s book down I almost immediately began to try to see if I could reshape the words of Niebuhr to be descriptive and enlightening for this moment in the troubled history of healthcare in our nation. He described a vulnerability that arose from “hatred and vainglory.” What has made us vulnerable to losing ground in our efforts to secure the Triple Aim? Perhaps not hatred or vainglory although it is hard to argue that our efforts so far are a demonstration of love or respect for everyone living within our borders. My efforts led to something that was inadequate and might sound pretty ridiculous to you, if not actually blaming, pompous, or even self righteous, but the exercise gave me much to consider. Here goes:
If we should fail to achieve the Triple Aim it will not be because of the continued resistance to the idea of universal coverage and a lack of acceptance of the principle that in a society as wealthy as ours healthcare should be an entitlement. The primary reason for our failure would be that a majority of our healthcare professionals and our healthcare institutions have failed to see that the problem was rooted in our failure during more than a century of self protective behavior to put the needs of patients and the community first. We have failed to see that our priority should be much more than our own emotional well being, professional satisfaction, and financial security. Our priority should be to secure the optimal health for every person in every community, and to do so with a sense of stewardship that does not impair our ability to address our other collective concerns.
Those words sound “holier than thou.” They also sound as if they blame it all on our industry and its professionals and diminish the impact of other very real threats to universal coverage like the Republican commitment to reduction of entitlement spending by any means, the looming threat of a majority conservative Supreme Court, and the continuing efforts of an administration that is committed to using every available administrative tool available to reduce the number of people getting publicly supported healthcare.
Throughout Lepore’s description of the last one hundred years of our history she paints an accurate although superficial picture of the resistance of doctors, hospitals, and insurers to universal healthcare. The resistance blocked the progressive ideas of Teddy Roosevelt. The idea of including healthcare in FDR’s New Deal and Truman’s call for a national health insurance plan were actively resisted by the AMA, as were Johnson’s Medicare and Medicaid proposals.Our industry and profession did not effectively support the Clinton healthcare proposal as it allowed the insurance industry to lead the charge to defeat it. More recently the large majority of physicians have not spoken out against reforms for better care being available for more people, but they have not effectively spoken up for universal care either.
It seems we (healthcare professionals) find it easy to express our feelings about professional burnout, clunky electronic medical records, quality metrics that seem to be an onerous burden, or falling reimbursements for growing work loads, but few of us are interested in demanding a reduction of the barriers to care that are a function of injustices in the past that continue now. It is easy for us to defend and justify the failure of most professionals to demand universal coverage because it is likely that the large majority of them are overwhelmed with “today’s work.” Perhaps we feel vulnerable to the financial fragility of our practices and hospitals. It is true that we have been “running” faster and faster over the last quarter of a century as we work harder and harder to maintain incomes that are “flat” when adjusted for inflation. We are emotionally exhausted from the necessity to adapt to changes in the structure and organization of medicine. Often our response is, “This is not what I signed up to do.” We respond to questionnaires about our satisfaction by saying that we “would not do it again.” We hope that our children will be attracted to some other vocation. Many of us retire early if we can. Some of us can craft a partial retreat from practice to managerial positions that provide some respite from the exhaustion that accompanies full time practice. Most of the doctors or nurses I know can quickly produce a long list of complaints if they are asked what is wrong, but simultaneously they are not engaged with any effort to change any of the things that cause them to be weary of their world.
We are now calling the despair that mutes many of us “burnout.” In the post earlier this week I copied and pasted the diagnostic description of burnout that Atul Gawande obtained from Christina Maslach.
“…a combination of three distinct feelings: emotional exhaustion, depersonalization (a cynical, instrumental attitude toward others), and a sense of personal ineffectiveness. The opposite, a feeling of deep engagement in one’s work, came from a sense of energy, personal involvement, and efficacy.”
I can relate to “personal ineffectiveness.” I often ask myself about the real effectiveness of these weekly missives. The practice of medicine has always been an “autonomous” activity. No profession values independent judgement or protects the prerogative of the individual professional more than we do. We joke about change in medicine being a process similar to herding cats. We are so smart and so savvy that we can not submit to programs of care or changes in practice that we did not invent ourselves or negotiate. As a generalization our collective attitude is like the joke about the Harvard professor who said that if he wanted to read a book he would write it himself.
Our professional societies do not enable us to speak with one voice. The AMA no longer speaks for a majority of physicians. When the AMA was a legitimate voice of the profession it functioned much like the NRA, protecting the individual concerns of practitioners more than as an advocate for ideas like universal access to care. Not until the IHI evolved in the early nineties (1991) did we have an organization that had an effective voice that put the concerns of patients first, and still it took more than a decade, until the Triple Aim was announced in 2007, to shape those concerns into an expression of intent that was focused on the recipients of our efforts rather than ourselves. The IHI is influential, but I am sure its impact is still limited to a minority of individuals and institutions.
It seems that it takes a very long time for our ideas to jell into something that we can say in an “elevator speech.” I have long seen an evolutionary connection between Robert Ebert’s 1965 concept of how to improve healthcare and the more succinct Triple Aim of 2007.
The statement:
“The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.”
is not at odds with “better care for individuals and a healthier community at a sustainable expense.”
Ebert answers the question of what is needed to meet the needs of the population. We need two things: a better “operating system” and a better “finance system.” We have not come up with a better operating system. We know that the core of our current operating system, the hospital, is dysfunctional and often misused. More hospitals and bigger hospitals are not the answer. We have used hospitals as “revenue centers” but as such they are one of the reasons that American healthcare is becoming prohibitively expensive, and your health and mortality are less challenged in a New York subway than in a hospital. We are yet to deal with the fixed costs and wasted resources of delivering care in the ambulatory clinic which differs from the hospital as a center of expense only slightly. Our offices are still enormous producers of “fixed overhead” and most of them sit empty and unused more than 60% of the time. Both the hospital and the office are huge “cost centers.” The finance system drives this dysfunctional operating system and there is little or no recognition of the waste, even though we all give lip service to the need to lower the cost of care.
As long as we cling to fee for service payment we will misuse both the hospital and our ambulatory resources. Both require that the patient be seen for payment to occur. That may have made sense in 1918, but frequently is not necessary in 2018. Despite the fact that fee for service payment forces us to continue to invest in expensive physical structures and large budgets for personnel we are far from giving up either fee for service or our old models of care.
The New England Journal of Medicine Catalyst published a white paper this week entitled “Transitioning Payment Models: Fee-for-Service to Value-Based Care.” I suggest that you click on the link and download the paper. It is only about sixteen pages long. They see the glass as being a “quarter full” and are delighted.
In a survey of the NEJM Catalyst Insights Council in July 2018, 42% of respondents say they think value-based reimbursement models will be the primary revenue model for U.S. health care. Indeed, this transition is already happening. Respondents report that a quarter of reimbursement at their organizations is based on value, on average. While three-quarters of their revenue remains fee-for service, we see a remarkable change to a reimbursement system that was static for decades.
I too celebrate the progress that has been made, but at the rate we are moving toward value based payment there will be moss on many as yet un planted tombstones, mine included, before the job is done. It is perhaps even true that the marginal gains that have been made do not represent acceptance or understanding, but are hedges against the uncertainty of what will ultimately happen with fee for service.
Yes, Niebuhr is right. If our democracy ultimately fails it will not be because of hatred and our vainglorious pride. We will not be defeated by all the terrorists, rapists, welfare queens, drug users, and demagogues that plague us. We will be defeated by our own deficiencies and self centeredness. If the efforts to improve health fail like the war on poverty, the war on crime, and the struggle for equality have failed so far, it will not be because the Triple Aim was a bad idea or at variance with our stated impression of who we are and what we should support as medical professionals. The failure will be because we were too concerned with our own interests to give adequate attention to correct our part in the cold hard fact that healthcare costs too much. Conversely, if we made the needs of every patient in our community our highest concern, the lives we save may include our own.
Getting Through The Dark Days That Are Coming
This time of year more and more of my daily walks begin around twilight. It is dark now before 4:30, and in a little over a month it will be dark before 4PM. I make accomodations. I have a reflective vest with a blinking light on the back so that cars and trucks approaching from the rear will see me, and I wear a headlight both to help avoid the hazards on the ground in front of me, and as a signal to vehicles that are approaching me. It feels a little silly to put those things on when I leave the house at 3:30, but the evening falls fast this time of year and my average walk is about an hour and a half. The darkest hour seems to come first this time of year.
I took the picture that is today’s header around 4PM last Tuesday evening at the turnaround point on my most frequent walk. It had been a stormy day, but as is often my experience the weather cleared late in the afternoon, and I was able to walk in the chill under the heavy cloud cover that persisted once the heavy rain that had followed the earlier snow had finally stopped. What you see in the picture is a rain swollen Kidder Brook as it flows into Little Lake Sunapee from the hills to the north. The rain did not wash all the snow away. A quarter of a mile upstream the book flows over a series of cascading waterfalls that drop into inviting pools full of “brookies” which will rise to a fly on a warm summer evening.
The last quarter mile of the brook’s run to the lake is across a flat plain that has been created by the glacial silt that accumulated over the last twelve thousand years as that block of ice that was one mile high melted. My house sits at the other end of the lake where some of that silt built a dam high enough to create the lake. The plain through which the brook approaches the lake is as flat as your kitchen table and is just large enough to accomodate a nine hole par three golf course.
A geologist has studied the creation of the lake. His summer home sits on the lakeshore next to the golf course, and is the house closest to the brook as it enters the lake. His data suggests that the path of the brook has changed many times over the last ten thousand years as it has created the “delta” that has become the flat plain that accommodates the golf course. There is a large sandbar of silt in the lake just beyond the inflow of the brook. It is interesting to ponder the fact that all I can see from my time limited perspective is how the scene varies with the seasons when at the same time things are evolving in much more profound ways and the shape of what is to come is driven by powerful forces that I can not appreciate because I am trapped in a very small window of time that makes what I see seem final and permanent.
I was motivated to take the picture because the moment felt ethereal, and I thought it was somewhat of a metaphor that works at many levels for what is and what lies ahead. Many people do not understand how we got to where we are either as a nation or as the healthcare system. Our perspective is limited. We just know a few seasons, and not the broad history of what has been, or what interesting and perhaps better things are yet to come. I do think that better things are coming. I just do not know how long it will take or how often our course will change on the way to that better future. Over the next few months as a new Congress convenes and as a new court majority begins to hand down decisions, it will be interesting to observe what changes in our world, and who knows, what we see may give us a hint of what is yet to come.
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
