22 March 2019
Dear Interested Readers,
Musing With Friends About Healthcare
This week’s letter lives up to the title of “Healthcare Musings.” The dictionary says that musings are periods of reflection or thought. I would add that when I am musing I am processing my experiences for the insights that they provide that will give me a sense of direction for the the future. Musing is best when it is a team sport. As I think back about the work I did and the professional joy I have had, I realize that the best ideas, the greatest joys, were the products of collaborations or musings with friends and colleagues who were similarly concerned and motivated by the challenges of caring for others and were eager to share their experiences and the ideas that those experiences engendered.
I was blessed to live and work in an environment where there were many people who loved their work as healthcare professionals and enjoyed thinking and talking about the complexities of healthcare. I realize that not everyone has the privilege of being surrounded and supported by others who are eager to engage in the challenge to improve the experience of patients. I write these notes each week in an attempt to stay in those conversations. What is “awesome” is that through the magic of computers the conversation can include so many people. Conversations are often lost in memory, but now I can let the system search for an old idea that comes to mind as you will see later when I reference a Musing from 2015.
What follows is a chronological retelling of this last Wednesday when I had a rare day that was just like the old days. I was in Boston for a board meeting, and had the pleasure of three long face to face conversations with people I respect and from whom I have learned so much. All three are leaders and representative of the energy and intellect that I believe is available among us to improve what we do for patients, and for our communities and nation.
I could have just gone to the board meeting and driven back to New Hampshire, but was delighted to discover that the trip offered me the opportunity to connect with three old friends and former colleagues who are “interested readers.” Two were in town for a brief time and the other was generous enough to accept on very short notice my invitation to get together. Each one has a special expertise and has been a source of insight and a great partner in dialog about how practice and the organization of care might evolve toward the goals of the Triple Aim.
The first meeting was with Dr. Anita Ung. Anita was back in Boston from her new home in Illinois for a “spring break” vacation with her family. Anita and I began to have long conversations over coffee when she was practicing primary care at Harvard Vanguard and was the genius in our quality department who could make the numbers talk in ways that gave us insight into how to measurably improve the quality of our care. Anita can turn a spreadsheet into a fascinating story, and make it a source of energy and emotion that can launch programs that excite clinicians and benefit patients. She brings humor as well as perspective to the presentation of our triumphs and failures. She can bring a smile to your face, as well as ideas to your head, while proving that you may not be as good as you could be. That is a rare talent. Anita had contacted me after I had posted the piece on March 12, “The Persistent Problems of Rural America.” She was coming to Boston and wondered if we could get together while she was in town. Recently she has become concerned about the plight of rural communities, the quality and sustainability of our food sources, and the devastating realities of economic inequality. She wanted to know if I had read an article in The Guardian, “How the American Food giants swallowed the family farms.”
Talking with Anita always gets me thinking. Economic inequality is invariably associated with healthcare disparities and food deserts. We know that your health and your longevity are likely to be as much a function of your zip code as your genetic code, and that where you live is determined by the resources you have. We know that there is a socioeconomic gradient in health. The WHO reports:
The poorest of the poor, around the world, have the worst health. Within countries, the evidence shows that in general the lower an individual’s socioeconomic position the worse their health. There is a social gradient in health that runs from top to bottom of the socioeconomic spectrum. This is a global phenomenon, seen in low, middle and high income countries. The social gradient in health means that health inequities affect everyone.
Anita’s concerns for the rural poor and for the importance of access to good food for everyone are well founded. The fact that the socioeconomic gradient in health exists in all countries whether or not there is universal access to care does not mean that we should set universal access aside as an objective. It means that we need to focus on the issues that are creating an even wider economic gulf with greater disparities in outcomes within our country that is the wealthiest country in the world. The recent government shutdown revealed how close to the edge, and paycheck to paycheck, so many people in the middle class live. The Federal Reserve Board recent published that 40% of Americans can’t cover an unexpected $400 expense.
On a recent trip to Birmingham I forgot to bring an antibiotic that my dentist has prescribed for prn use when I have an episode of recurrent gum infection. I was in pain, and worried that things would get worse so I asked a relative who lives in the area and is a dentist if he would phone in a prescription to Walgreens for me. I decided that since the drug was generic I would just pay cash and not use my insurance card until I was told that the charge was $287. I quickly produced my Blue Cross card and had my prescription filled for $22. I am fortunate to have Federal Retirees Insurance as the spouse of a nurse practitioner who was a Federal Employee at a VA hospital, but I was in a “red state” where there are many hard working people who would have needed to turn around and walk out of the drug store without their prescription. Had I been a self employed family farmer who was already struggling with heavy debt, I would likely have soon been an edentulous elderly farmer. I have a diabetic relative who is comfortably retired but is justifiably upset when he is in the “donut hole” and is forced to pay over $400 for a month’s supply of Lantus Insulin. If forty percent of Americans can’t cover a $400 bill, how many are thrown into bankruptcy by unexpected medical expenses? How many would not have died or would not have required an expensive and debilitating hospitalization if they could have purchased, or better yet, been given, the prescription their doctor wrote? When the WHO wrote, “The social gradient in health means that health inequities affect everyone,” they were channeling John Donne who was a prescient healthcare futurist when he wrote in 1624:
No man is an island,
Entire of itself;
Every man is a piece of the continent,
A part of the main.
If a clod be washed away by the sea,
Europe is the less,
As well as if a promontory were:
As well as if a manor of thy friend’s
Or of thine own were.
Any man’s death diminishes me,
Because I am involved in mankind.
And therefore never send to know for whom the bell tolls;
It tolls for thee.
Anita Ung knows quality healthcare and what it takes to produce it. Her concern for our diets and for the plight of rural America are shared by many healthcare professionals who may not know what they might do to make a difference other than just continuing to do what they do and hope for a miracle. I am sure that most healthcare professionals who have personal experience with the poor and even with those struggling in the middle class share Anita’s concerns about economic inequality and its impact on health and the care that they are able to provide.
Some people have wondered if it might be possible that part of the epidemic of “burnout” that has hit healthcare professionals might be really better called “moral injury.” In 2015 I told the story of a dear friend and colleague whom I felt had experienced a “moral injury” that was derivative of the way PCPs can be poorly supported by the systems and hospitals that they depend upon. Systems issues feel beyond the reach of most busy clinicians. We must continue to work within systems that we know can fail us, and are frustrated, exhausted, and sometimes outraged by the barriers to the care that we want to provide that we encounter in the economy and in our institutions. We grieve when we see people harmed by broken and inadequate systems of care, or by their economic exclusion from care, or worse yet from illness and infirmity that is driven by their economic status even though they live in communities where many have more than they could ever need. As I drove away from my coffee with Anita, I was trying to get my head around all the things we had touched on in a little over an hour.
I headed down the Jamaica Way past the Brigham and all the new buildings that have sprung up since I last noticed. My trip took me past the Beth Israel Deaconess Medical Center which has recently merged with the Lahey Clinic while guaranteeing at least a billion dollars of savings over the next seven years. A little further on I drove by my old office at the Kenmore Center of Atrius Health near Fenway Park and thought about their creative new relationship with Blue Cross as I approached the Boston Common Garage. After parking, I enjoyed a brisk walk up Beacon Hill past the State House and Augustus Saint-Gaudin’s Memorial to the famous and heroic Massachusetts 54th, and then through Government Center to meet Chris Jedrey outside his law office on State Street. Chris is a long time friend and adviser. In my opinion he is the best healthcare lawyer in America, and I share that opinion with most everyone who has ever had the privilege to know him. Chris has a national practice and I am guessing that he has probably helped mold more of the important institutional changes in American healthcare than any other single individual. One of the few sacrifices that I made when I retired to New Hampshire was that I now have fewer long walks with Chris. Chris shares my passion for trying to pursue the Triple Aim through improving and transforming the performance of systems within established healthcare institutions. No one has a better understanding of good governance than Chris.
Chris has always told me when I was about to go over a cliff pursuing an unrealistic idea. It is great to have a friend and adviser who can gently and supportively say, “That may be right, but did you consider…?” Chris can ground me. He has “been to the theater.” He knows how the world works even if he would rather see it work in a new and more generous way.
As we walked, Chris and I reviewed recent events in the evolution of healthcare in Massachusetts. The big systems are still looking to improve the way they align with market opportunities. Massachusetts embodies a quote from William Gibson, a science fiction writer, that Zeev Neuwirth used in the introduction to his most recent “Creating The New Healthcare” podcast:
The future is already here. It just not widely distributed yet.
To the knowing eye the future of healthcare can be seen strewn in bits and pieces all across Massachusetts in its famous healthcare organizations, innovative start ups, huge biotech industry, and in the interface between its citizens and the state government in an import experiment, The Health Policy Commision that was designed to push Massachusetts toward the Triple Aim. Chris is a good guide that I can count on to help me join many pieces of the healthcare puzzle. Chris can do more than talk healthcare law and business. Chris can integrate healthcare with a philosophical nod to complex ideas because he also has the perspective of the Harvard College history professor that he was before he became a lawyer. A conversation with Chris is like setting your camera for a wide angle panoramic shot.
On our Wednesday walk I wanted to return once again to Chris’ perspective on the tensions between fee for service payment and the very slow movement toward value based reimbursement. What did he think of the current state of payment reform in Massachusetts? An almost five mile walk from State Street through the Commons and Public Garden and out Commonwealth Ave to the Fenway and back wasn’t enough time to catch up on all that had happened in our private lives as well as get his full perspective on the slow progress of payment reform, but like Anita, Chris got me thinking.
I have always questioned both the logic and the ethics of fee for service payment for healthcare. Dr. Robert Ebert and my observations of Kaiser have convinced me that the finance mechanisms that we call prepaid, capitated, or value based, have much more to offer than fee for service payment does for patients, the consumers of healthcare, and providers whether they be individual practitioners or systems of care with or without hospitals. I was very excited when “Romneycare” was rolled out in 2006 and a short time later the Massachusetts legislature passed a law that articulated the audacious goal that by 2013 all healthcare payments in Massachusetts would be through capitation. As a CEO, my number one objective was to have our organization prepared to accept risk contracts without compromising quality or safety. Indeed, I have always believed that fee for service payment would always be a much greater risk to quality and safety. It is possible to incrementally improve the quality and safety of fee for service systems just like you can teach a dog to walk on it hind legs, but as the saying goes, it is never pretty. It’s also not very efficient. I still believe that someday we will discard fee for service in favor of methods that focus payment on the resources that are required to deliver care for populations. Until that day it will be important to have the wisdom and council of people like Chris. Even when the day comes that fee for service is just a disturbing memory, we will still need the wisdom of healthcare professionals like Chris who can help us make good contracts, understand good governance, and aid our ability to merge organizations for greater efficiencies.
After walking Chris back to his office, I had just enough time to get to my board meeting. I love board meetings with the financial reports, compensation discussions, and the strategic planning involved with trying to make antiqauted systems as functional as possible until they collapse under the weight of their complexity and fatigue from resisting change. Large enterprises are more comfortable with the pain they know than with the gain they might experience when they embrace the possibility of a better future with change. The great business guru, Peter Drucker, preached that the biggest error we make is to hold onto failing systems through desperate attempts to find success by making cuts and shuffling programs and personnel rather than embracing the possibilities that thoughtful change offers. The behavioral economists have known since the seventies, and the wise ones among us through the ages have known even longer, that we fear loss more than we anticipate the pleasure of gain. I have a continuing struggle to hold my thoughts to myself in most board meetings, but I have finally learned that saying less well, and at the right time, has a better chance of achieving an objective. Patience and a “duty to care” are requirements for ethical participation on a board as well as in the practice of medicine. It is interesting and important to muse on whether or not burnout may precipitate “moral injury” by intermittently blunting the ability of providers to respond adequately to their “duty of care.” Could it be possible that poor systems induce fatigue that diminishes the ability to fulfill the “duty of care?” Could system induced exhaustion create the errors that generate the self loathing and despair that is often associated with burnout? If there is any possibility of truth in those musings, then many of the proposals to address burnout that are discussed at boards will fail because they do not address burnout as a systems issues.
My final stop for the day was for dinner with an old friend, John Gallagher, whom I met many years ago when Atrius Health hired Simpler Consulting to help us improve our delivery system using Lean as a tool and philosophy of continuous improvement. John was in town for a few days for business with a new client. Whenever his travels bring him to Boston, I try to get together with him. John was my management guru. He is a wise man with a wealth of practical knowledge and experience in improving systems. He is an engineer with the expertise of a psychiatrist. He is the master of the motivating question. John and his colleagues at Simpler convinced me of, and converted me to, the truth that is imbedded in Lean philosophy. To err is human. I know that we tolerate systems that err and injure, but I also know that we can always reduce the errors and diminish the number of injuries if we embrace a philosophy of continuous improvement. John and I always talk about the possibilities that change presents, and the barriers that must be understood and managed for it to occur. These days Simpler is part of IBM Watson and that presents John with the opportunity to participate in learning how to effectively integrate the possibilities of AI into healthcare using Lean tools and philosophy. IBM’s first run at applying Watson to healthcare was not a great success, perhaps because people who think like John were not part of the effort. IBM’s idea was to apply AI to the most complicated of medical problems when it may be best employed to give us relief from what house officers of my era called “scut work” or to the primary care office to free physicians from repetitive administrative tasks while giving them more concise information that is pertinent to the patients they are seeing.
I believe that AI will be part of our better future, just as value based reimbursement will eventually be the dominant form of healthcare payment. We also will eventually treat healthcare as an entitlement, ban automatic firearms as they are doing now in New Zealand, and maybe someday we will address the damage that economic inequity and global warming pose for all of us. I believe that we are making progress on all those fronts.
William Gibson is right. The future is here; it’s just not widely distributed. Well maybe the ideas and knowledge required for a better future are here; we just need to sell them to a wider audience. We have the knowledge to make great improvements that will benefit us all. The knowledge resides in thousands of people like Anita, Chris, and John. The assets are waiting to be assembled into innovative products and processes that will replace the ones that are failing us now.
After I left John and was driving back to New Hampshire, I remembered an article that I had seen earlier in the month in the New England Journal written by Kevin Schulman, M.D., and Barak Richman, J.D.,Ph.D. entitled “Toward an Effective Innovation Agenda.” I reviewed the paper after my journey was over. Their paper eloquently asks some of the same questions that John and I had considered over dinner:
Why, then, have investments in digital technologies largely failed to lead to meaningful improvements along the axes of health care’s “quadruple aim” — enhancing patient experience, improving population health, reducing costs, and improving the lives of health care professionals? And why have well-intended efforts to adopt digital technologies had so little systemic impact as compared with those in other industries?
Those are rhetorical questions that they are quick to answer a few sentences later:
One reason for this failure is that too often, the health sector neglects one of the essential elements of successful innovation, in both the technology sector and the broader economy: a disciplined approach to meeting consumers’ needs.
For greater clarity they refer to Clay Christensen’s concepts of customer orientation. They say:
The innovation scholar Clayton Christensen has formalized this idea, recommending that organizations aiming to bring novel solutions to market focus on “the job to be done.” He suggests homing in on “the progress that the customer is trying to make in a given circumstance — what the customer hopes to accomplish.”
They remind us that we look at the problems from our point of view. You have heard it before. Where is the patient? In a subtle way it delivers a message to entrepreneurs like those at IBM Watson who see health systems and the public as their customers when in fact their effectiveness depends on meeting the needs of a potential customer that they frequently forget, the struggling clinician who is on the verge of burnout. They continue on with their analysis that focuses on the failure of policy makers and institutions fail to consider the real needs of the end user of healthcare services and how those needs may require creative thinking rather than plodding along the well known pathways of the status quo.
Most policy approaches start with crystallized ideas of how physicians and hospitals ought to be organized and ask how existing resources might be deployed. For instance, most policymakers conflate inadequate access to primary care with a shortage of primary care physicians, even though training more physicians and nudging them toward careers in primary care is an enormously expensive solution. Expanding the availability of primary care services — the job that needs to be done — could instead involve new workforce models (for example, featuring allied health professionals such as nurses or physician assistants), new service models (for example, encouraging use of telemedicine for care and behavioral guidance), and new policy approaches (such as amending scope-of-practice laws and licensure limitations that might limit the realization of this approach).If policymakers focus on the job that needs to be done, they would open their minds to exploring these innovative solutions.
I admit that as a leader my focus was often on how to use what we already owned or understood which was self serving, rather than to look for solutions that were a better fit for the patients and a required invention that was associated with the “creative destruction” of an asset that we were invested in preserving. The authors explain:
Examining the services needed by the patient, rather than the available delivery-system resources, would lead to exploration of ways of delivering those services most efficiently and effectively.
Their summary is consistent with much of what my friends and I had discussed during the day and leaves me musing about how we will promote the change in approach and the changes in attitude necessary to apply their wisdom. The authors envision an ongoing struggle between the status quo and the world of new opportunity offered by innovation.
A transition to a services model will be difficult for leaders of our existing health care organizations. It will engender conflict between organizations operating under legacy business models and the new, more efficient services organizations that will emerge. But innovation as a reform agenda can only truly succeed when it forces change in business models and practices throughout the health care system.
In the end, I conclude that there will be much to discuss the next time I gather with old friends for coffee, a long walk, or a great dinner. I can hardly wait.
Another Friend. It’s Trying To Be Spring, Sort Of, And It Is Maple Syrup Weekend.
Today’s header once again features my friend, Lightning. What happened to his brother Thunder is a mystery to me. Lightning always looks cold, bored, and lonely standing in his snowy pasture. I decided to take an apple with me on my walk yesterday to give him. When I arrived at his place he was on the other side of the pasture about a hundred yards away. I waved my arms and flashed the apple. He got the message and I got a nice picture of him as he trotted through the melting snow to get his treat. He is a big fellow with very big teeth in his huge head which made me a little apprehensive about delivering my gift because I am not an experienced presenter of apples, but together we got the job done.
Last night the snow returned and it is continuing with a little intensity even as I finish up this missive to you. It will give us a fresh coat of white to cover the now dirty, sooty snow of last week. At the end of the storm there may be a little rain and wind to mess it up and to insure that there will be muck to traverse as we travel around to the sugar shacks that will be open for visitors this weekend. Just click here for the details on New Hampshire Maple Weekend. How sweet it is! Come on by and see for yourself.
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
