23 August 2019

Dear Interested Readers,

 

Let’s Not Forget The Triple Aim As We Debate The Future of Healthcare

 

I am not really complaining, but I have been waiting for a very long time. Living in expectation on the cusp of a better future is not easy. Let me explain. I graduated from high school at the end of May in 1963. John Kennedy was our president. Change and the possibility of a better world for everyone seemed just around the corner. Martin Luther King, Jr. inspired me in August with his “I Have a Dream Speech.” I reported for football practice and college a few weeks later. My university admitted its first African American students that fall, and then on a bright November day, as I was headed to my favorite class, American Literature, taught by Jack Russell, the most popular professor on campus, the son of basketball Hall of Famer and first coach of the Boston Celtics, “Honey” Russell, I heard stupid voices chuckling something about the president getting what he deserved. It made no sense until I got to class where Professor Russell told us to go away, the president was dead and he could not teach through his tears. 

 

I was not excited about LBJ. He seemed like a shadowy figure, and I had lived in Texas recently enough to know that he walked a fine line between proprietary and purpose, but then good things began to happen. The Civil Rights Act of 1964 and the War on Poverty were surprises I had never expected after Kennedy’s death. 1965 was even better as Medicare and Medicaid were signed at the end of July, followed by the Voting Rights Act in the first week of August. Then came Vietnam and in 1968 the assassination of Dr. King and Bobby Kennedy. The momentum of the War on Poverty was lost in the endless struggles over Vietnam and the foolishness of Watergate. The years when I was in medical school, residency, and my cardiology fellowship were noteworthy for their music, the protests against the war, and the sense of continuing struggle for a better world. I didn’t make it to Woodstock, and I never lined up in a protest that was dispersed by the National Guard, but I did see soldiers and police in riot gear in Harvard Square, and I marched with other medical students and our Dean from the “Quadrangle” of the Medical School on Longwood Avenue to Harvard Stadium on the Charles River in Brighton to join the protest over the reaction to the moment, and the injustices that had precipitated the confrontation.

 

Nixon was a complicated guy. His legacy included Kent State, Watergate and the continued bombing of Cambodia, but he also gave us the EPA, opened China, and the HMO Act was passed in 1973, and he signed it. I joined Harvard Community Health Plan in 1975 feeling like I was signing on to the leading edge of a transformative movement in healthcare. My biggest challenge was explaining to my relatives back home when I would visit why I was not coming home to “hang up a shingle.” I gave up trying to explain that the traditional practice of medicine was in its last few minutes of existence, and that I had no interest in sending out bills for services rendered, nor could I tell them that I had no desire to live in a community that was still oppressing half of its population. I did not have enough experience with the power of the “status quo” to know that those last few minutes would be much longer than the forty years that Moses and the Children of Israel would wander in the Sinai on their way to the “Promised Line.” 

 

I should have paid more attention to The Grateful Dead. In 1977 the Dead summed up, or in a way prophesied, how I would retrospectively view my experience on “the cusp of change in healthcare.” From the vantage point of 2019, as I look back over the more the half century between my enthusiasm for a new day in healthcare and the cacophony and confusion of the current conversation, I must admit that those guys nailed it when they recorded “Truckin” with its famous line:

 

Lately it occurs to me

What a long strange trip it’s been.

 

There were some great high points between the disappointments, and/or learning experiences of those years living in expectation. What has happened is that we have developed a language and set of concepts that we did not have in the late sixties, the mid seventies, or even through the disappointing failure of the Clintons in the nineties. Things were really looking up with the establishment of the IHI in the early nineties. Ideas began to come together in a new way with the publication of To Err Is Human:Building A Safer Health System in 1999. In 2001 when Crossing the Quality Chasm: A New Health System For the Twenty First Century was published by the IOM, we all learned that true quality for the individual is care that is patient centered, safe, equitable, timely, efficient, and effective. The definition made a lot of sense to me, as did the entire effort to bring quality and safety to our practices. 

 

Things got even better five years later when Massachusetts supported the concept that healthcare is a human right by passing “Romneycare” that gave access to care to virtually every citizen of our state. The passage was brave because it was fueled by the hope was that it would enable a lower “cost of care” without compromising quality or safety. I was delighted to participate on the Cost and Quality Advisory Council and other conversations between the community of practice and the state. Over the next few years our legislature passed a series of laws that led me to believe that we would be moving quickly to value based reimbursement, and I welcomed that prospect because through all my years in an organization that accepted risk I was convinced that capitation was the finance mechanism that best supported the objectives of the quality and safety movement, and the concepts of better care articulated in Crossing the Quality Chasm. 

 

I applauded all of the thoughtful process that President Obama used in 2009 to pass the ACA in 2010. The compromises were disappointing. I was angry when Joe Lieberman was able to block the Public Option.  I bit my nails as Scott Brown’s election to Ted Kennedy’s seat threatened to prevent the bill from crossing the goal line. Every roadblock thrown in the way of its success from President Obama’s ill advised comment that “You can keep your plan if you like it,” through the disastrous roll out of the exchanges, to the Supreme Court challenge in 2012, were moments of trauma for me, and preparation for the suffering that I would experience after Trump came to office, and the moment of profound relief I would experience when John McCain turned his thumb down. 

 

Yes, it has been a long strange trip. There have been a few moments of elation, and many episodes of inspiration woven between the persistence of frustration from our continuing inability to organize the supermajority necessary to deliver what I thought was imminent in 1975. What do we have to show for our efforts and the traumas we have experienced? 

 

I think we have learned that the ACA was an effective next step on a long process of reform. A majority of Americans do believe now that healthcare is a human right, and that every American should have the right to expect quality care, although there is a wealth of data to prove that those ideas are just unrealized concepts and not yet realities. Even after the ACA African Americans and Latinx Americans are still waiting for equity in access and effectiveness of care.

 

We are now at a strange juncture on our journey. The Republican leadership is passively complicit in efforts to erase what is left of the ACA as the Trump administration has backed the effort in the courts to throw out all we have accomplished and learned. While the Republicans have been looking to the courts, the future of healthcare reform has been put into jeopardy by a Democratic debate over issues of tactics that obscures principles and has gotten in the way of progress, while it threatens the first step in a winning strategic process, which is to regain the presidency.

 

You might be wondering why in my review of the last fifty years of effort to bring about universal coverage and meaningful healthcare reform I did not mention the Triple Aim. It is my opinion that the Triple Aim is the organizing principle that must be the framework of any vision that will allow us to carry the concept that “healthcare is a human right,” and should be an entitlement of every American, beyond a slogan to the reality that has been the focus of my expectation for over fifty years of working, wanting, hoping, and waiting .

 

In my timeline I purposely omitted the Triple Aim which emerged in 2007. That was when John Whittington and Tom Nolan, who were working as the IHI, brought their idea that would become the Triple Aim to Don Berwick. That is the way Don tells it in a video of less than three minutes that is worth a click from you.  Has the concept of searching for operational systems and finance mechanisms that improve the experience of the individual and improves the health of the community at a sustainable cost ceased to be our goal? This week I’ve been to the websites of Joe Biden, Bernie Sanders, Elizabeth Warren, Kamala Harris, and Mayor Pete (I could not find his last name on his website other than on the outside of his logo) Buttigieg. There is a lot of rhetoric about how bad healthcare is, but except for the ten year transition plan Harris suggests to migrate us to Medicare For All, there is little substance to prove that they really understand the history of why change has been so hard or the potential complexity of the process of getting anything passed after they are elected. I have heard very little about how the cost of care compromises improving education, repairing our crumbling infrastructure, or combating the climate threats to our environment.

 

I am upset with the thin debate of tactics, and long for a discussion of the principles of the Triple Aim. We now have a multitiered tiered system of care along dimensions of race, location, and coverage benefits. Outcomes are more  a functions of luck and privilege than the product of thoughtful design and practice. If we are to judge the technical understanding our politicians have of the challenges that we face in improving healthcare by their rhetoric, we are in trouble. I want to think that they know more than their conversation reveals. A reference to the Triple Aim would provide some reassurance that they understand the problems in a way that might foster lasting resolution. If we look to our community of practice, our expectations are further diminished.  We do not see evidence that practicing clinicians are any more involved in the future success of the Triple Aim as a national goal than they are engaged in securing the success of the Triple Aim within their own organizations. 

 

Has the Triple Aim become a cliche? Have we learned to repeat the six domains of quality and the Triple Aim like some piece of religious dogma that we can chant without ever living out its meaning? The IHI has been concerned for a while that the Triple Aim has lost some of it meaning, or that it has been misused. Things have not changed much since they wrote in 2014:

When IHI first developed the Triple Aim framework in 2007, the idea of trying to improve the patient care experience, improve the health of a population, and reduce per capita health care costs at the same time was considered somewhat radical. It took years for such an ambitious concept, and the words used to describe it, to enter the health care mainstream. Fast forward to 2014 and type the words “Triple Aim” into a Google search, and you’ll get 32,100,000 results.

The words Triple Aim, however, and the terms that are part of its lexicon, are often misused. We recently offered practical guidance on how to make sense of and use population-focused terminology. 

 

The piece was written by Ninon Lewis who goes on to say:

 

 

About five years ago Tom Bodenheimer and Christine Sinsky, who were concerned about burnout and the destructive apathy that it engenders for clinicians and the risk that it poses for patients, suggested that we up the concept of the Triple Aim to the Quadruple Aim. The abstract of their article sums it up:

 

The Triple Aim—enhancing patient experience, improving population health, and reducing costs—is widely accepted as a compass to optimize health system performance. Yet physicians and other members of the health care workforce report widespread burnout and dissatisfaction. Burnout is associated with lower patient satisfaction, reduced health outcomes, and it may increase costs. Burnout thus imperils the Triple Aim. This article recommends that the Triple Aim be expanded to a Quadruple Aim, adding the goal of improving the work life of health care providers, including clinicians and staff.

 

I sympathize with their concern about the consequences of burnout both for healthcare professionals and patients. When organizations adopt the Triple Aim as their internal strategic objective then the Quadruple Aim is a laudable objective. It is my opinion that the greatest utility of the Triple Aim at this time is as a template for future legislation, as it was a template at some level for the ACA. The ACA did not succeed in achieving the Triple Aim, but it was meant to advance all three of it objectives, and an objective analysis would show that the ACA did provide legislative support to each of the Triple Aim objectives. 

 

We will never achieve improved health of the population without addressing the issues of the social determinants of health. Two of the greatest obstacles to the improvement of the social determinants of health are the growing federal deficits that have been substantially fueled by the president’s trade policies, woefully inadequate administrative attention, his misdirected tax cuts, and the continuing increases in costs of healthcare. We learned this week that we are on schedule to experience annual deficits of over a trillion dollars a year every year for the next ten years. Whether or not that happens, we can accept the fact that our dominant methods of practice, as well as our current Fee For Service finance system are antithetical to the success of the cost per capita leg of the Triple Aim.

 

I strongly believe that the voices of practicing physicians, nurses, and other healthcare personnel are needed in the cost discussions at the practice level, at the state level, and at the national level. There are decisions to be made. Those decisions must be bipartisan, and the result of a process of collective political discernment, and not an exercise in political power that will be impossible until one party holds the presidency and large majorities in both houses of Congress. In our dual roles as providers and citizens with expertise in the issues that threaten the health of our individual patients and the future of the nation, we have a professional responsibility to be truly patient centered and nation centered. We should put the needs of the people who seek help from us, and who live in the communities where we live and practice before our own personal concerns. Bringing forth the objectives of the Triple Aim will take leadership, energy and passion from us, as well as from some insightful politician who demonstrates an understanding of its principles and the leadership skills to move the Triple Aim forward. I wish that at the next debate some journalist would ask the straight forward question, “Could you explain how your thinking about the future of healthcare is aligned with the Triple Aim?” Meanwhile, it is our professional responsibility to offer our expertise in any effort that could improve the experience of care for our patients, improve the health of the nation, and lower the per capita cost of care to a sustainable expense that does not preclude progress on other shared concerns. I am still waiting for what the naiveté of my youth led me to believe was about to happen fifty years ago.   

 

Summer Sunrises, Catch Them When You Can!

 

Over the past few years I’ve tried to capture pictures to share with you from around my home, or from other places that I have seen in my travels. The large majority of the pictures are about the beauty of the physical world. A few have captured wildlife, and fewer still have shown people, although it is a given that my intent is to draw people, usually you, into the place or the experience of the picture. My methodology then includes a recommendation or a challenge for you to find such a place near you. I usually suggest that you take advantage of the outdoor opportunities that the picture suggests await you and a friend. 

 

I should confess that almost all of the pictures that I have used were taken in the afternoon or evening. I am retired, and revel in the opportunity to sleep as many hours past five thirty or six as I want to as repayment for the thousands of times over the last fifty plus years when I had to rise at five thirty or six, sometimes even earlier, to fulfill my professional and parental responsibilities. Now I am a night owl. I am usually up long after midnight reading or absorbing the wisdom of Stephen Colbert. Is it a surprise that I stay in bed until at least nine, unless there is a compelling reason to rise earlier? What you see in the header today is not a sunset. I have shown you many sunsets. It is a summer sunrise taken on the morning of July 4th. 

 

I had no reason to wake up early on July 4th. For some reason I just woke up at around five fifteen and before going back to sleep decided to step out onto the deck to check out the red sky that I could see through my east facing bedroom window. What I saw demanded a response. After watching the leading edge of the sun as it appeared over the horizon, I grabbed my iPhone and tried to capture the moment. I’ve tried to catch the sunrise a few times since then and have come to realize that just like sunsets, rainbows, and new moons coming over the mountain, every sunrise is a little different and you don’t get something spectacular with every attempt.

 

I am lucky to have an unobstructed view of the eastern horizon, but even that is not enough to guarantee a return on the investment of rising early to see what can be seen. On many mornings there is light, but heavy clouds obscure the sun. Some mornings are shrouded in fog from the lake. In my opinion the best sunrises are ones where you can see the sun make its progress as it rises above the hills, and there are just a few clouds on the horizon to reflect those first sunbeams.

 

I am looking forward to my continuing study of sunrises. In Boston, even though I was up early, I rarely saw a sunrise because buildings, trees, overcast skies, and other obstructions robbed me of the joy that is now easily available to me on many mornings. I am looking forward to my continuing study of sunrises as the season turns to fall and then winter. I hope that you will have your own opportunity to catch a sunrise this weekend. 

 

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