25 October 2019

Dear Interested Readers,

 

Pondering What the Future Might Hold

 

My last letter to my colleagues at Atrius Health was published on October 25, 2013. In that letter I reviewed what I thought some of the challenges of the future would be. In a letter written on September 20, 2013, I had announced my retirement. In that letter of announcement I had talked about the view from Mount Pisgah. Then, as now, I felt that I needed to explain my metaphor for looking into a future where one’s role is uncertain. I mentioned to my readers that there are many Mount Pisgahs around the country, including one modest hill in central Massachusetts, where on a clear day you can see all the way to Boston, or as I implied, all of Atrius Land. 

 

I assume that the reason for the abundance of Mount Pisgahs around the country is that early settlers were very familiar with scripture. For those of you who are not familiar with the Hebrew scriptures, the surprise at the end of the story about Moses’ leadership during the forty years of wandering in the Sinai is that he never got to the Promised Land. Why God did not allow Moses to go to the Promised Land seems to be a matter of some theological relevance. I was always told that it was because in a moment of frustration and anger he had disobeyed God. Perhaps, it was just time for a new generation of leadership. It is possible that some of our older candidates for the Democratic nomination for president should consider the reality that although age offers some perspective, it is also associated with substantial age related uncertainty. There is much that can happen to a septuagenarian over a four year horizon that might make an older “player” a better advisor than leader. As Cindy Boren wrote in the Washington Post this week, we all, including Tom Brady, need to be able to envision a future where our part changes.

 

God did allow Moses to climb Mount Pisgah where he was able to see the beauty of what was to come. The story is the last chapter of Deuteronomy, the fifth book of what is called the Pentateuch, the first five books of the Bible, often referred to as the Torah. Traditionally, Moses is considered to be the author which was always another point that confused me as a child since the story goes beyond his death that occurred despite what seemed to be his good health. I wondered who wrote the last chapter? Here is the King James version of the story.

 

“And Moses went up from the plains of Moab unto the mountain of Nebo, to the top of Pisgah, that is over against Jericho. And the Lord shewed him all the land of Gilead, unto Dan, And all Naphtali, and the land of Ephraim, and Manasseh, and all the land of Judah, unto the utmost sea, And the south, and the plain of the valley of Jericho, the city of palm trees, unto Zoar. And the Lord said unto him, This is the land which I sware unto Abraham, unto Isaac, and unto Jacob, saying, I will give it unto thy seed: I have caused thee to see it with thine eyes, but thou shalt not go over thither. So Moses the servant of the Lord died there in the land of Moab, according to the word of the Lord. And he buried him in a valley in the land of Moab, over against Beth–peor: but no man knoweth of his sepulchre unto this day. And Moses was an hundred and twenty years old when he died: his eye was not dim, nor his natural force abated.”

‭‭Deuteronomy‬ ‭34:1-7‬ ‭KJV‬‬

 

I have had a better outcome than Moses. He died. I have enjoyed six years of rewarding retirement and I am looking forward to many more. I get to look back at what I thought was going to happen, and simultaneously look around to see what actually did happen over the last six years. Six years ago as I tried to imagine what would be true about the future, I wrote:

 

One of my favorite subjects in junior high school was plane geometry. I liked it because you could solve problems with principles or axioms. The axioms were statements of truth that had been proven. There was then a logic to how you used what was known to be true to answer questions and solve problems. The ten concerns for the future that I identified last week are problems that will need to be solved by all of us in healthcare… We are connected and we draw from the same resources of finance, from the same pharmaceutical and medical device industry, and from the same system for healthcare education. A few of the “predictions” on the list are likely to be inevitable outcomes of processes that will be difficult to change. The workforce shortages of the future are an example of that category. Every problem on the list is hard to think about without some orienting “axioms” to assist us. The problems are much less daunting if they are approached with a set of principles and a few tools.

 

As a reminder, here is the summary of the ten problems I described last week:

 

• We need to get to universal coverage or an unhealthy population will cause greater problems in our economy.

 

• We need a better financing mechanism, probably some form of global payment.

 

•  We need to promote transparency and cost control at the national level

 

•  There will be a rationalization of compensation between the various clinical disciplines.

 

•  Inadequate numbers of professional staff to populate current models of care will cause new roles to be conceptualized and old roles to be redesigned.

 

•  Primary Care as currently practiced will be challenged by disruptive innovators in lower cost environments.

 

•  Behavioral Health, social services, geriatric medicine, survivorship programs in oncology, musculoskeletal medicine, and physical/occupational therapy all will become increasingly important parts of the ambulatory practice.

 

•  Hospitals will become smaller as more of the chronic disease complications are managed either in ambulatory environment or in the home.

 

•  Those that pay for the care will control the conversation and provider organizations will receive less reimbursement.

 

•  Eventually regulators will approve new affiliations and mergers only for higher quality more efficient care that uses resources more wisely.

 

As I review the list through the lens of the intervening six years, it still seems pretty good. Some of the things have happened. Some of the things are in process. Some of the things may still occur. I would phrase some of the predictions differently, but none of them were far off target. The biggest takeaway is that things have just moved more slowly than I had imagined they would evolve. Who would have predicted in 2013 that Donald Trump would be president in 2019?

 

In an attempt to discuss how to try to focus on what might happen, I suggested what I thought might aid predictions. I wrote:

 

So where do we find the axioms and the tools to fix these problems and others that you might add? Dr. Ebert’s wisdom, the Institute of Medicine’s six domains of quality, and the triple aim rise to the level of axioms for me. Lean and other forms of continuous improvement are a combination of axioms and tools. Other important tools are our data capabilities, human resources capabilities, project management skills, understanding of traditional and behavioral economics, and finance and contracting skills.

 

I often hear people approach difficult problems by saying that they must “think out of the box”. This competency within an organization is very important and clearly is required for creative solutions to complex problems and for true innovation. For me, thinking out of the box means not being trapped by conventional thinking like “the world is flat and has an edge from which you can fall”. A flat world concept makes it difficult to venture far from sight of land. The “world is round like a ball” opens up possibilities and frees you from the fear of falling off the edge of the world. Discovering how the current organization of practice and our current practice rules are limited by conventional wisdom may create new degrees of freedom for creative solutions to vexing problems. Physician compensation and concepts of productivity, the role of the physician on the clinical team, and the optimal relationship between the ambulatory practice and hospitals are all areas where conventional thinking may need to be replaced by new wisdom if our intent is to manage the future for the benefit of our patients and the survival of our mission.

 

If you are a regular reader of these notes you will not be surprised that I continued describing my “tool bag” for preparing for the future with a reference to Dr. Robert Ebert.

 

If I could ask you to remember one thing to consider as you approach your problems in the future, it would be to go back again and again to the work and thoughts of Dr. Robert Ebert. In many of my letters the pivotal idea has been Dr. Ebert’s core philosophy expressed by 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.”

 

It seems only right for me to offer Dr. Ebert’s profound statement …to use as an axiom and strategic tool in imagining solutions for a future that will be a continuing challenge to every individual who works in healthcare and to every organization in the healthcare industry. The issues will be challenging for large well­ capitalized organizations with large amounts of fixed overhead and for small financially vulnerable practices in need of capital. The challenges of our common future are problems that are like global warming and air pollution. Everyone is vulnerable not only to their own decisions, but also to the decisions of others. No single institution, no matter how well positioned by the metrics of conventional wisdom, can be certain that what they think is an asset today will not be a liability tomorrow…

 

Dr. Ebert’s statement is most useful because his description of the problem remains accurate today. Furthermore, his sense that understanding the misconceptions we have from our common wisdom about which assets will be valuable is a huge advantage to those who listen. Finally he describes what will constitute a good starting place for a solution. What is surprising is that no one has yet used his description effectively even though in 2001 the landmark book from the IOM, Crossing the Quality Chasm, expanded his cryptic formula and put real meat on the outline that he had provided.

 

In the letter I went on to emphasize the description of an optimal system of care as presented in Crossing the Quality Chasm that incorporated the spirit of Dr. Ebert’s thinking. I then tried to connect it all to the Triple Aim:

 

…The six domains of quality from  the IOM are profound in their wisdom and a simple description of a destination for healthcare. Care that is equitable, patient centered, safe, timely, efficient and effective is the goal. In 2007 Nolan and others at IHI reasoned that care that met the Crossing The Quality Chasm definition would be care that would improve the health of individuals, the health of the community, and would be economically sustainable. Crossing The Quality Chasm also gave us ten descriptors of an effective system. They advised that an innovative system should be sure to include the following attributes:

 

 

•  Care based on continuous healing relationships: Care should be given in many forms, not just in face to face encounters. The system should be responsive 24 hours a day.

•  Customization based on patient’s needs and values.

•  The patient as the source of control. Encourage shared decision making.

•  Shared knowledge and the free flow of information: Unfettered access to medical records with effective communication between patients and clinicians

•  Evidence based decision making. Practice should not vary illogically from clinician to clinician.

•  Safety as a system property.

•  The need for transparency.

•  Anticipation of need. [For me this is an exciting challenge. We say that we practice “preventative medicine”. Is that the same as “anticipatory medicine”?]

•  Continuous decrease in waste. [Compliance with minimal standards of accreditation in the future will require demonstration of some form of continuous improvement as an active and effective process. It will not be enough for an organization to say that it does Lean or Six Sigma; demonstration of effective waste reduction will be necessary for accreditation as well as financial viability.]

•  Cooperation among clinicians. [“I to we” within practices, across practices, across systems and throughout the community.]

 

I must admit that I am frustrated because the current political discussions about the future of healthcare seem to ignore all of the considerations about how to provide better care for everyone at a sustainable cost.  When you hear that one solution to the effort to provide universal coverage will add a trillion dollars of expense over the next ten years or that another one will add 30 trillion, you can rest assured that the numbers do not include any concepts of the re engineering of care toward improved quality at a lower cost.  The Commonwealth Fund has recently published an in depth cost, coverage, and benefit analysis of eight political options that range from tweaking the ACA to fully adopting Bernie Sanders’ vision of Medicare for all which is really “Medicare plus a lot more care for all.” His program includes enhanced benefits and no charges at the point of service. It also includes long term care. You should at least peruse the Commonwealth Fund report because it tells you what the politicians may not understand. What ultimately happens will be determined by whether or not the anger and frustration of our patients over their increasing costs and diminishing satisfaction with our poor population outcomes results in the election of a new leadership that is willing to confront the resistance of the status quo.

 

I was reminded this week of the “resistance of the status quo”  when I had a conversation with an “interested reader” and former colleague. She is one of the many talented leaders who have “graduated” over the years from a formative experience at Harvard Community Health Plan, Harvard Pilgrim, Harvard Vanguard or Atrius Health, and gone on to assume a leadership position in another organization where the principles learned in Dr. Ebert’s practice can be applied. Her “graduation” occured about fifteen years ago, long before I was the CEO, but we have stayed in touch. She has taken the values that she learned at Harvard Vanguard to her subsequent experiences. She reported that she was at a recent national meeting of ACO leaders. She could feel the collective fatigue associated with the struggle to promote ACO principles and value based reimbursement. Her observation underlines for me just how difficult the road ahead will be. 

 

I once had a colleague who liked to use an inappropriate metaphor for the road to our local success and the Triple Aim. He would talk about the “glide path” to success. More than once I interrupted him to argue that the path forward would be more like climbing the face of “El Capitan” than something as simple and effortless as “gliding.” The recent attempts by Massachusetts to move all of its Medicaid clients into ACOs underlines not only the potential of the concept, but also the challenge of getting clinicians and institutions to understand and accept the concepts of population health upon which successful ACO practices are established. I am encouraged by the fact that the “rock climbing” skills my former colleague has developed in her efforts to establish the principles of ACO practice have made her capable of managing toward the objectives of the Triple Aim in any future environment. I am encouraged that there are other leaders who remain committed to the effort, no matter how long it takes, to make the Triple Aim a reality. 

 

At the end of that last letter to the Atrius practice I tried to identify the characteristics that would be required, if they were to achieve Triple Aim success for their patients, their communities, and their institutions. I wrote:

 

The axiomatic statements of Dr. Ebert, the IOM, and IHI are necessary as is a deep commitment to mission. Additionally, successful healthcare organizations will also need continued progress toward a broader spread of new attitudes and competencies if we are to be successful. Since I am thinking in lists of ten, here is my list of the new attitudes and competencies that organizations will need:

 

•  Leadership from motivated individuals in every part of the organization.

 

•  A culture of teamwork and respect that weathers internal controversy while working through the tough issues.

 

•  A culture of service that is deeply rooted in mission and functions as a natural reflex.

 

•  Widespread competency in a methodology for continuous improvement and innovation like Lean that becomes a basic business system and a common language.

 

•  Data literacy that empowers everyone ­ Just as there was a time when few could read, we now live in an emerging time when only a part of the practice understands the importance of measurement and is facile in the use of data for improvement.

 

•  Courage and commitment to the task that can endure short term failures and market surprises.

 

•  The ability to avoid the traps of conventional thinking in the search for solution.

 

•  The ability to put the interest of patients, the community, and the practice ahead of personal interest.

 

•  The ability to learn together through experience and reflection and to accept the discoveries of others who are trustworthy as sufficient for the adoption of a better practice, and,

 

•  The ability to sell the importance to our business partners of the necessity of collaborating along the objectives of the Triple Aim if indeed they are to be our partners.

 

As I reread that last letter to the Atrius practice that I wrote six years ago, I find that the challenges have remained the same. I am not surprised, since the challenges have not changed much in the last fifty plus years since Dr. Ebert began his search for solutions to the existing deficiencies in health care. I am pleased to think that over the last decade, since we began the legislative process that resulted in the ACA, we have made measurable progress. We know much more now about what it will take to deliver the Triple Aim for our nation. I sensed six years ago, and believe even more now, that most of the major barriers to success are within the control of our medical institutions, and that our professionals, and our industry, could deliver what the nation needs, if there was a widespread acceptance among medical professionals of the need to lead change. What is encouraging, is that we have made some progress in our “rock climbing” efforts.  We know now much more about what it will take to be successful. We are making progress very slowly, but there is measurable progress. The question I keep asking myself is why we can’t accept the professional responsibility to move faster when there are so many people who suffer everyday as we continue to try to find an easy way to do what it will take hard work and commitment to accomplish. 

 

Checking Out The View From Mount Moosilauke

 

We have had a wonderful fall. Today’s header is just another reminder from the drone videos of my neighbor of just how beautiful it has been. What is amazing is that when he flies low the scene looks just like what one would see on a walk in the woods. I was drawn to today’s image because of the light. 

 

With some luck, about the time this letter reaches your in box, I will be finishing the last leg of a 7 plus mile loop to the top of Mount Moosilauke and back. I mentioned, back in the summer, that Tom Congoran, the equally retired former Atrius and Harvard Vanguard CFO, and I were hiking up mountains near our homes here in New Hampshire. Our ultimate goal is to “do” all of the 48 mountains in New Hampshire that are over 4000 feet. So far we have been “training” under the guidance of a younger friend on some of the “shorter” New Hampshire mountains from the list called “52 with a view.” We have been planning for some time to make Moosilauke our first “4000” footer. I hope that we will have a view of the fading colors of fall, but most of all I hope my knees are up to the challenge. We’ve had some pretty nice weather this week. It’s been a bonus that I hope will continue through the weekend for me and for you. 

 

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