28 September 2018
Dear Interested Readers,
This Week’s News Makes Me Think of Berwick’s Era Three in Medicine
It has been an unusual week in the news. One advantage of being retired is that you can listen in real time to some pretty bizarre things and form your own opinions about what is being said and done. I have doubled that advantage this week by being on a long car excursion in Oregon and California where I had little to do but look at the scenery and spin the dial on the radio looking to satisfy my craving to keep up with current events. I am a news junkie.
I wish that I could say that my confidence in our public processes has been increased by the time I have invested this week listening to testimonies and press conferences plus endless NPR commentary. I have heard all of the known mechanism of deflection and refusal to answer a yes or no question while continuing to talk in the attempt to avoid answering uncomfortable inquiries. The sort of processes that I tuned into were pretty reminiscent of dances with the truth that go back at least as far as the Senate McCarthy hearings of the ‘50s. I was reminded of that low point in American history by a reference to those hearings coming from Senator John Cornyn of Texas, a Republican member of the Senate Judiciary Committee who was two years old when those hearings were held. The senator complained that the Democrats had descended to the level “of no sense of decency” in their behavior during the hearings for Judge Kavanaugh’s nomination to the Supreme Court. The reference was to the question that Boston lawyer Joseph Welch directed at Senator McCarthy. With those words Welch reinstituted norms that McCarthy consistently violated. It was the beginning of the end for McCarthy.
The performances of Lindsey Graham and Chuck Grassley reminded me much more of the performances of the all male members of the Judicial Committee during the Anita Hill/ Clarence Thomas version of the “she said, he said” back and forth from 27 years ago than they did of the McCarthy hearings. I listened to the CSpan rebroadcast of Anita Hill’s testimony to the Judicial Committee back in 1991 on Wednesday night just to get into the mood for the committee’s treatment of Dr. Christine Blasey Ford. The strategy of the Republican committee members this time was to hire a woman who is a prosecutor of sex crimes to do their job. The optics seemed to backfire. It is depressing to realize that the outcome will probably have little to do with either facts or believability. It will probably be all about who holds the cards. If your plan is to control the future with a minority, you must be willing to play hardball.
As I have listened to the Kavanaugh hearings, I have heard nothing about healthcare in the testimonies regarding Judge Kavanaugh’s worthiness to join the Supreme Court for a term that could run longer than my life expectancy. There is no doubt in my mind that if confirmed he will be a decisive vote in the resolution of some of the core questions that will determine the future of healthcare. During the election of 2016 Donald Trump promised his base that he would give them a court that would reverse many of the laws pertaining to healthcare, social justice, the right of all people to have a range of choices that are not diminished by their sexual orientation, improvement of the social safety net, and the right that women have to make reproductive choices. The list of desired reversals is longer, but that is good enough for starters. The “progressive” outcomes that enrage the conservative minority that elected the president were debated for decades before being settled through a combination of legislation and judicial decisions. Trump promised his base a fix, and he is making every effort to deliver on his promises.
As I was riding down the Oregon Coast I was amazed by President Trump’s press conference that followed his visit to the United Nations. His rambling comments were mostly about what a fabulous job he is doing across the board on all the issues that have perplexed us for decades. What I noted was a comment about healthcare that he tossed out as he was discussing the efforts of his administration to bring peace to the Middle East. I think most commentators were overwhelmed with trying to make any sense of his word salad and his brief comment about healthcare did not create much response. I have seen no comments in articles on the Internet reporting on his healthcare comment, but I did find a YouTube clip of the comment. What I noticed was that he said the issues of the Israeli/ Palestinian conflict were not as complicated as healthcare. He claimed that he was making great progress on healthcare which was harder than peace in the Middle East, and implied that perhaps since the healthcare issues were on the road to solution that he would soon resolve the core conflict between the Israelis and the Palestinians that is the central issue in the Middle East.
I was flabbergasted by the statement and was left to wonder what he meant. Was he referring to ending the mandate? What healthcare problem did that solve? Perhaps he was referring to the administrative decision to allow “association plans” that offered cheap policies with reduced benefits, and limits on dollar amounts of coverage that essentially dissolve when, and if, you ever develop a significant medical problem. From my perspective those and other administrative moves designed to undermine the ACA can only be said to fix healthcare if your idea is that federal spending on healthcare reduces the ability to cut taxes. Do his moves fix healthcare if you don’t have the personal resources to buy coverage, or if your employer does not care enough to provide you and your family with healthcare? If that is the case, heaven help you because you have failed a competency test and your situation is some function of your own inadequacy, and not an issue of the responsibility of other more gifted or prudent citizens.
Both the Judiciary Committee hearings and the president’s stream of consciousness and self congratulatory press conference generated enough heat within me to bring my internal juices to a rolling boil. I tried to calm myself by focusing on all the efforts to expand healthcare coverage going back to the last days of FDR’s presidency. I was reminded of Harry Truman’s passion for healthcare as an an entitlement, and his efforts to pass healthcare for everyone, but especially for children, the elderly, the poor and the disabled. I remembered Hubert Humphrey’s comment about what made a great nation. He called it the moral test of government:
It was once said that the moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; and those who are in the shadows of life—the sick, the needy and the handicapped.
I remembered LBJ’s efforts to pass Medicare and Medicaid. I remembered the efforts to innovate in the HMO era. I remembered the transformational concepts about quality and safety that were documented in Crossing the Quality Chasm. I remembered the Triple Aim. And then it occurred to me just how important Don Berwick’s concept of a Moral Era, Era 3 of healthcare, is to the future for the kind of healthcare that I hope for. And then I realized just how defunct a set of concepts, how moral bereft the intent, and how desecrating to the core values of healthcare this man’s lack of knowledge about healthcare has been. If healthcare is his forte, then anything he claims to know about anything else is questionable.
I can remember how uplifted I felt when I was present in Orlando when Don Berwick introduced the concept of Era 3. The idea is summarized on a seven minute video from the IHI. Perhaps we all should read his “Viewpoint” article in JAMA in April 2016. Unless you are a subscriber to JAMA it is hard, but click here to download it as a PDF.
In an article from the Advisory Group we read:
A clash between healthcare’s two eras of “professional dominance” and “accountability and market theory” is harming clinicians, communities, and patients—but there’s a better way forward, former CMS administrator Donald Berwick writes in a JAMA viewpoint.
I have posted the Advisory Group’s great review of Don’s concept in a past letter. I encourage you to explore all three: the video clip, the JAMA article, and the Advisory Boards take on the idea.
In the end, the professional attitudes that are supported by Don’s concept are foundational to efforts to achieve the Triple Aim. He approaches the challenges of this moment with an evolutionary analysis that then supports a hypothesis that describes what needs to change, and the benefits to patients, to professionals, and to the nation of making those difficult changes.
Just in case you do not have the time to study the core components of the description of Era 3, they are summarized in the Advisory Board document:
- Reducing mandatory measurement. Much of the current era’s mandatory measurement is “useless,” Berwick argues, wasting valuable time and money for providers. Berwick says that payers should work with the National Quality Forum to reduce the volume and total cost of mandatory measurement by 50 percent within three years and by 75 percent within six years. “The aim should be to measure only what matters, and mainly for learning,” Berwick says.
- Stopping complex individual incentives. For most, “if not all,” clinicians, Berwick argues that the best form of compensation to promote value-based care is “salaried practice in patient-focused organizations.” He says payers and health care organizations should halt complicated incentive programs for individual clinicians and that CMS “should confine value-based payment models for clinicians to large groups.”
- Shifting the business strategy from revenue to quality. Improving quality is “a better, more sustainable route to financial success” than focusing on maximizing revenue, Berwick says. To that end, Berwick argues that health care leaders need to view “mastering the theory and methods of improvement as a core competence,” while payers need to delink reimbursement rates from input metrics that “are not associated with quality and drive volume constantly upward.”
- Giving up ‘professional prerogative’ when it harms the team. “The most important question a modern professional can ask,” Berwick says, “is not ‘What do I do?’ but ‘What am I part of?'” He adds that young doctors should be trained to value citizenship over professional prerogative, and “physician guilds should reconsider their self-protective rhetoric and policies.”
- Using improvement science. “Four decades into the quality movement,” Berwick observes, “few in health care have studied the work of Deming, can recognize a process control chart, or have mastered the power of tests (‘plan-do-study-act’ cycles) as tools for substantial improvement.” Improvement science, he says, must become a core part of preparing clinicians and managers.
- Ensuring complete transparency. The rule for transparency, Berwick argues, should be, “Anything professionals know about their work, the people and communities they serve can know, too, without delay, cost, or smokescreens.” He says Congress, insurers, and regulators should take steps to ease data sharing, and that states should adapt all-payer claims databases.
- Protecting civility. “The rhetoric of era 1 can slide into self-importance; that of era 2, into the tone of a sports arena,” Berwick says. “Neither supports authentic dialogue. Medicine should not … substitute accusation for conversation.”
- Hearing the voices of patients and families. Further empowering patients and families to shape their care will improve care and lower costs, Berwick says. “Clinicians, and those who train them, should learn how to ask less, ‘What is the matter with you?’ and more, ‘What matters to you?’
- Rejecting greed. Berwick lists several ways he says the industry has “slipped into tolerance of greed,” from high drug costs to “profiteering physicians.” Berwick says that stakeholders need to “define and promulgate a new set of forceful principles for ‘fair profit and fair pricing,’ with severe consequences for violators.” He also calls on professional organizations and academic medical centers to “articulate, model, and fiercely protect moral values intolerant of individual or institutional greed in health care” (Berwick, JAMA, 4/5).
I get some relief from my “Trump induced” boiling blood when I ponder what healthcare would be like if we could just get a majority of healthcare professionals to accept and work to make these concepts core values for us all. I fear that if we do not make the effort we are left in a state of increasing confusion and loss. Our patients and communities are vulnerable to the continuing erosion of what we had once accomplished, and we risk the loss of any hope for new achievements in a quest for quality and safety with true equity in care at a sustainable expense that benefits every individual and every community. The image generated for me by Era 3 feels much better than the joy of continuously “winning” that our president tries to describe at his rallies, or the prospect of watching a Justice Kavanaugh join a conservative majority on a court that undermines the progress that a majority of voters say they want.
The Joy of Early Fall in Oregon
The picture that is the header for this week’s post was taken on the beach at Manzanita, Oregon. We have been to Manzanita many times. It is one of our favorite places to go, both for its beauty and the great conversations with very dear friends who have a vacation home there.
The beach at Manzanita is broad and long. There are always people walking the beach. Dogs chasing balls and frisbees are everywhere. On clear days there are kite surfers. The beach is huge. It begins at Neahkahnie Mountain which overlooks the Pacific on its northern end, and runs south for seven miles to the mouth of the Nehalem River in Nehalem Bay. Behind the beach is a quaint West Coast village with a terrific bookstore. On a gray day with a chilling wind the bookstore and the coffee shop next to it make great final stops after a walk on the beach. My wife and I go to Manzanita to enjoy the vacation home and friendship of dear friends, Doug Beers and Leslie Taylor. The walks on the beach with Doug and Leslie are a high point of every visit.
Doug Beers was my colleague at Harvard Community Health Plan before 1984 when he decided to go back to the West Coast and take a teaching position at Emanuel Hospital in Portland. Emanuel has always served a large population of patients with no insurance or with coverage through Medicare and Medicaid. Doug has trained hundreds of house officers over the last thirty four years. For more than thirty years his practice has been largely populated by patients suffering from HIV, Hep C and other chronic problems. Leslie is a nurse who for many years has functioned as a case manager for the state of Oregon caring for homebound elderly, debilitated patients. Since my wife was a nurse in many different environments before becoming an NP who managed patients with CHF, the four of us often find it hard to keep the subject of our conversation on the beauty of nature. We begin talking about our children, the natural beauty of Oregon or some other appropriate subject, but invariably we get to the challenges of medical practice, politics, and the future of healthcare. On the beach in Manzanita surrounded by the power of the Pacific, the beauty of the coastal mountains, and all of the activities around us, we should be able to distance ourselves from concerns about the future of healthcare, but we can’t. Our futures are relatively secure. If we are in trouble, so is just about everyone else. The beach, the ocean, and the mountains will persist far further into the future than we can possibly see. Next year, five years from now, a mere decade into the future is unsettled for anyone who cares about the future of healthcare.
I envy Doug because he has the opportunity to have an impact for at least as long as the last resident he trains continues to practice. That reach should go beyond the mid century. I am sure that forty or fifty years from now Manzanita will still be a good place for older doctors and nurses to walk as friends and talk about practice and the future of healthcare. I wonder what the significant subjects they discuss then will be. I hope they will be talking about the breakthrough concepts of the third era of medicine that finally enabled us to “cross the quality chasm” and move the Triple Aim from a dream to a reality.
It’s early fall in Oregon and there are yellow and red leaves popping out on the deciduous trees on the mountainsides. I hope that you have some place to walk with friends this weekend that is as beautiful as the beach in Manzanita. Great conversations can be generated on a good walk almost anywhere.
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
