February 23, 2024
Dear Interested Readers,
Old Connections For Current Progress
When I look back on the almost six years that I was leading Harvard Vanguard and Atrius Health it is probably impossible for me to give each activity and each contributor adequate acknowledgment in these reflections. It was a wonderful journey for which I will be grateful for the rest of my life. My plan is to hit a few of the high points over the next few weeks and then finish this very long remembrance of the people and events that were woven together over many decades to create the foundation of my medical-moral sensibilities.
Even though it has been more than ten years since my retirement, those very exciting years still impact what I think and do today. It amazes me that people and events still reverberate in my mind and memories. Sometimes it takes a few minutes to remember names, but I can call up their faces in an instant. Let me describe a recent event that presents an example of how one of the most significant activities and individuals from yesterday still impacts today.
One of my best friends here in New London is Steve Allenby. Steve is a retired lawyer whom I have mentioned before because of his love of making maple syrup. During his working life, he was a lawyer who spent most of his professional life as an executive in one of the eclectic companies in Vermont. He and his wife retired in their fifties to be near some of their grandchildren here in the Upper Valley. Steve may have retired from the electric company, but he never will retire from social activism. He has always been a “social activist” who was asking, “How can I help make someone’s life better?”
Steve enjoys mentoring and being involved in a wide variety of community activities. I first met him when he brought a woman to our house to pick up some furniture that we were offering for free to anyone who wanted it. The woman was escaping an abusive marriage and was setting up a home for herself and her son.
As we were loading the furniture, we got to talking, and before I knew it, I was recruited as a volunteer for action in many of Steve’s “flash missions.” That relationship and Steve’s energy have evolved into a very vigorous and successful organization, Kearsarge Neighborhood Partners (KNP) which was established after a year of planning as the pandemic began. KNP now has more than a hundred active volunteers, an electronic record, and a part-time paid coordinator. KNP is always ready to help anyone accomplish what they can’t do for themself. If you visit the website through the link above you will see Steve who is our president and be able to review how we support the community with the hope of improving the social determinants of health and just giving a neighborly hand to those who might need a little help. We deliver wood, We have a gardening program in response to concerns about food insecurity. We give people rides to the doctor. We counsel people with financial problems. We provide cars, and help get cars repaired through an activity that we call “Kars for Kearsarge.” We are concerned about social isolation. We are making efforts to encourage more affordable housing and better transportation services in our region.
Steve is the president of KNP, but that is not all he does. He is on multiple charitable boards including the Ausborn Sargent Land Trust and our local hospital which is part of Dartmouth Health, He is at the center of a consortium of people working hard to build sixty units of workforce housing. The list of his involvement in charitable endeavors is even longer. Steve understands the social determinants of health, and everything he does is an example of what one citizen can do to improve the lives of others. I am always nervous when my wife answers the phone and tells me that Steve wants to talk to me. My first reaction is usually to cringe at the thought that I am about to be roped into yet another of Steve’s efforts to make life better for someone. Steve has more ideas than hundreds of people could complete in a decade.
Recently, Steve called to ask me what I knew and could tell him about current pilot programs with value-based reimbursement from CMS. Steve would like to see Dartmouth Health apply for one of the newer programs that seek to incent health systems to make efforts to improve the social determinants of health for the communities they serve. What I know about current programs being offered by CMS is very superficial. I am way past my “sell-by date,” but I knew that my old colleague, Emily Brower who I knew had moved on to Trinity Health in Michigan, could give him a much more detailed discussion. Emily is a Senior Vice President of Clinical Integration and Physician Services for Trinity Health. Trinity Health is one of the largest healthcare systems in the country. According to Wikipedia:
Trinity Health is an American not-for-profit Catholic health system operating 92 hospitals in 22 states, including 120 continuing care locations encompassing home care, hospice, PACE and senior living facilities. Based in Livonia, Michigan,[3] Trinity Health employs more than 120,000 people including 5,300 physicians.
I didn’t have a current email for Emily, so I had to do a little research to contact her, but she responded immediately to my email request that she talk with Steve. I knew that she could help Steve. What I underestimated was just how active she was in the effort to increase the percentage of Americans who get their care from ACOs and other value-based reimbursement programs. A recent news release from Trinity Health quotes Emily about the success of Trinity’s ACOs over the past eight years.
“We are committed to our Mission of improving the health of the patients, families and communities we serve,” said Emily Brower, senior vice president, Clinical Integration and Physician Services for Trinity Health. “Our ACOs enable us to do just that while spending smarter on the preventive care that keeps our patients healthier.”
There is more, Emily is also The Immediate Past Chair of the Health Care Transformation Task Force. On its website, the task force describes itself and its mission:
Formed in 2014, the Health Care Transformation Task Force serves as a private sector driver for health system transformation. Our mission is to bring together patients, providers, payers, and health care purchasers who share a commitment to implementing innovations that accelerate the transition to a sustainable, cost efficient, consumer focused health care delivery system built on value-based care. Our immediate goal is for our members to have 75 percent of their business in value-based payment arrangements by the end of 2025.
So, how do I know Emily? In 2008, not long after I became CEO, Harvard Vanguard was approached by The Urban Medical Group. This large practice tried to provide quality care to many of the residents of Boston’s more disadvantaged neighborhoods. They asked us to consider bringing them into our family of health centers. They were suffering from their inability to make ends meet on the low reimbursement that they received for most of the care of the population they served.
I was well aware of their reputation as a forward-looking group committed to providing care to some of the distressed neighborhoods in Boston and had great respect for their commitment to serving underserved populations. The situation is well described in an article from The Jamaica Plain Gazette in 2009. At the time, Emily was the Chief Operating Officer of the Urban Medical Group.
Through extensive discussions over many meetings with the executive team at Urban, I was impressed with Emily’s skills. Ultimately, we regretfully decided that their problems were too big for us to solve. Both sides of the discussions were extremely upset with the financial realities and challenges that we both faced as the financial markets were in free fall. We were vulnerable to being unable to service our own considerable debt. I saw tears in Emily’s eyes as we presented the reality to the Urban team that we could not bring them into Harvard Vanguard even though their mission was highly aligned with ours. I still think we made the right call, but it is a call that makes me sad every time something brings it to my mind.
Not long after that sad day, I was told that Emily was in the job market. We did not have a job to offer her at the time, but everyone who had met her believed that she was an exceptional business leader who shared our values. We knew that some way she would add value, so we hired her with no immediate responsibilities. It was like a professional team drafting “the best athlete available” even if they already had a star player at the draftee’s usual position.
Emily immediately found ways to contribute even though for a while she was without a “portfolio.” Everyone wanted her to help with their projects and responsibilities. And then along came the Affordable Care Act which created CMMI (The Center for Medicare and Medicaid Innovation) within CMS which launched the Pioneer ACO as one of its first projects. One of my distant goals was that the time would come again when most of our patients were part of a value-based reimbursement system that would be a modern-day iteration of the system of capitation that Dr. Ebert had launched as HCHP in 1969. I called ACOs capitation 2.0. I was excited about being a part of the brave new world of the Pioneer ACO. It was immediately obvious that Emily was the perfect person to lead us to success as a Pioneer ACO.
I had early knowledge of and contact with the leadership at CMMI. You might remember that President Obama nominated Don Berwick as the administrator of CMS. Don’s nomination met vigorous resistance from Republican senators who opposed him because they feared he was a left-wing socialist. Don had been given the non-British citizen equivalent of knighthood by Queen Elizabeth for the work he had done to improve healthcare delivery in the NHS, the U.K.’s state-sponsored system of universal healthcare. That accomplishment plus the fact that he was president of the IHI which advocates for universal access and other improvements in our healthcare, some senators vigorously opposed his nomination. Before Obama had announced his nomination, the FBI had called me as part of a background check on Don. I was thrilled to think he would have the position. After the failure to get Senate confirmation, Obama gave Don a “recess appointment.” Recess appointments are limited to eighteen months. Don served from July 2010 until December 2011.
Not long after Don settled in at CMS, I made a trip to Washington to try to explore with him how Harvard Vanguard and Atrius Health might be included in some of the innovations that were on the drawing board. Honestly, I was looking for an inroad to a grant. Don, quickly told me that given the fact that about 40% of healthcare spending was waste, my organization had more than enough money. We didn’t need a grant. We needed to be more efficient. After our chat, and with my ears burning with embarrassment, he walked me down the hall to introduce me to Rick Gifillan whom he had put in charge of CMMI and the efforts to launch a Medicare ACO.
Don did not know that I had met Rick a year or so before when I had taken members of my executive team down to Geisinger Health in rural Pennsylvania to learn more about what Glenn Steele, the Geisinger CEO, was doing to improve healthcare delivery and quality. I knew Glenn because Joe Dorsey had hired him as one of HCHP’s surgeons back in the seventies. At the time, Rick was in charge of Geisinger’s health plan which was where much of the innovation in primary care was occurring. Rick immediately remembered me, and I remembered him. Don left me with Rick, and we began a conversation that would result in Harvard Vanguard and Atrius being one of the first thirty-two organizations in the Pioneer ACO.
The Pioneer ACO was a challenge for us, and we might have failed if it had not been for Emily’s skill. Consider it a flaw, or unfair, that an organization’s budget was based on its CMS income per patient before joining the ACO. Organizations that had been wasteful and had been well paid for their inefficiencies and poor quality had larger budgets than we had because we had less waste and higher quality to start with. Nevertheless, with Emily’s leadership, we did save money. More important to me was the fact that we had one of the highest levels of quality across all measurements. During the process, Rick Gifillan got to know Emily and appreciated her work just as I had appreciated her work at Urban Medical Group. It should not surprise you that after I retired and after Rick left CMMI to become the CEO of Trinity Health he hired Emily. Rick has now left Trinity, but Emily tells me that she continues to enjoy her work, and she and her family love living in Ann Arbor.
Steve and one of the Dartmouth executives had their call with Emily on Wednesday. Steve emailed me early Thursday:
Gene, had a great call with Emily, who is connecting us to her colleague, Jamie Dircksen, at Trinity. I just checked out Jamie’s annual report and found this mission, vision and values. Now that is something I could get behind!
Steve
Our Mission
We, Trinity Health, serve together in the spirit of the Gospel as a compassionate and transforming healing presence within our communities.
Our CORE VALUES
Reverence
Commitment to Those Experiencing Poverty
Safety
Justice
Stewardship
Integrity
Our VISION
As a mission-driven innovative health organization, we will become the national leader in improving the health of our communities and each person we serve. We will be the most trusted health partner for life.
I know Steve well enough to expect that he will be pushing Dartmouth Health to accept the challenge to work to improve the social determinants of health for those of us who live in the Upper Valley where Dartmouth Health and its affiliated hospitals are the primary source of our care. It is great to see that two of my heroes have collaborated. It gives me hope that there will be improvement in our future.
A Little More Winter, Please
Over the past month or so of warmer weather, the local nightly news has regularly featured videos of rescues of people who have fallen through the ice on some local pond or lake or are rescued from an attempt to climb a snow-covered mountain. When I worked in emergency rooms fifty years ago, I observed that I would frequently see similar presentations of common accidents. I frequently saw a v-shaped laceration on the index finger of women. The story was usually that they were washing dishes in soapy water and did not see a broken glass which was like a booby trap. Men had their accidents also, their lacerations and amputations of fingers were from table saws and snow blowers. The frequent story with the people falling through the ice was that they we out for a walk near a pond with their dog that was off the leash. The dog then dashes off across the ice and falls through into ice water. The dog’s owner then ends up in the chilly water trying to save the dog.
We are told to be careful with broken glass, table saws, snowblowers, frozen ponds, and winter hiking in the mountains. Explainable circumstances lead to either a lack of attention or risk-taking which leads to injuries and the need for rescues. We shake our heads and say, “When will we/they ever learn?” The problem with this winter is that normally this time of the year the ice on most of our ponds is thick enough to drive a truck on it. It looks the same now, but in many places, it has been too thin to support a dog.
After all the thin ice and rescues, winter returned this week for a short encore performance. Until yesterday, the temperature was in the low teens at night, and the days featured clear skies, bright sun, and high temps that struggled to reach the upper twenties. It has been a beautiful winter week, finally. It is the week of the President’s Day holiday, and many schools are taking the week off. I am sure that this week will be one of the most lucrative weeks of the winter for our local ski resorts, but all things pass and today after a brief dump of a couple of inches last night and this morning, we are in for at least ten days of warmer weather. The brief encore of winter was nice while it lasted. February is on track to be the hottest one ever.
My neighbor and his wife have compensated for the warmer weather here by taking several trips out west to ski in Utah, Colorado, and Montana. They ski over a hundred days every winter. It’s been at least five years since I have put on skis because of my progressive orthopedic problems. Having grown up where it rarely snows, I never skied until I was in my mid-thirties, and then I immediately tore the ACL in my right knee on an icy beginner’s trail at Stowe. Forty-three years ago ACL repairs weren’t so good, and I was advised that any attempt at repair might compromise my running. I was advised to keep my quads strong and wear a brace when I did anything with lateral movement. Eventually, I did enjoy skiing with my brace on “bunny trails,” and the loss of the ACL did not prevent me from running many marathons. Ironically, because of old football injuries to my left knee, my right knee is now my “good” knee.
Currently, I am waiting to hear when surgery on my lower back can be scheduled, and the idea of taking a walk on a frozen lake or attempting to ski down even a beginner trail on our local mountain triggers distant memories that will possibly never be repeated. For the last month, I have not been able to take my daily walk, do Pilates, or ride my Peloton. I spend my days trying to find a comfortable position. I spend a lot of time lying on pillows on the floor in front of my fireplace.
One activity that brings me pleasure that I can still do if I am careful is to bring wood from the woodshed attached to the back of our garage into the living room. I have a great woodcart. I push the cart down a ramp I have built and then about twenty-five yards to the woodpile where I fill it with about twenty-five logs. I then slowly and carefully pull the cart back down the stone path from the woodpile to the ramp. To complete the task, I pull the cart up the ramp that I have constructed that rises from our stone patio up to our deck which has an entrance into our living room through a sliding door that is next to the fireplace. The cart with its wood sits in front of the sliding door which allows me to fetch wood as I need it.
I burn about a cart of wood every day and about three cords of wood a winter. I think my neighbor will bring in my wood until I recover after my surgery. A crackling fire is a pleasure, and I hope that I never need to give up my “real fires.” Many of my friends have fake logs in their fireplaces that provide a “faux” fireplace experience with a gas flame. Worse yet are the electric attempts to create a false fireplace atmosphere. I demand the real thing! A picture may add clarity. You can faintly see the ramp, and discern that it is just a few feet from the deck to the frozen lake.
Late Monday afternoon, I needed more wood. The task took me outdoors where the temperature was in the high teens. The sky was clear, and the sinking sun was bright. Shadows were creeping across the lake from west to east. It was an exhilarating scene. Then I saw something that I have rarely seen this winter. There were some adults and children out on the ice several hundred yards from shore. I could not tell if they were just walking or were trying to clear some snow for skating. At times, I thought I could see that one of the men had a shovel or a hockey stick.
.
It was a terrific scene and you can see it in today’s header. By the time I got my wood, the people on the ice were gone. I keep watching, but no one has returned. Maybe, I will see more people on the ice this weekend. Perhaps before the ice melts, I will see a few people fishing through the ice. The earliest “ice-out” I can remember over the last fifteen years that we have been here was in mid-March. The latest was sometime in the third week of April. “Ice-out” may also set a record this year. “Ice-out” is a big deal. People place bets that rival the wagers on “March Madness” about when “ice-out” will occur.
I hope that you have a few winter pleasures planned for the weekend. It is startling to realize that the Red Sox started their spring training this week. If it keeps getting warmer, sometime in the future the Red Sox may not need to go to Florida for spring training. For this year, like it or not “mud season” is probably just around the corner.
Be well,
Gene
