October 25, 2024
Dear Interested Readers,
Looking Back With Some Nostalgia. Looking Forward With Hope
Today, eleven years ago, I sent out my last letter, number 296, to the Harvard Vanguard and Atrius Health employees. Initially, the salutation on my Friday letter published every Friday from February 22, 2008, until October 25, 2013, was “Dear Harvard Vanguard colleagues.” The readership was every person who got a paycheck from us. On one occasion, I had an irritated physician say that the letter seemed to be targeted for her medical assistant. I thanked her for noticing. Initially, the letter circulated to about 5,000 Vanguard employees, As time passed, the salutation changed to “Dear Atrius Health colleagues’ which meant that it was going to more than 8,000 people in all of the Atrius affiliated practices. By October 2013, many of the letter’s readers were not Atrius employees. Because I was aware of the wider audience, the salutation on the letter was changed to “Dear Atrius Health colleagues and other interested readers.” The title of that last letter was Looking At the Future Together One More Time. (Click on the link to see or read the letter.)
I announced in the September 20, 2013 letter, that I would retire at the end of 2013. That letter had a subtitle referencing Mount Pisgah, where we read in Deuteronomy 34:1-12 that Moses had been taken to look into the “Promised Land” which he would never visit. Ironically, there is a small mountain named Mount Pisgah since colonial times in the western suburbs of Eastern Massachusetts. On a clear day from an outcropping of granite at the top of the little mountain, you can see everything from New Hampshire in the north to Cape Cod in the south, as well as east through Boston and out to the Atlantic. What I realized was that from our little Mount Pisgah, you could see most of the area that our practice served. Metaphorically, you could say that you could see the possibilities of Atrius from the summit of our little Mount Pisgah. I imagined that our progress toward the Triple Aim, a sort of “Promised Land,” would continue long after my brief period of service was forgotten.
I had initially planned to write until the end of December, but Marci Sindel, who edited my letters, suggested that I should stop writing at the end of October as the organization was transitioning to new leadership. It was a ruse. What she wanted was to prepare an 1100-page leather-bound copy of the 296 letters that I had already written. To my great surprise, the volume was entitled Be Well, Gene. It was presented to me along with other gifts of appreciation at our annual awards dinner in late November 2013.
When I wrote that last letter to “Atrius colleagues,” I thought it was the end of my writing. I did not write again to my “Atrius Health colleagues,” but four Fridays later, on November 22, the 50th anniversary of the assassination of John Kennedy in Dallas, I began to write again at the urging of my friend and “guru” in all aspects of “Lean,” John Gallagher. I had the email addresses of several hundred non-Atrius employees who had asked over the years to be included in the distribution. I wrote to them. The title of that “return letter,” addressed to just “Interested Readers,” was Volume II. (Click to read.)
I have enjoyed good health, and to my amazement, there has been a letter every Friday since November 22, 2013. The writing remained the same, but the presentation changed for the better in January 2015 when my very steady technical guru, Russ Morgan, helped me launch StrategyHealthcare.com. For several years, I also wrote a letter on Tuesdays. I often wonder how long I will continue to write. Certainly, now is not the time to stop.
I hope that after the election I will be able to continue to write about fabulous progress toward better more equitable care coupled with vast improvements in the Social Determinants of Health. If the 2024 election ends with the same outcome as the 2016 election, I will do as I did between 2017 and 2021. I will write to remind us of what we are losing and strategies to preserve some of the progress that has been made over the last sixty years that I have been observing healthcare. [My first job in healthcare was as an orderly at the South Carolina Baptist Hospital in June 1964 in Columbia, S.C. My dad had advised that if I wanted to be a doctor, I should see what it was like to work in a hospital.]
There was no pending election in that fall of 2013, but for me, there was a great sense of uncertainty. I had no way of knowing what to expect, but I was filled with hope and acceptance of the fact that change was inevitable. As I reread those letters of October 25 and November 22, I am struck with the sense that the message in them is mostly appropriate for today. In the October 25, 2013 letter, I repeated a list of ten concerns or predictions for the future that I had first published the week before in the next to last letter. Most of the issues remain a concern eleven years later:
- 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.
When I wrote again on the fiftieth anniversary of JFK’s death, I referenced a speech on the need for access to healthcare (what we would call Medicare) for Americans over 65 that JFK had delivered at Madison Square Garden on May 22, 1962. You should listen to the speech. He talks about the resistance to his idea by the AMA. In the letter I wrote:
The most public manifestation of JFK’s healthcare policy was his famous speech at Madison Square Garden that was nationally televised on May 20, 1962, the day after Marilyn Monroe had made some sort of history singing “Happy Birthday” to him at a gala event and after he had spent much of the day at the hospital with his father who was recovering from his CVA. You can easily hear the speech on “YouTube”. In it, he makes a case for what will become Medicare Part A. He is aware of the opposition of the AMA and indeed the next day the president of the AMA gave a rebuttal speech while standing in the middle of Madison Square Garden before the clean up from the crowd at Kennedy’s rally the night before.
His speech is full of empathy for the elders of the country who unlike his father can’t pay for their own care or unlike him can’t afford to pay for the care their parents need. It is ironic that a few hours before his assassination, Wilbur Cohen, who was the Assistant Secretary of HEW (Health and Human Services of today was called Health, Education and Welfare in 1963), met with Wilbur Mills of Arkansas, the powerful Chairman of the House Ways and Means Committee, and secured his support for the legislation that would become Medicare. Mills was wily and Johnson had to work on him some more before Medicare became the law in 1965 but like Civil Rights, Johnson completed the legislation that Lee Harvey Oswald prevented Kennedy from finishing.
The 150 years since Gettysburg and the 50 years since Dealey Plaza teach us that the journey from idea to awareness, dream to reality is a long one. Plato saw the connection between ideas and realities but failed to make much of a comment about the time, effort, and commitment that was required to connect the two. Professor Debra Ancona of MIT writes about the role of leadership as involving visioning, sensemaking, relating, and inventing. In healthcare, Kennedy was well into the task of visioning and sensemaking, and his May 20, 1962, was an excellent act of relating. Because of the events of November 22, 1963, most of the inventing was left to others like [Lyndon] Johnson, Dr. Ebert, and now us. The process goes on and on. Kennedy was aware of the slow and evolutionary path that healthcare would by necessity follow. He anticipated the critics in his speech as he closed by saying:
In closing, let me say that on this issue and many others, we depend upon your help. This is the only way we can secure action to keep this country moving ahead, to have places to educate our children, to have decent housing, to do something about the millions of young children who leave our schools before they graduate.
Every day I am reminded of how many things were left undone. Thirty years ago they provided that no drugs be put on the market which were unsafe for hogs and for cattle. We want to take the radical step of doing the same for human beings. Anyone who says that Woodrow Wilson, as great a President as he was, and Franklin Roosevelt and Harry Truman, that they did it all and we have nothing left to do now, is wrong.
We ask you, the citizens of this country, the responsible and thoughtful doctors, the hospital administrators, all those who face this challenge of educating our children, finding work for our older people, finding security for those who have retired, all who are committed to this great effort of moving this country forward: come and give us your help.
As I think of our two candidates for president in 2024, Kamala Harris seems to better understand the responsibilities and gravitas of the office. It is hard for me to simultaneously think of our greatest presidents and Donald Trump, our absolute worst president, at the same time. It is even harder for me to anticipate what it would feel like to know that we will have four more years to endure his inadequacies. The contrast between Trump’s “concept of a plan” for healthcare, and the passionate description of the “progressive” concept of Medicare that Kennedy was pledging to pursue leaves me sad for us in this moment. I put progressive in italics, bolded, and bracketed by parentheses, because Kennedy was unafraid of labeling his idea, himself, or those who believed that the elderly should have healthcare, as progressive. Today “progressive” is a label that requires political courage or if you prefer, a lack of political savvy.
In past election years, we have had “October surprises.” There is some debate as to whether some event or revelation just weeks from an election can make a difference. I keep hoping for a “surprise” that convinces a significant majority of undecided voters in the “swing states” that Trump is not only unworthy of their vote because of the deficiencies of his character but also causes them to realize that he is a threat to the quality of everyone’s health.
If you have come this far and still support Trump and his ideas, I am pretty sure that there is no October surprise including his threat to use the army against dissident citizens, his lewd suggestions about Arnold Palmer’s anatomy, or any other revelation that is likely to change your mind. Even though it probably will not make a difference in the outcome of the election, this week Ezra Klein has published a new podcast/ long column in the New York Times that is his in-depth analysis of Trump’s hold on his followers and why he is a threat to the future of more than just healthcare.
After laying out his analysis, Klein makes a tongue-in-cheek statement:
What Donald Trump has done is remarkable. It is historic. It is unique in the entire history of American politics. To run as an outsider to a political party and capture that political party totally. Break its fundamental consensus. Slander its previous standard-bearers. To then become president having never held elective office or served in the military, while saying things and doing things that, until you, everybody believed you could not do or say in politics. To achieve something unique, you must yourself be unique. Donald Trump is unique.
At the end of the piece, Klein is more direct. The problem is larger than Trump’s narcissism and lack of character. He raises the same concern that so many others have raised. In the first Trump presidency, there were people like General John Kelly who recognized him for what he was and effectively limited the damage that he could do. This week, Kelly went so far as to assert that he met the definition of a fascist. A White House full of “minders” working to corral Trump’s bizarre behavior will not be the reality in a second Trump term. Klein describes the situation:
Donald Trump is not cognitively fit to be president. The presidency is a position that requires an occupant able to act strategically and carefully. That Trump is not such a person is obvious if you watch the man. And so, for years, his supporters have said: Don’t watch the man. Don’t listen to what he says. Look at the results. But those results reflected the power and ability of others to check Trump, to inhibit him when he could not inhibit himself. It is not just the man who is now unfit; it is the people and institutions that surround him.
Now my future is uncertain, but not because of retirement. I have done well as a retiree. Now my uncertainty arises as a man approaching eighty with a growing list of physical problems who is a little self-interested and fearful that another Trump presidency would be a setback for progress toward improvements in healthcare that might be beneficial to me! The future of healthcare is more uncertain now than in 2013 because of the emergence since 2015 of the MAGA politics of Donald Trump. It is a week and a half till all the votes will be cast, and it may be several days or even weeks after Election Day before we know what the next four years might hold for healthcare and the health of our democracy.
Eleven years ago when it was time for me to retire, I knew that there was still much that needed to change if we were going to find the operating system and finance mechanism that Dr. Ebert advised would provide for the health of the nation. What President Kennedy called for in May of 1962 and Congress passed in 1965 was a first step. The picture of what should be done was well described in the pages of Crossing the Quality Chasm in 2001. Berwick and others focused the challenge with the Triple Aim in 2007. Over the fourteen years since the signing of the ACA, we have made slow intermittent progress toward universal access to care. There has been much effort by many people to slowly bring us toward the concept that everyone should have a right to affordable, sustainable, safe, efficient, equitable, and patient-centered care. A Trump presidency will threaten that progress.
When I retired, I had no idea that the pathway toward better health for everyone, not to mention the future of democracy, would be threatened by a politician with the “skills” of someone like Donald Trump. I do not fully comprehend his allure for enough people to give him the possibility of another victory in the Electoral College even though it is likely to be true again, as it was in 2016, that he will not win the popular vote, but here we are—under a very dark cloud of uncertainty for the future.
I do look forward with the hope that sometime after November 5 we will be assured that the storm has passed and that we can look forward with excitement to what might be accomplished over the next four years. I hope to wake up from a long nightmare, and realize that it is really a new day that is an equitable “morning in America.”
When “All The Leaves Are Brown”
This time of year my external world is changing fast. Inevitably, I find myself humming the song “California Dreaming” by the 60s group The Mamas and The Papas. You probably remember the opening lines:
All the leaves are brown (all the leaves are brown)
And the sky is gray (and the sky is gray)
I’ve been for a walk (I’ve been for a walk)
On a winter’s day (on a winter’s day)
I’d be safe and warm (I’d be safe and warm)
If I was in L.A. (if I was in L.A.)
California dreamin’ (California dreamin’)
On such a winter’s day
The peak color has passed. It goes very fast. What was red, bright orange, and yellow last week is still sort of a semi-attractive burnt orange, and there are still a few more bright yellow birches and beeches in patches on the hills. (Interestingly, beeches don’t drop their leaves until spring.) But, for most of our deciduous trees, we are quickly headed toward brown and down. All around town and in my yard, the boats are out of the water, the docks are sitting in yards, and the swim floats and floating docks have all been hauled off to wherever they spend the winter. The whole town is ready for Halloween and the first snow which in years past has often come by now.
I am frightened, not by the ghosts and goblins that decorate lawns, but by the Trump signs that seem to be multiplying. We have retaliated by putting up a Harris-Walz yard sign at the entrance of our drive and putting Harris-Waltz stickers on our vehicles, but we get very few people coming down our dead-end road who might see our sign and most of our driving is just to the post office and grocery store so the cars don’t get seen much either. I don’t know what to do. The election tension has put me in a negative mood. I am tired of the negative political ads on TV with the evening news, and I will be glad to see the return of ads for new drugs and metal roofs which I enjoy loathing.
It is a shame to have so many negative feelings when the truth is that even though the fall foliage is rapidly fading to brown and down, we have enjoyed warm weather with clear skies most of the week. It has been “Indian Summer.” There is some debate about what constitutes an Indian summer day. The strict definition is something like temps over 70 after the first frost. Less precisely, just a warm fall day is frequently called “Indian Summer.” Being somewhat of a purist, I am delighted to report that we did have a real frost with overnight temps falling below 30 degrees during the last week of September. So, I was delighted when the cold, heavy rains that came our way last week finally ended, and the temperature shot up to the mid-seventies this week to give us some “official” Indian summer days, The prediction is for clear skies, and temps in the fifties and sixties without rain or snow for at least the next ten days which will take us almost to election day.
I think that I will have at least three or four more days to enjoy the old Japanese maple in my front yard. I did not plant it, but I am thankful that a previous owner of the property did. If you look very closely at the header in today’s post just past the Harris-Walz sign and the garage/ guest house at the head of my drive, you can glimpse the orange/red of the leaves of the elderly Japanese maple (Acer japonicum) in the front yard. Over the sixteen years that we have owned the house, it has lost limbs and has frequently required special attention from an arborist. I am reminded every fall when I look at the tree that every living thing is vulnerable and will not last forever. I took its picture yesterday. It had already dropped many of its leaves, but unlike many other trees in the area, its leaves will not turn brown until they are down.
I hope that you will be able to be out and enjoy the weekend. We are making a quick trip to Maine to see our youngest grandson who just became nine months old and can pull himself up to standing! It is amazing and somewhat reassuring to realize that with good healthcare and some luck, he will be walking far into the next century, even if Trump wins the election.
Be well,
Gene
