10 July 2015
Dear Interested Readers,
Inside this Week's Letter
As I promised last week, this week’s letter is a discussion of the “Plus One” part of the Triple Aim plus one. I found the discussion needed some introductory comments to frame the subject.
The letter also includes the reproduction of the “Top Ten Health Industry Questions for 2015” lifted from healthcarefinancenews.com. It may not be your list but it is a list worth examining for the insights that it might yield.
Here is a little bonus for anyone who shares my interest in Dr.Ebert. Last week I discovered a wonderful video of a conversation between him and his brother Richard about his career and his concerns. It was recorded in 1992.
I want to remind you that strategyhealthcare.com is one click away and that if you or someone else would like to be on the distribution list for these “Musings” you can sign up while you are on the site.
Introductory Thoughts To Discussing “Plus One”
Near the end of last week’s letter I made the following statement:
I believe that the four legs of the “Triple Aim plus one” are not all of the same weight. The care of the individual is paramount, but unless we insure that the care of individuals is free of disparities we have not accomplished the real goal. Unless we eliminate disparities we will not achieve the second objective of healthier communities, nor will we realize the full benefits that we project will accrue to us all in terms of the lower cost of care that healthy communities generate. I will delay my comments on the fourth leg of the “Triple Aim plus one” until next week’s Musings. The achievement of that leg has operational, ethical and professional considerations that are definitely connected to the future resolution of healthcare disparities but the discussion will be a letter of its own.
I began to be apprehensive about this week’s letter the moment that I wrote that paragraph because I anticipated that, at best, a thorough examination of the “Plus One” leg would be a difficult piece to write without sounding “wonkish”. I also knew that it had the potential to become a controversial discussion. I was most daunted by the understanding that much of our discourse as we attempt to make a point relies on rational arguments and any attempt to make the Triple Aim Plus One a conversation based on reason ignores the power of personal, cultural and emotional factors. On the other hand, approaching the subject from a more emotional mindset risks the possibility of sounding unrealistic, overly emotional or even “preachy”.
At a minimum the Triple Aim is a subject that contains great tension between the rational and emotional components of our approaches to the responsibilities that we have as physicians and professionals in healthcare. Our profession is far from homogenous in its orientation to anything. A practical expression of our individuality and love of autonomy is the disfunction of widespread practice variation. A great sense of independence and autonomy can be a strength but often is a barrier to acting in concert to achieve great things for our patients and their communities. I challenged myself to try to avoid confrontational arguments for the “Plus One” discussion. I wanted to present a discussion balanced between reason and emotion and decided to seek a more holistic presentation that would have a transformational attraction. I hoped to offer a new perspective for consideration to everyone involved in the current discussion.
As someone who is often torn between the rational and the emotional or the metaphysical complexity of existence, I knew that this self assignment was impossible for me to pull off. My tendency is to articulate a rational argument that is then undermined by my own emotional or metaphysical tendencies with the result that anyone granting me the courtesy of their attention can be confused. I apologize now for what follows.
If my goal had been to win you over to my point of view, just attempting this piece informs me that a better goal is just to get you thinking about the complexity of the subject armed with a few ideas that I have adopted from others. These are concepts that I have found useful as I try to live and work in anticipation of the day when we preserve and improve health so efficiently and effectively that we will universally provide individuals and their communities with the happiness and fulfillment that only good health brings. For that victory to have durability we will be required to deliver care in a way that is economically sustainable in perpetuity and leaves resources available for other important collective expenses that contribute to the world we desire to inhabit.
I do believe that along the way we will discover that the journey includes understanding and removing the barriers to health that create the current disparities that we measure. In the speech that I quoted last week, Dr Ebert coupled a sense of social responsibility with the goal of improving health. Physicians and healthcare professionals with a sense of social responsibility must be engaged in the effort to achieve the Triple Aim if we are ever to act on the insight that he gave us when he said:
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.”
Looking at the “Plus One” Leg of the Triple Aim
The fourth leg of the metaphorical construct of the destination of the road to better care that we describe as the Triple Aim is an “add on”. As originally presented in 2007, the Triple Aim is a noble concept that seems to assume that providers and healthcare professionals will be drawn instinctively to the rational nature of its goals. Experience has shown that the progression toward acceptance of the Triple Aim has been slow. In the organization where I worked the addition of the “Plus One” enlarged the conversation and made it a subject of interest to many more physicians. Intuitively the expression “Plus One” sought to align physician self interest with the interests of patients and communities in a way that could foster physician engagement in the journey. The objective of ideal care becomes a construct that stands on the original three legs of the Triple Aim plus the fourth “Plus One” pillar of improving the professional experience. The “Plus One” adds the reality that progress can’t be made without “physician engagement”. It also offers a more satisfactory experience of practice as a “carrot” or payoff that is both part of the objective and the reward for achieving the objective.
“Physician engagement” is widely postulated as a necessary ingredient for successful healthcare reform or for any of its tactics like the establishment of ACOs. Just how to engage physicians is one of the most recurrent themes of healthcare conferences like GPIN, AMGA, and any ACO meeting and is fundamental to any quality improvement or continuous improvement process like Lean or Six Sigma. We have limited possibilities if we seek to improve care treating physicians as barriers to change. It is logical to realize that physicians and all healthcare professionals must be supportive at a minimum and at best, actively engaged leaders of transformation.
“Plus One” was also a response to the realization that professional “burnout” was increasing and that there was widespread uncertainty, fatigue, vulnerability and anger among physicians. Doctors were talking about the loss of the “joy of practice” when they were most thoughtful about their plight and of leaving practice when they were most despondent or angry about the pain they were experiencing from the mounting burden of negative externalities . The physical and emotional complexity of healthcare reform and the associated regulatory changes in the environment, plus downward pressure on revenue, have taken a heavy toll on individuals who we frequently heard saying, “This is not what I signed up for!”.
The new attention to the concerns of physicians has the potential to anger others who have worked equally hard for change or survival and who are further removed from power or influence than physicians are. When the stated objective is “physician engagement” and the carrot is to exclusively improve their professional experience, the statement has the potential to cause PAs, nurses, medical assistants, other clinicians and administratives workers and executive all to say, “What about my concerns? Why is everything addressed from the perspective of physicians?”. It is a dilemma because when we present “Plus One” as an objective that is inclusive of all healthcare professionals we risk diminishing the attractiveness of the conversation to physicians.
I have recently learned that as the concept of the Triple Aim was evolving there may have been some who actually argued for some sort of “Plus One” concept in the original declaration. Perhaps we would have moved faster toward broad based acceptance of the Triple Aim if from the start we had been talking about the “Quadruple Aim”. I wonder if the conversation back then among the ones engaged in the launch anticipated the nuanced difficulties of how to balance the objective between physicians and other professionals, or whether it was just the assumption of the authors that their rational arguments for the Triple Aim were so compelling that physicians would see the wisdom of engaging without adding the explicit complexity of “Plus One” to the objective. The stand alone power of the Triple Aim certainly worked for me. I can guess that the objective that caused the authors of the Triple Aim the most prospective worry was the cost issue. Perhaps they were trying to avoid “scope creep” or keep it simple as the explanation for leaving out the “Plus One” at the start.
Let’s step back for a moment and realize that we are talking about a process of transformation that we can trace back more than one hundred years. The core concern, even in 1915, was how to provide care to more people. The wealthy in areas with great commerce and educational institutions have, and always will have, access to good care. The wealthy in less populated areas or in places that are further from the latest technologies can use their resources to travel for the care that they want. You can go to the world-renowned medical institutions in Boston, New York, and in any other large American city, any day of the week and see people, usually of wealth, who have come to these Meccas from the four corners of the world looking for the best care.
If good health is a human right or, at a minimum, an economically desirable objective that supports better societies, the issues are reducible to the question of how to provide everyone everywhere with care that recognizes their unique individuality and has the power to maximize their health. Even that statement contains evidence of transformational thinking and remains controversial since so much of our industry and our resources are still differentially focused on the treatment of disease. Efforts to restore health after the presence of disease seem more interesting and challenging than the more effective strategy of enhancing health and preventing illness from occurring. Such a health promotional strategy will require medical professionals to work in concert to achieve social objectives that feel somewhat foreign to the focus on curing disease in individuals. We seem to like to fix what is broken and have found those activities to be more aligned with our professional responsibilities and core interests than preventing the emergence of disease. Why aren't we interested in moving upstream to the elimination of more and more of the causes of disease and illness which as a new strategy has the power in combination with disease treatment to maximize the health of every individual? It follows that we invest our assets in what interests us. For many institutions building a new bed tower attracts more interest than investing in a data warehouse or in creating a Lean competency.
Perhaps the reason for not mentioning the “Plus One” in the original articulation of the Triple Aim was the reality that the authors were focused on the enormous and extensive changes that would be required to achieve the objective of a sustainable expense. I was not a part of the discussion, but had I been, I would have had no problem as a physician accepting the goals of better health for individuals, and through the summation of the impact of better access to care I would have seen that achievement as logically leading to a healthier community. I too would have been more skeptical in the late twentieth century about the realistic likelihood of improving access, quality, safety, and the health of everyone and doing it for less expense.
My original apprehension about being able to achieve long term cost control was based in what I had been taught. I had often heard the respected healthcare leaders in the seventies and eighties say with conviction that you could have only two out of three objectives when balancing cost, quality and access. All of the following combinations were thought to be true: - If you want higher quality and better access, expect a higher cost.
- If you want lower cost and better access, expect a lower quality.
- If you want high quality and lower cost, expect restricted access.
The progress that prepared us for the realistic articulation of the Triple Aim was derivative of the enlightened view of many of the best thinkers in healthcare who ask the fundamental question: What part of the problem are we? The “we” includes everyone that works in healthcare but it is most focused on physicians and those leaders who control the status quo of healthcare.
Thought leaders usually began their attempts at rational arguments by noting that as a nation we provide care to a smaller percentage of the population than other similarly developed countries and that the care we provided was often unsafe, fragmented, disrespectful, ineffective and expensive. We began to hear more organized voices coming from patients and families, employers, and taxpayers that made many of us increasingly aware of their opinion that we managed the system to work for us and that their issues were secondary to ours. Their demands were for safer care delivered with better quality and service and with better access and a lower cost. Simultaneously we began to appreciate the power of systems thinking, the high cost of poor quality, and the economic and moral costs of inattention to safety.
Informed by the voices of customers and payers and armed with the humanistic enlightenment of To Err is Human, the IOM produced Crossing the Quality Chasm in 2001. That work stands as a blueprint for universal improvement. It has made a difference but its impact has evolved very slowly because the work is as much about deconstructing what does not work as it is about constructing what might be better. In essence, Crossing the Quality Chasm invisions healthcare reform as a huge “brownfield” project. Transformation is often about deconstructing what still works a little bit but has no future, and then constructing what seems foreign and at times in conflict with the established norms. Crossing the Quality Chasm calls for a huge exercise in adaptive change.
I have written about adaptive change in the past but the link above is a terrific brief review of the subject in general and not specific to healthcare. The author, Erik Van Slyke, quotes Dr. Ron Heifetz of the Kennedy School at Harvard who is one of the most persuasive proponents of the importance of teaching the leadership skills to address adaptive problems. The quote below succinctly presents much of the theory. He writes about the difference between technical problems and their solutions and the more difficult to manage issues of adaptive change.
Adaptive problems, on the other hand, [in contrast to technical problems] are difficult to identify and often easy to deny. They require changes in values, beliefs, roles, relationships and approaches to work. They usually require change in numerous places and they cross defined boundaries and turf. Adaptive problems require that the people with the problem do the work of solving it. The solutions can take time to implement because they often require experimentation and an iterative process of discovery. There is no predefined solution. There is no expert with the answer.
Some signs you have an adaptive challenge? - Crisis
- Problems resurface time and again
- Persistent conflict
- People will need to learn new ways of behaving or working
- Current know-how won’t solve the problem
- Collaboration is required to solve the challenge
It is my thesis that the problems associated with the implementation of healthcare reform and the realization of either the Triple Aim or the Triple Aim “Plus One” are explained in part by the concept of adaptive change (think clinical autonomy). The statement below is key to the understanding necessary to make progress:
They [the problems that require adaptive change] require changes in values, beliefs, roles, relationships and approaches to work.
It is my belief that we will make more progress toward the Triple Aim “Plus One” only after we recognize and discuss the feelings of loss experienced by many physicians as they are challenged with the changes that are inevitable. The Triple Aim offers motivation that can arise from aspirations that are consistent with the myths that we say drive our opinions and actions. The alternative is motivation rooted in “loss avoidance”.
It is my opinion that Crossing the Quality Chasm had it right. We can have quality, safety, access and lower cost if we embrace quality as inclusive of waste elimination and improved patient service and access, and if we embrace the reality that unsafe care leads to avoidable expense. Our greatest asset is that reduced waste, improved quality and service and improved safety are all products of better engineering of the delivery system that can be achieved by robust processes of continuous improvement that engage physicians and all healthcare professionals.
The old scripture based adage “physician heal thyself” gains a new meaning when you see doctors joyfully struggling with a process of improvement during a Lean kaizen event. I believe that “Plus One” is key and is a derivative outcome of improving the experience and quality of care, eliminating disparities, and leading the progressive reduction of the waste in our flawed systems so that we will have better care at a lower cost.
Good minds are embracing the Triple Aim Plus One and there are resources out there that approach the subject in a systematic way. Recently while surfing the Internet for the thoughts of others about the Triple Aim Plus One, I happened onto an excellent presentation of its importance from a healthcare consultancy, Lumeris, that had reduced the search for the Triple Aim Plus One to a nine point “rational” presentation that is a logical and data oriented argument. You can read it for yourself and download it as a PDF at:
Two weeks ago I reported on the 6th ACO Summit that is the joint production of Mark McClellan of the Brookings Institute and Elliott Fisher of the Dartmouth Institute. I sent a copy of the letter to Elliott Fisher. You might remember that at the end of the report I wrote:
My thesis that “the strategic objective of healthcare transformation is the Triple Aim Plus One and that ACOs are our most powerful tactic in pursuit of that strategic objective” seemed confirmed by all that I had heard.
The perfect methods for the transition ahead of us, especially for the implementation of new financial models and rules that will surely come, are still to be discovered. Clinician and patient engagement are the keys to the future. One thing is clear, organizations that are willing to accept the challenges of a self-prescribed clinical transformation will have a successful future, but it is good to remember what Glenn Steele said, “There will be winners and losers”. Whether your organization will be a winner or loser may be a function of your ability to lead a transformational process.
Elliott Fisher wrote me back and said:
...I agree (If I’ve got your point right) that the fundamental problem and what I hoped ACOs might help accomplish is about changing how we deliver care (“the practice”). It’s about getting the payment model out of the way of delivering really good care. The glimmers of light and hope that I see are from places where physicians (and often others) say: it’s up to us. We can achieve the quadruple aim (Triple Aim plus joy in work)...
He is right. It is up to the practice. It is up to us. The choices are clear. What has been is quickly passing. Adaptive change is hard. It is true that physicians and everyone in healthcare is experiencing great uncertainty and tremendous stress. We may not have “signed up” for what is happening but most of us did sign up to put the interests of our patients and by extension of that reality our communities ahead of our own expectations. It is quite ethical to expect that if you have improved the quality of care that your patients experience, and have improved the health of the community while lowering the cost of care, that you will be rewarded with a professional satisfying experience and can expect that you and your institution will be economically rewarded.
What are the Top Ten Health Industry Questions for 2015?
You can imagine that when I saw that question in an article from the online publication healthcarefinancenews.com I was immediately interested and thought that you might also like to see their list. Here it is.
Top 10 Health Industry Issues of 2015
1. Do-it-yourself healthcare
U.S. physicians and consumers are ready to embrace a dramatic expansion of the high-tech, personal medical kit. Wearable tech, smartphone-linked devices and mobile apps will become increasingly valuable in care delivery.
2. Making the leap from mobile app to medical device
A proliferation of approved and portable medical devices in patients’ homes, and on their phones, makes diagnosis and treatment more convenient, redoubling the need for strong information security systems.
3. Balancing privacy and convenience
Privacy will lose ground to convenience in 2015 as patients adopt digital tools and services that gather and analyze health information.
4. High-cost patients spark cost-saving innovations
The soaring cost of care for Medicare and Medicaid “dual eligibles,” aging boomers and patients with co-morbidities will foster creative care delivery and management systems.
5. Putting a price on positive outcomes
With high-priced new products and specialty drugs slated to hit the market in 2015, increasing demand for new evidence and definitions of positive health outcomes are expected.
6. Open everything to everyone
New transparency initiatives targeting clinical trial data, real-world patient outcomes and financial relationships between physicians and pharmaceutical companies will improve patient care and open new opportunities.
7. Getting to know the newly insured
2015 will be a revelatory year for the U.S. health sector as a portrait of the newly-insured emerges, fostering better care management programs and shifting marketing strategies.
8. Physician extenders see an expanded role in patient care
Physician “extenders” are becoming the first line of care for many patients, as doctors delegate tasks, monitor patients digitally and enter into risk-based payment models.
9. Redefining health and well-being for the millennial generation
As the economy rebounds and baby boomers retire, employers and insurers look for fresh ways to engage, retain and attract the next generation of health consumers.
10. Partner to win
In 2015, joint ventures, open collaboration platforms and non-traditional partnerships will push healthcare companies out of the comfort zone toward new competitive strategies.
The list may not contain what interests you. Many of the subjects seem off the mark of what is really important to me, but the takeaway is that the list is yet another example of the diversity of viewpoints that exist in healthcare today. If you are really interested, the article, which you can access by clicking on the link, will also give you the list for 2014 for comparison.
It Is Really Summer!
How much better does it get than a summer evening on the town green listening to the brass band from a nearby town? [As you can see in the header picture.] Well, watching the Red Sox win another game on you birthday is not too bad either. There are many reasons to be actively engaged in trying to stay healthy, but enjoying summer must be near the top of the list. Whatever your best reason for staying healthy, I hope that you will find the time to enjoy it this weekend right after you get in a good walk which is a reason enough to be healthy. |
