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11 September 2015 Dear Interested Readers, Inside this Week's Letter I have come to believe that everything is connected. Some connections are more obvious than others. Some of the most significant insights flow from connections that were not immediately obvious. One of the objectives of these “Musings” is to discover information that can be mined and put to use to encourage and provide us with new ideas from many places that are not obviously labeled “healthcare”. Perhaps the ability of obscure connections to add to our understanding in healthcare is because insights into good stewardship, respect for everyone’s rights to be heard and the pursuit of happiness and success are universal values that are discussed in many places even as they are core to transformation in healthcare. In Lean these competencies connect to “True North Values” and when we couple them with systems skills and professionalism, plus our commitments to community and empathy for all people, we then have a mindset that best fits the challenges we face on the road to the Triple Aim Plus One. This prologue seems appropriate because the first section of this letter is about my memory of 9/11 (the picture in the header is from a recent visit I made to the 9/11 Memorial at the World Trade Center site). The last section contains my reflections on how my worldview has been influenced by listening to Garrison Keillor for thirty four years. Neither section has an obvious direct connection to healthcare when we view things only as they appear on their surface. I hope that you will be able to see some deeper connections. The middle section is a reflection on my experience with Paul Levy who announced this week that he will no longer be writing his daily healthcare blog which has been a real resource for many of us in healthcare over the last nine years. The letter closes with insights from watching the return of TB12 last night and some comments about what I will be doing over the next few weeks. I hope that you have are developing the habit of checking out strategyhealthcare.com and will continue to tell your friends about it. Don't forget to tell them that strategyhealthcare.com provides a signup opportunity for these musings. It Seems Like Only Yesterday I am sure that anyone who reads this weekly letter remembers with great detail where they were and what they were doing fourteen years ago today when they first heard of the attack on the World Trade Center. It was one of those unforgettable days, like the day the Marathon was bombed or that earlier day in Dallas when JFK was assassinated. Those are days that you can still play in your memory like a DVD. There was only one Zapruder recording of what happened in Dealey Plaza at the foot of the Texas School Book Depository Building, but the next day most of us who are over sixty saw history happen when together we watched as Jack Ruby shot Lee Harvey Oswald on live TV. Like the film Zapruder made in Dallas, videos taken at the time of the first plane hitting the Towers showed most of us what we had not been present to witness. I fear that many more were watching when the second plane hit and even more saw the Towers fall as the live reporting continued. CBS News has shown the attack on the World Trade Center to be the most viewed event of the last 50 years. According to CBS, Sony and Nielsen collaborated on research that ranked events like 9/11, Katrina, the JFK assassination, and seventeen other events, twenty events in all, for their impact. The outcome of the ranking was judged on the basis of more than just how many people saw the event. Also considered was whether people remember where they watched it and whether they talked about it with others. Katrina was a distant second with half the impact of 9/11. I remember very clearly where I was on that beautiful fall Tuesday morning . The clarity of my memory confirms me as one who was profoundly affected. Perhaps you also go back in your mind on this day each year to some place where in a sudden and unexpected moment you realized that the world had changed, or more realistically, suddenly revealed to you that it could no longer hide its deep divides. Prior to 9/11 we had ignored many signals that huge forces and long held anger divided humankind into hostile camps or points of view that seem now, fourteen years later, to be more separated than ever. Sadly, the opposing views of the world and what it means to be in it that created 9/11 are as unresolved now as they were fourteen years ago. On that beautiful but awful fall Tuesday morning I was seeing patients in medical specialties at the West Roxbury Offices of Harvard Vanguard/Atrius Health. I had recently resumed seeing patients there after a hiatus of several years. I loved my Tuesday mornings at West Rox. The administration and staff treated me like a visiting potentate and enabled me to be very efficient. Many of the patients I saw at the site had seen me there in the mid eighties when it was the home of our cardiology department and then followed me to Kenmore, Wellesley or Braintree when the cardiology office was moved to a new and larger space at our Kenmore Square office that sits in the shadow of Fenway Park and within a short walk of the site of the Marathon bombing. I had known many of the patients in the West Roxbury community for years, if not decades. I was delighted when it became possible for me to come to them once again rather than have them travel to me at some distant and unfamiliar site. Our receptionist knocked on the door of the room where I was sitting and talking with an old friend who occupied the exam table. We were sorting through her meds and recent symptoms. Juanita said, “Dr. Lindsey, you and Mrs.xxxx should come with me to see something”. Patients and staff were gathered around a television in the waiting room as the loop showing the initial disaster played again and again. As we watched, fragments of information filtered in from Washington and a rural field near the abandoned Diamond T. Mine in Stonycreek Township in Pennsylvania. The horrors that we viewed as people jumped to their deaths and buildings collapsed brought tears to our eyes and a sense of community to us as our senses were bombarded by images that we would never imagined as possible if they had been part of a Hollywood production. I stayed in the office with the staff and patients until almost one o’clock before rushing away to my Kenmore Office for the afternoon where the scene was essentially the same. Only the most pressing work was being done. I remember calling my wife who was doing a clinical rotation in her NP program at Regis College. We had a great sense of family vulnerability since she was having her first day at an inner city clinic over forty miles away in Worcester and our oldest son had just left for his freshman year at Reed College in Portland. We had an intense desire to gather family around us so that we could be sure that everyone was safe or at least together as fear from the uncertain threat seemed to grow. The visions that we saw on the screen were made more frightening because of our sense of the possibility of the continuing horror with subsequent attacks in other venues that could touch us or distant family and friends. The unique horror of that day was heightened by the universal uncertainty that existed in those first few hours after the world changed. What happened had already come closer to us than we could have ever imagined. It would be a day or so before we learned that a man in our neighborhood whose son was a highschool classmate of our younger son was on that first plane from Boston. As you go about your own routine on this national day of remembrance, I hope that you not only pause to honor those who lost their lives that day but also spend some time thinking about why the anger and disagreement across the world seems as raw and dangerous now as it did fourteen years ago, and how that great sense of national unity that thrived for the first few months after 9/11 has faded as time has made us more accustomed to our new world. The last fourteen years have been a continuously rolling revelation that the deep divides that threaten our world are deeper and wider than ever. The divide exists not only between the western world and the chaotic world of the Middle East but also between us and our partners in what was once called the “free world” and within the borders of this great land. Our divides go deep and exists even in healthcare as we have great diversity of opinion about what we owe one another and what we can righteously claim for ourselves without concern for the cost of that claim to others in our community. I have no solutions to offer but I do know that nobody, no nation, and no religion escapes the reality of humankind’s flaws and imperfections. I have come to believe from all that I have learned in what is now seven decades of a life that has contained many sudden and unexpected moments that I could have and perhaps should have been able to anticipate, that a good place to start in resolving any difference or uncertainty that threatens us is to ask the question, “What part of the problem am I?”. That question opens up the discussion at the place where you have the most control because you need only to negotiate the answer with yourself. Perhaps by our attempts to answer that question we can begin a journey that will honor those who died that day and may in some small way contribute to the larger effort to make sure that such an event never occurs again. Paul, Say It Ain’t So Paul Levy is an “Interested Reader” that gives me feedback on these notes in a regular and consistent way. I am also one of thousands of regular readers of his blog which he began nine years ago under the title of Running a Hospital. Over the last few years after he left his position as CEO of the Beth Israel Deaconess Medical Center in Boston, the title has been Not Running A Hospital. Through the entire experience Paul has been an amazing voice that has continuously called for efforts to improve safety and quality. He has talked about and also demonstrated by actions that often required great courage, the importance and core value of transparency in any genuine effort to transform healthcare to what it could be. He has always advocated for care for everyone that would meet the standard that anyone would want for their own family. He has regularly called out physicians and institutions when they have had relationships with big pharma and medical device manufacturers that involve finances that potentially hinder their objectivity about what is efficient and effective and adds waste to the total cost of care. He has been an outspoken advocate for a competitive medical marketplace and has not accepted simplistic, quick and intellectually thin fixes for the complex issues of healthcare finance and delivery. Through it all he has argued that systems analysis and systems solutions as presented by Lean, coupled with leadership that is based in respect for the people doing the work and the individuals and families receiving the care, is the most certainty path to the quality, safety and value that is our collective goal. I am deeply appreciative of the fact that many of the readers of this weekly letter came to it through Paul’s kind and generous remarks in his blog. You might imagine my sadness and sense of potential personal loss, as well as my concern about the loss of such a strong voice for the things that seem important to so many of us, when I opened my email last Thursday morning and found a very brief message from Paul with a timestamp from the middle of the night. I clicked on the url and discovered with the deep visceral response of a sudden sinking feeling in the pit of my stomach that something that I had taken for granted was going away. As I reread the posting several times I got a little relief from the fact that he was still going to be writing and might occasionally comment on healthcare (as he did in his very next posting about lessons to be learned from near misses, September 8 and again yesterday in comments about coaching); nevertheless, I felt a personal sense of loss learning that these pearls would come less frequently. In his words: To my loyal readers: I've been writing this blog for over 9 years, starting during my tenure as CEO of Beth Israel Deaconess Medical Center, and continuing now over four years later. During that time, I've had a chance to tell many stories and express lots of opinions with regard to various aspects of the health care industry, and you have rewarded me with your readership and your comments. I am deeply grateful for that opportunity and for that connection with so many of you. As my life has moved on, my other activities have evolved. While health care will always be an underlying interest for me (and anybody else getting older!), I am getting more and more distant from the day-to-day policy issues and industry struggles. There are other people who are better suited to write about those matters. So, starting after the Labor Day break, I am planning to shift the focus of this blog to topics where I might be able to contribute to people in a broader range of industries and sectors. The focus will be on my core set of activities and interests--negotiation theory and practice, leadership training and mentoring, and teaching. Some days, clinical process improvement will be covered, as that subject overlaps all of those topics--but you will not be seeing stories about health care policy, industry structure, market power, and the like. I'm also going to reduce the frequency of these posts, from the current daily schedule driven by current events to something more sensible (and personally sustainable!) I'm hoping not to leave my health care followers behind, but I am hoping that others, too, will find the topics of value. Please continue to stay in touch and, as you have done so generously in the past, forward these links to others who might be interested. Thank you. Paul was someone I had heard a lot about before I met him in 2003. At that time Harvard Vanguard was in a period of reassessment following its near death experience after Harvard Pilgrim went into receivership. We had a new CEO, Ken Paulus who retired as CEO of Allina in Minneapolis this year. Ken was leading the board and management through a fundamental reassessment of everything we did with the idea that we must reduce our overhead. We had rented out much of the unused clinical space that had been created by the loss of more than 100,000 patients who no longer trusted the financial stability of Harvard Pilgrim and had left that insurer and our practice. We were building relationships with the other non profit payers in our market but more than 90% of our patients were still coming to us through Harvard Pilgrim. We were on a road to recovery but there was still much to be done. Not only were we trying to open up relationships with more payers but we were going through a reverse situation to the stress that faces most healthcare organizations now. We were going from value based reimbursement to volume based FFS revenue generation and were dealing with all the management confusion that exists in a mixed economic model. We still had many HMO patients for whom we held financial risk, even though we were rapidly learning how to function in the fee-for-service world. Concepts like “revenue cycle” were not an obvious part of our previous world of prepaid care. We had been focused on quality and coordination of care for thirty years and the different priorities and skills necessary for fee for service success were just beginning to sink in. Even as we struggled with finding revenue, we also knew that the cost of the care of our residual capitated patients was a big issue, as was our productivity in the hospitals we used but did not own. [Having lived in that world of transition going from value to volume with a mixed economic platform of finance, I admit that the wailing and complaining of those now asked to shift from volume to value, doing the transition the other way, does at times annoy me. There I have said it!] In a world driven by volume we realized that we could not afford to be giving away care to hospital partners who did not respect our relationship with our patients. It was strange to understand that we were in competition with our suppliers! We were realizing that the cost of the care that we bought as “outside utilization” needed to be managed as part of our “value chain”. The world became more complicated when we realized that those costs were not only a problem as a major part of our expense because we were accountable for the excessive services that our suppliers added, but that our partners were taking away revenue from us by “capturing” our patients and controlling their care. It made a big difference who our hospital partner was. The balance at the time to be considered was the extra expense of using the Brigham versus the loss of patients who felt connected to the Brigham as well as to us. What would really happen if we were to move away from the Brigham? It was not clear whether or not our patients valued the relationship they had with us enough to follow us into a new relationship with a different hospital. Management and the board decided to try to resolve some of the ambiguity that froze us by inviting the Brigham plus the BIDMC, Boston Medical Center, and Tufts Medical Center to make presentations to our board about the value that a relationship with them would bring to our patients. By this time our patient flow was pretty much taken for granted by the the Brigham and Partners and I shared Ken’s idea that a minimal expectation of this process would be to bring some leverage to the continuing conversation with the Brigham. As chairman of the board and as a physician whose patients occasional had been seen in the other Boston hospital systems either by their intention to see a specific specialist or by the accident of predetermined ambulance destinations, or the increasing issue of emergency rooms going “on diversion”, I had patients in hospitals other than the Brigham. I could discern no differences in the quality from institution to institution, but I could see huge differences in cost. Paul led the presentation that his team from the BIDMC made. It was the best presentation that we heard. He understood the principles of “coopetition” as more than an extension of game theory. It is necessary to see, understand and manage areas of coopetition in today’s complex medical environment. The process revealed that the greatest concern of many of the members of management and the board was that there would be resistance from physicians and patients if we were to try to move our principal clinical affiliation away from the Brigham. Our finance people were also concerned about the long term financial health of any Boston hospital other than the Brigham and its affiliated institutions within Partners. Six years later things were different. I was CEO and, with the board and the management team, was concerned about the increasingly negative external reality of falling revenue. It was clear that the era of year over year increases in payment of 7-10% were over. Our revenues were approaching 2 billion dollars a year with small margins because of high rates of outside utilization. Any flattening or downturn of revenue growth would result in oceans of red ink in the twinkling of an eye. The only logical responses to getting paid relatively less for more work and the demand for higher quality was to reach for a tool like Lean and a business partnership like the one the BIDMC offered. In the interim my clinical impression that the quality care at the BIDMC was as good or better than any hospital in the city, or perhaps the world, had been substantiated by objective data. With Paul’s leadership and the response from the good people at the BIDMC, they had made huge gains in putting their wonderful organization with a terrific history of patient centered care back on a stable financial footing. So, using Lean as our major tool, we made the move to the BIDMC. Looking back now with the benefit of more than five years of perspective, it was a good move for both organizations. Paul was a major contributor to the success of this complex strategic move and I will always cherish the opportunity to have worked so closely with such a master of leadership, motivation and solid business principles. I do however, disagree with his idea as expressed in the recent blog: While health care will always be an underlying interest for me (and anybody else getting older!), I am getting more and more distant from the day-to-day policy issues and industry struggles. There are other people who are better suited to write about those matters. I understand where he is coming from but for very selfish reasons I disagree with his opinion and his conclusion that it is time to reduce his blogging about healthcare. The wonderful thing about working with Paul is that an apparent disagreement is often the beginning of learning. It is my sincere hope that by working within a wider area of expertise he will, as he has always done, provide those of us who fly closer to the ground in healthcare the benefit of lessons learned from a wider scope of view. Whatever Paul writes in the future I will be reading it. I wish him well with this next step in his very interesting personal journey. Garrison, Say It Ain’t So I once referred to myself as a Garrison Keillor groupie, but that was hyperbole. It is true that over the last 34 years listening to his program on a very regular basis has been a source of great pleasure and substantial enlightenment for me. In the spring and summer of 1981 I spent a lot of time in Middlebury, Vermont hanging out with a new set of friends. It was a transitional year in my private life and I was open to new experiences. The group was a talented, very intelligent and eclectic bunch and they regularly listened to this silly recreation of something like the "Grand Ole Opry" every Saturday evening at six that was sponsored by fictitious enterprises like Powdermilk Biscuits and Bob’s Bank. I eventually moved on from the Middlebury group but I did hang on to the routine of checking in with “Prairie Home Companion” most Saturday evenings to get updates from the the Side Track Tap, the Lake Wobegon Leonards and to keep up with the church social events down at Our Lady of Perpetual Responsibility. As the years rolled by and life became busier and busier on Saturday evenings with two young sons, I started recording the two hour program on a cassette so that I could listen to it on my Walkman while running during the week. That habit went on until the shows were available on the Internet! Over time I collected hundreds of hours of Prairie Home and was all set with my own reruns when about twenty years ago Garrison ran off to Denmark for a few years or so to marry the Danish exchange student to his high school that he had reconnected with at a high school reunion. This last Saturday evening, while I was peddling around the lake in my kayak trying to catch some fish and listening to Garrison broadcast from the Minnesota State Fair, the rumor that I had heard that this would be Garrison’s last season seemed confirmed by clues in the program. A quick trip to the Internet gave me the whole story. I always knew that this time would come. At least I have almost a year to prepare for my loss. Keillor is famous as a storyteller. He has created a world where we can study community and human nature using as a stable focus his fictitious hometown, Lake Wobegon, Minnesota that is located off the map somewhere “north of the cities”. In Keillor’s art Lake Wobegon has become a gentle and forgiving learning lab where we can laugh and be slowly co opted into a search for a better world by his humorous and fanciful tales about a simple place where issues like pride, fear, low self esteem, narcissism and the mismanagement of every event from the local baseball team to the fourth of July celebration become a source of insight for life in more complicated times. That learning lab opportunity is supported by humor and irony laced with nostalgia. His stories never become sermons and any potential for controversy or tension is defused by good music and “pretty good jokes”. I see him as a dispenser and promoter of a philosophy and ethical framework for life in complex and morally ambiguous times. He is often compared to Mark Twain, and it is also possible to argue that there are shades of Will Rogers in his formula. He has been at his craft so long that perhaps we should turn the comparisons around and compare Twain and Rogers to Keillor. Garrison has provided me with many hours of pure listening pleasure. His presentations, whether enjoyed on the radio or in a theater, have the ability to suddenly launch me and, I assume, many of his several million listeners, on our own journeys of self examination with questions about what we fear, what we hide, and why we are so anxious. His characters are acceptable imogees for ourselves, and viewing their mistakes and successes provide us with the ability to explore the control we have in our own lives. Some seminary should give him an honorary doctorate in applied theology, or perhaps some school of economics an honorary degree in behavioral economics. The isolated evaluation of his singing, his parodies of old favorite songs with new and humorous lyrics, his presentations of poetry and his funny but uncomplicated prose, will never put him into any higher echelon of recognition. We will miss him because he has masterfully blended all of those marginal talents with an exceptional ability to tell a story and a palpable empathy for all of us as we struggle with our personal concerns. His stories suggest that he cares about people and they gently suggest that if we can laugh at ourselves we will discover a way to live in harmony with one another, exercising empathy for everyone no matter how misguided they are by our own personal reference points. I am all set Garrison. I will have 35 years of your material to protect me from the crazy things that occur in the real world. I will use my tapes and your echo on the Internet to return again and again to Lake Wobegon, “where all the women are strong, all the men are good-looking, and all the children are above average”, perhaps because they are getting “pretty good” healthcare. Thursday Night Drama and The Next Two Weeks Whether delighted or enraged with the outcome of the non resolution of the core issues of “deflategate”, the world of those who live and die watching or waiting to watch NFL games began to spin on its axis again last night. It is a bimodal world composed of those for TB12 and Bill “in the hoodie” versus those who consider TB12 and Hoodie Bill to be a threat to all that is pure and worth protecting in a world that is off the tracks and headed to some bad place that associating with “cheaters” will carry us all. Whether you think the righteous prevailed or the forces of evil continue to claim victories they do not deserve neither P.T.Barnum nor Florenz Ziegfeld could have done a better job with the hype that launched the first game of this annual celebration of mayhem, strategy and faux significance that is a diversion from a world where we are more clueless about process and what is important than Roger Goodell is. I thought it was a pretty good game and will not attempt to draw any conclusions about the wages of sin based on what is essentially theater. On Saturday my wife and I depart for a trip to South Africa. I have every expectation that you will receive these letters over the next two weeks, just as I wrote from our river cruise on the Rhine two years ago. We are working on our bucket list. Travel does broaden the possibilities for my “musings”. I should say that one of my favorite books in early childhood was about Ruppert, the near sighted rhinoceros. All of his troubles were resolved by good glasses that allowed him to see that the world was not full of threats. I am hoping to finally meet Ruppert on our trip. I hope to walk more than I write. We will see how it all turns out. Be well, Gene Dr. Gene Lindsey http://strategyhealthcare.com The Healthcare Musings Archive Previous editions of the "Healthcare Musings" newsletter, by Dr. Gene Lindsey are now archived and available to you at: www.getresponse.com/archive/strategy_healthcare
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