| 13 May 2016
Dear Interested Reader,
What's Inside This Week’s Letter
This week’s letter begins with thoughts that were generated by comments from a very loyal “Interested Reader” about last week’s letter. I hope that you will enjoy the journey of thought that those comments generated. I also hope that you will be forgiving of any errors in my interpretation of history and the leaps that I might take as I attempt to find insight by jumping back and forth from the past to the present.
Is anticipating the future and then creating and executing a vision and strategy to optimize the future for the collective the most critical and difficult task that faces us? If so, then living together in the imperfection of the moment is almost as difficult and more immediately painful. It would be nice to settle all of our current controversies by examining the past for the truth that has emerged from common experience; but alas, even though the past is common to all of us, we seem to view it with as much variation as we see this moment and the future. What the past means is as vulnerable to the opinions, biases, variability in awareness or the spectrum of understanding from disinterest and ignorance to awareness and insight, as is the present.
I know from electronic monitoring of this letter that the links get the attention of about 17% of you. I understand. I am offering up thousands of words and it is a lot to ask you to carefully read some of what I have written, and even more to expect that the majority of you will follow the links to obscure references. I do frequently follow the links in other people’s writings, but I am retired and am not that busy. I am also a reader of footnotes and endnotes and find that I learn as much or more from the links and references as I do from the piece in front of me. Give the links a try. Just click on anything that is blue. Some of the links just go to Wikipedia, but others connect to surprising places. Who knows what you might discover following links to links?
After musing on the observations about my possible shift in attitude regarding the future of healthcare reform, I move on to describing a wonderful experience that I enjoyed at the conference in downtown Chicago where I spoke last week in the shadow of Trump’s Tower. I would characterize that meeting as a private “GPIN lite”. Participants from eight organizations varying from a large AMC to regional health systems and a large multispecialty group practice gathered to share experiences in the transition from volume to value. They came from a mixture of sectarian and faith based enterprises. Despite variation in size, market realities, and whether they are in a blue state or a red state, and furthermore regardless of their prior history or experience with capitation or fee for service, no one is having an easy time, but everyone is trying hard. One story in particular moved me and was a great example of what is possible from a combination of concern for those suffering in the moment and a growing awareness of the benefits offered by attempting to embrace the principles of population health and accept the challenges of preparing for risk and moving from volume to value to improve the health in your community.
Spring finally arrived in New Hampshire this week. The water is a little warmer and the fish are waking up to discover that they are hungry. Today’s header is the portrait of the first of many rainbows that I hope to scold for impulsive behavior this summer before giving them a second chance. The loons are doing what they do before doing their thing that they are not very good at doing, which is making more loons. Loons and panda bears are a lot like people in that they seem to require a lot of help surviving in a world that they are not designed to inhabit nor are quite equipped to survive without a little help from their friends.
Success can be fleeting and sometimes depends on the opposition that you face. Whether it is normal cause variation, new and reliable competence or just weak opponents, I have enjoyed the recent success of the Red Sox. In the last section I try to see meaning in their struggle to regain the lofty heights of 2004, 2007, and 2013 during this last year of the Big Papi era.
Getting the most out of this week’s letter will be assisted by doing a refresher of last week’s letter. That is very easy to do by following this link to strategyhealthcare.com where you will find that “Games about Volume to Value” has been cut in half and is waiting for you since Monday, May 10! Persuasion or Compulsion as Drivers for Value Over VolumeFollowing last week’s letter a very faithful “Interested Reader” wrote to me:
An uncharacteristically downbeat letter, Gene, but interesting and challenging. I sent you a response a while ago about the usually very powerful forces behind any status quo, and this is an excellent, though not in a good way, example of that point. The 19th C American reformers, especially anti-slavery and anti-alcohol, vigorously debated the persuasion/compulsion options. Both issues were, of course, ultimately resolved by compulsion. This may be a similar kind of issue, where the compulsion will come from governmental and private payors. In those old debates, I expect that you would have inclined to the persuasion side because that is based on the belief that people will do the right thing if only that can be brought to see the truth, a very Protestant view.
If you did not read last week’s letter, my pen pal is referring to my musing about the “war games” experience that I had in Washington two weeks ago. I did leave that meeting with a mixture of feelings but they were not new, just dramatically reinforced. I have always been aware of the power of the status quo to resist change and the slow pace of change that is the resultant outcome of the interaction of that force with the compelling need for change. You can check out an abridged and edited version of last week’s letter on strategyhealthcare.com. Perhaps my friend was reacting to my sarcastic comments about the clouds that shade our hopes for the Triple Aim and the low likelihood that it will be achieved anytime soon. I did say:
The introductory comments to the “war games” excited me when I heard that the objective was the Triple Aim. As the first hour of discussion introducing the exercises came to an end I had to admit to creeping realism and a growing cynicism. I kept my self righteous thoughts to myself. What was going through my mind that perhaps I did not have the courage to point out was that the goal was not really the Triple Aim, but rather a revision which I described as “two heavily qualified hopes and one impossible dream”. Based on that I was ready to wordsmith the goal to read:
Care for most of us in the future that is about as good as some of us can find now, health that gradually gets better for more people sooner or later, cost that continues to finance the system without much change, as long as can be afforded by transferring more resources from other concerns, …for at least eight five percent of people most of the time… with the hope that our grandchildren might be smart enough to do better.
The most important idea in my pen pal’s note was not the question of my mood but his use of history to speculate on how change will occur in healthcare. It was a discussion of the relative value of carrots and sticks. What is also unique in this moment is that both CMS and private insurers are picking up sticks, although they are attempting to hide them in velvet sheaths. Or as my pal eloquently says:
The 19th C American reformers, especially anti-slavery and anti-alcohol, vigorously debated the persuasion/compulsion options. Both issues were, of course, ultimately resolved by compulsion. This may be a similar kind of issue, where the compulsion will come from governmental and private payors.
My interested reader knows me pretty well when he suggests that I prefer persuasion or carrots to compulsion or sticks. I am not sure if that is a function of my religious heritage or some other factor in the mixture of nature, nurture and personal experience that has made me who I am now on the front end of my eighth decade. There are a lot of Protestants in health care and politics with a point of view that is 180 degrees from mine. Donald Trump is a Presbyterian. For whatever set of reasons, it is my nature to be drawn to leaders who are advocates for the common good. My heroes are women and men like Eleanor Roosevelt, Dorothy Day, Frances Perkins, John Kennedy, Martin Luther King, Jr., Bobby Kennedy, and Don Berwick.
Who among us is not moved or at least for a moment pauses and reflects when we hear a phrase like:
My fellow Americans, ask not what your country can do for you, ask what you can do for your country.
or :
I have a dream that my four little children will one day live in a nation where they will not be judged by the color of their skin but by the content of their character.
Most American’s never heard of Frances Perkins, or if they saw her name on the front of the offices of the Department of Labor, just off the Mall in Washington, they would not know that there are few people who added more positively and quietly and without personal profit to our society than she did as the first woman in a Presidential cabinet. She was always remarkable in the steadiness, consistency and positivity of her character during her more than twelve years as Secretary of Labor under Roosevelt and Truman. She said many inspiring things like:
Out of our first century of national life we evolved the ethical principle that it was not right or just that an honest and industrious man should live and die in misery. He was entitled to some degree of sympathy and security. Our conscience declared against the honest workman's becoming a pauper, but our eyes told us that he very often did.
We owe much of what we enjoy today as social security and the concept of a minimum wage to her sense of what is right and her commitment to an ideal. She has a body of work that affirms that quietly she did contribute to America’s greatness. By nature I am also drawn to the patient but active methodology for change advocated by Bobby Kennedy:
Few will have the greatness to bend history itself, but each of us can work to change a small portion of events. It is from numberless diverse acts of courage and belief that human history is shaped. Each time a man stands up for an ideal, or acts to improve the lot of others, or strikes out against injustice, he sends forth a tiny ripple of hope, and crossing each other from a million different centers of energy and daring those ripples build a current which can sweep down the mightiest walls of oppression and resistance.
In healthcare I have looked to Don Berwick for more than a quarter century for the words that persuade and sustain me. His words always reveal the facts that we do not want to face or have ignored and the human reasons that we should no longer be deaf to the call to do something. Consider these two thoughts from Don.
Any health care funding plan that is just, equitable, civilized and humane must - must - redistribute wealth from the richer among us to the poorer and the less fortunate. Excellent healthcare is by definition re-distributional.
And also:
The quest is clear. It’s not power or accountability or reward or punishment or score sheets or metrics or profit for its own sake. It’s a search for meaning in the value of the person who has come to honor us with his or her quest for some help.
These are “persuasion” people who advocated for a better future for everyone. Some like the Kennedys and Perkins had the ability to both persuade and for a little while, when in office, the ability to use some compulsion.
Ironically, as my Interested Reader points out most of the measurable progress has occurred through the action of the agents of compulsion like Abraham Lincoln, Thurgood Marshall and Lyndon Johnson. What is missing in his analysis is the interaction between long suffering persuasion and definitive compulsion. What would Johnson have been able to do for Civil Rights through legislation or “compulsion”, as my reader infers, without the simultaneous efforts at “persuasion” being pressed by Dr. King and those who responded to his call? Would Lincoln ever have had the opportunity to sign the Emancipation Proclamation or the insight to push for the 13th Amendment had it not been for efforts of committed public figures like Thaddeus Stevens (as depicted by Tommy Lee Jones in Stephen Spielberg’s Lincoln) and the well organized abolitionists like Harriet Tubman whose image will grace our new twenty dollar bill.
The portrayal of Stevens is most remarkable because history apparently corroborates that he had the insight and courage to tame his tongue and modify his objective to achieve an improved state that was less than the perfection of full equality he wanted and that is still a matter of national concern 150 years later as demonstrated by “Black Lives Matter”. Perhaps it was the tension between the “pew time” I logged as a child where I heard the teachings of Christ on Sunday and the reality of what I witnessed the other six days of the week in the South during the Civil Rights struggles of the fifties and sixties that makes me aware of the realities of the “persuasion/ compulsion” options.
What is more amazing to me in this election year than the bizarre collection of candidates that we have been offered, and from whom we will choose a new leader, is the fact that a majority of voters, if you combine those advocating for America's “return to greatness” or the end of the “advantages of billionaires”, are in favor of profound change. Their desire for change is an expression of their sense of being wronged or injured by the status quo. If we survive this year, it will be because as a collective we are willing to trust once again that the changes required to achieve justice still can be negotiated within the framework laid out by the Constitution.
What is frequently misunderstood and often frustrating about our Constitution is that it makes change painfully slow and seeks to protect the established rights of some minorities, even when those minorities are wealthy and self interested. It also makes it very difficult for minorities that lie far outside the eighteenth century definitions of those who were franchised to obtain a voice. But time and time again, progress has been made. It just takes time to extend the franchise to newly recognized minorities. The uninsured are an example of a minority that is yet to grasp its franchise.
What I witnessed at the “war games” was like powerful theater. We were play acting but we participated in the hypothetical scenarios as actors who really knew their roles from experience in the real world and whose performance in the play was likely to be highly predictive of the actions that they or others like them would take in real life. All of the actors had “been to the theatre” in the real world of healthcare.
The imaginary market, “San Optimo”, at my table was in a “red state” that had not accepted the Medicaid expansion of the ACA, but had lower than average Medicare costs. In San Optimo there was significant cost shifting from relatively expensive commercial insurance to cover bad debt from the uninsured and to provide comfortable incomes for providers and institutions. Even though there was a persistent large uninsured population that generated bad debt for institutions and poor care for those without coverage, at the steady state the majority of providers were satisfied with the status quo and threatened by suggestions of change, even though employers were unhappy with the costs they were forced to bear and taxpayers were unwilling to extend Medicaid to their neighbors in need.
One of the players or actors at my table had actually been one of the architects of the Harry and Louise resistance to the 1993 attempt by the Clintons at healthcare reform. I found him to be incredibly believable, positive, informed, focused and ethical in his role in our imaginary community as he played the role of the CEO of a for profit hospital system. Things in our play world and in the real world are never as black and white as they are in the literature or in a political debate. This new acquaintance does not reject the principles of the Triple Aim but he does want to protect a constituency that he is aligned with and benefits from as we make the transition from volume to value.
There are human reasons that make it very hard to change the status quo, even when “the platform is burning”. Next week I hope to explore loss avoidance, the endowment effect, and prospect theory as they pertain to risk and the shift from volume to value. It will be a real stretch for a novice in the nuances of behavioral economics.
In Chicago last week there were several experiences that connected to the question of the interplay between “persuasion and compulsion”. Perhaps the best story was one told by a hospital system that could have been in “San Optimo”. In this real world story there is a hospital system in a moderate sized city with a good university and medical school in a red state with a well publicized history of racial tension and attempts to enforce what some would call limitations of personal choices that offend conservative Christianity. Needless to say, that this state has refused to expand Medicaid and over 20% of its population is poor by any standard and uninsured.
There is no DSH hospital in this market. All of the hospitals take care of large uninsured populations but still make a small margin because of cost shifting from commercial payers. The hospital management is responsible and very concerned. What can they do?
What they chose to do was an excellent exercise in population health and compassion that was the result of persuasion and the reality that they sense compulsion is coming. As they examined their bad debt and tried to understand what they might do to limit their losses, they identified a population of underserved patients who had issues of chronic disease and behavioral health and frequently came to their emergency service and had to be admitted because of the severity of their illness. Remember, we have had a law since 1986 that forbids us from allowing people to die in the street. Remarkably, they decided to do something different. They established and funded a system of free care that provided outpatient resources that were geographically proximate to the patients and designed to meet their needs with the prospective goal of improving their health!
The result was a dramatic reduction in EW use, hospitalizations, and bad debt. The quality metrics and health of the patients improved. The reduction in bad debt was greater than the investment from the hospital’s margin! This also could theoretically prevent the extra costs that employers bear as they funded, whether they knew it or not, the hospital’s cost shifting.
This is an example of “persuasion and compulsion” in action in concert. I would propose that it was a function of Don Berwick like sensibilities arising from providers and a system that cares about its community, warts and all, and is also aware that things are inevitably changing. They realize that they need to begin to explore what the shift from volume to value might mean for them. They were doing Triple Aim thinking and their little pilot will provide enough heat to keep my flickering hopes alive for yet a little while. It is not time to give up. It is time to learn how to effectively manage the balance between persuasion and compulsion.Grand Slams and Big Fish as the Sox Come AliveIt is rare for there to be more Red Sox grand slam homers than good sized fish that I have caught at any point in time in a season. Baseball season nicely matches my fishing season. This year the Sox have at least two grand slams to my one really nice fish. That may seem like a combination of unrelated events in your world, but in my world of infinite metaphysical associations it is a statement that makes perfect sense.
Dustin Pedroia probably has the highest home run to body weight ratio of any professional baseball player in the history of the game, and he has hit a grand dinger already this year, along with five ordinary shots over the fence. Jackie Bradley, Jr. continues his remarkable coming of age with three dingers including a grand slam as he victimized the below par pitching of the poor Oakland A’s, a team that always deserves more than it gets, and every other pitcher he has seen in a remarkable 18 game hitting streak.
I think these Sox are really talented. Last night David Price pitched consistent with his paycheck and there were more homers and doubles. The A’s pitching was sketchy but the opposing pitcher for the Astros last night was 20 game winner, Dallas Keuchel, who also won the Cy Young award as the best pitcher in the American league last year! The last time the Sox scored eleven or more runs four nights in a row was in 1950! The last time they scored ten or more runs in four games was in 2007, and we know what happened that year!
My fishing this spring had been more like the recent playing of the A’s and Astros than of the Sox. I had caught a few pretty ordinary fish but collectively they did not add up to much. Wednesday evening both Jackie and I had a good time. Homers and nice fish always arrive as a sudden electric thrills. The difference is that you have to land the fish; the homer is gone the second it leaves the bat. I enjoy making up games and now I have a new one. The competition has commenced. My fish count versus Red Sox homers. I am rooting for both teams. This is one game where I really can’t lose.
And finally there is the election. Enough said for now. We have until November and forever to explore the relationship between party politics and the health of the nation. Whether you are a baseball fan, a political junkie, or neither, I hope that you will be active outdoors this weekend. I had a terrific six mile walk in the rain last Sunday with one of my new friends. I am always looking for companions on the trail or on the water.
Please stay in touch, like my friend who has a sense of history does, and be creative like the folks who are doing their best to provide great care, despite the unfortunate reality that they and their patients suffer the consequence of living with the misfortune of the inconsistencies of thought and the short sightedness of red state politicians. |
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