15 May 2015
Dear Interested Readers,
Inside This Week's Letter
This letter was harder to write than I anticipated as I laid it out in my mind during my travels and reflections this week. The first section is more than the review of Atul Gawande’s latest New Yorker article. In the discussion I try to put his impact on my thinking and understanding of the issues of the moment in the context of other thinkers who have influenced me. I do eventually get around to discussing the article. The second section is a brief recounting of two meetings that I had the pleasure of participating in this week. There was much to learn. The second section is a brief recounting of two meetings that I had the pleasure of participating in this week. There was much to learn. What can be better than that?
I hope that you are learning to visit strategyhealthcare.com mid-week for the new weekly posting. I would like to welcome several new readers this week and encourage all of you to let friends and colleagues know that there are still some free things to be had. As I type “free” I remember that in our times it is often true that “free is not cheap enough” and reading is never a free exercise because it costs you your time and attention. Thank you for investing your time and attention if you choose to read further.
Appreciating Atul as My Latest Hero
I have this theory that there are those who walk among us who must be from a different planet. They operate at a level that is remarkably beyond what others can accomplish and they see things that others of us who have more normal capabilities can only dream about seeing. We read about these people. Sometimes we read what they write. Rarely we have the honor of meeting or knowing them personally. I keep a mental list of the exceptional people that I have met in healthcare.
If you have not noticed that I have an abiding admiration for Dr. Robert Ebert, you have not been paying much attention to what I write or you have not read much of what I write. For many reasons he is at the top of the list of people that I have known who seem to me to have intellectually come from a “different planet”. You know, like Superman from the planet Krypton.
Chronologically the next giant on my list may surprise you. It is Dr. Sam Thier who was the CEO of Partners. Prior to that he had been president of Brandeis University, President of the Institute of Medicine, Vice Chair of Medicine at Penn, Chair of Medicine at Yale and CEO of the MGH. I knew him in the spring of 1968 when he was 31 years old and was my lab instructor. He had recently been the Chief Resident in Medicine at the MGH and had become the MGH Chief of Nephrology at age 30. His lectures to our class were short and to the point, rarely filling the hour and in the lab he explained things in a way that one did not forget. He was always available for the “dumb” questions. He was my best instructor in medical school.
My next encounter with someone from another intellectual world was Don Berwick. Of all the interesting and inquiring people walking around Harvard Community Health Plan in the seventies and eighties none came close to Don in terms of character, imagination and intellect. What happened during those early and formative years was just a preview of what he was to lead us all to understand after he left HCHP to found the Institute for Healthcare Improvement. I will never forget the day sometime in the very late eighties when he ran up to me in the hallway of our administrative offices and announced in a very excited voice that he had data that showed that it was “unsafe to get care” in our offices. Well you cannot fix what you do not recognize or measure. It was not a surprise to me when he presented data to the whole country that it was not “safe” to get care in America. In both situations he turned his powerful skills to the work of leading us to make care safer.
It seems like I run into one of these people about every ten to twenty years. After Don, no one really fit my concept until one day at a board meeting of the newly merged Harvard Pilgrim Health Care a very young and physically imposing Charlie Baker walked into the boardroom to speak as a guest to talk about the issues in healthcare in Massachusetts. He had been invited in his capacity as Governor Weld’s Secretary of Health and Human Services.. The year was 1995. I had heard a lot about him and was not open-minded to his words initially because of some of the cost cutting measures that he had already instituted in the state’s mental health facilities; but as he spoke I became transfixed by the the easy flow of his words and the apparent clarity of his thought. I said to myself, “He is from another planet.”
A few years later when I was Chair of the Harvard Vanguard board we hired him to be our CEO. When Harvard Pilgrim was teetering on the edge of financial collapse I was part of a board decision to elevate him to the role of CEO of Harvard Pilgrim. No one will ever know for sure whether Harvard Pilgrim would have survived without Charlie Baker. With him HPHC did survive and continues to thrive. I am personally secure in my assessment that unless a person had had the managerial gifts of someone from another planet, he could not have done the job.
We read about all the different types of intelligence and genius. The accomplishments of Ken Paulus during the darkest hours of Harvard Vanguard’s struggle for survival after the receivership of HPHC in the last hours of 1999 were a fantastic demonstration of other worldly leadership and “just in time” strategic evolution. I remember calling Ken to tell him that he need not keep his commitment to take the job as our CEO. He was scheduled to start on January 17, 2000. I knew we were perhaps in trouble beyond recovery. Our auditor had told me, “Your organization is not a ‘going concern!. We had less than a week of cash. There was uncertainty about our ability to meet our payroll or pay our bills in the early months of the new millennium. It seemed only fair to suggest that we were willing to let Ken off the hook, given the precipitous change of fortune in the previous few weeks since he had accepted the job.
I remember the unrealistically positive and enthusiastic voice at the other end of the line. By the end of the phone call my spirits were higher and I was drafting on his enthusiasm. He coupled that positive attitude with a series of brilliant managerial moves that turned us around, but the mark of genius from another planet was his ability to relate to physicians. I have known many non-physician medical executives but in my mind to steal a phrase to describe Ken from Carly Simon, “Nobody does it better!”.
And then there is Atul Gawande. He communicates in books, New Yorker articles, in speeches and even on the “Colbert Report” like no doctor I have ever meet. As I was thinking about this piece I discovered that his website lists the 41 articles that he has published in the New Yorker since 1998. The same site lists his four very influential and best selling books since 2002. The last book Being Mortal has been on the New York Times list for 30 weeks now and I do not think the title applies to him. He is far from mortal. I have heard Dr. Gawande speak on many occasions. He mesmerizes audiences from the IHI meetings in Orlando to the annual AMGA meetings. He has also spoken at Harvard Vanguard where he was once was an exceptional general surgeon. My favorite speech remains the one where I first heard him discuss the difference between ignorance or lack of knowledge and incompetence where we do not know how to use the knowledge that we have available to us.
I was happy to find the list of Gawande’s New Yorker articles so that I can be sure that I have read them all. The one that appeared last week, “Overkill: An avalanche of unnecessary medical care is harming patients physically and financially. What can we do about it?”, is perhaps the best one he has ever written although I think that each time I read one of his articles. My all time favorite had been “Hot Spotters” from 2011, although the one that has probably had the most impact is “The Cost Conundrum” from June 1, 2009. You can read any of them by clicking on them on his website. The same page gives you access to all of his New York Times, Slate and other publications. I think he has written more words than John Grisham.
In last week’s letter I promised to comment on “Overkill” in this week’s letter. Your appreciation of "Overkill" will be enhanced by rereading “The Cost Conundrum” because an important part of this latest article is the description of what has happened in the medical world of McAllen, Texas since the physicians and executives there were exposed by Gawande’s article as being some of the most expensive utilizers of Medicare resources in the country. If nothing else, the new article chronicles the aftermath of this unwelcomed transparency and underlines the power of transparency to drive real change. I am getting ahead of myself but that statement alone emphasizes the potential of continuing change driven by this article and is testimony to the power of Dr. Gawande’s pen.
In the past I have suggested that Gawande is a Lean thinker who perhaps does not know it. I base my assertion on what he writes. He approaches his subjects with clarity about the “reason for action” and can even reach back in history as he did in his article on “Slow Ideas” to make the case for action as he did in that remarkable article mentioned in the Colbert Report clip about that you saw if you followed the earlier link. The “Cost Conundrum” moves quickly from reason for action to a description of current state and then offers a “box three” picture of a better world by taking the reader from McAllen to Grand Junction, Colorado.
In 2009 I was actually more interested in learning what the good doctors were doing in Grand Junction than what the worst of the most expensive were doing in McAllen. Atul also shows Lean thinking when he goes to the “Gemba” as he does his research for his articles. He does not usually write about what other people have written as I am doing here, but rather he goes to the scene and asks questions and makes observations. If that is not a Lean technique, then what is?
He is most competent in box four. He looks at and discusses all the angles and all the barriers in the motif of narrative non-fiction. The reader is never at a loss for the information necessary to begin to formulate a solution. And then there is the solution phase, or box five. He advocates for better communication in the “Slow Ideas” article. In “Hot Spotters” we come away wanting to try some of the things that Iora Health was doing in Atlantic City or that Jeff Brenner was pursuing in the innermost parts of Camden, New Jersey. The book Checklists is one big box five suggestion.
I will rest my case that Dr. Gawande is a natural Lean thinker with the observation that he must spend a lot of time in box nine deep reflections because each new article seems connected at its end to the next cycle of improvement that he sees as possible. There is a progression of thought and learning that you can follow as you look back over the body of his work and realize that he is always looking to advance everything by focusing on the principles that are universal to practice everywhere and that connect to the Triple Aim. Through the body of his writings you can see a potential picture of better care emerging one story at a time. In this latest article he really takes aim at a big Lean concept, which is the negativity of waste. Having made the case for his relevance as a Lean thinker that did not need to be made, let us now move on to what makes “Overkill” so good.
Gawande hooks us from the beginning with a story of waste from his own practice. The story achieves two things. It gives us a clear picture of how waste frequently emerges as a manifestation of good intentions and it also is a confession of his own failure that demonstrates empathetically how hard it is to function between what the patient wants and what constitutes good stewardship of resources. He continues with his expression of empathy as he describes the difficult decision that a friend was forced to make for his father. Once again, what seems like the pursuit of a few more good years backfires into a loss of time that could have been secured for certain, except for our addiction to trying to “do something”. He takes his solution, which is a combination of “caveat emptor” and second opinions, from “Click and Clack” the “Car Talk” guys on NPR. Tom and Ray are so wise and funny that they too must be from another planet, although they did not make my original list because they are not healthcare guys. [I had the privilege of knowing them both for many years through a shared friend who is an “Interested Reader”.]
Atul tells one more story before he returns to McAllen, six pages into the article. The story he tells describes how some employers are fighting back against overkill in practice by directly contracting for care with efficient and effective health systems. In his story a Walmart employee in Utah is taken at company expense to Virginia Mason where conservative treatment and not high risk surgery is the solution to the problem. After the Walmart story, he then returns to the discussion of McAllen.. As presented in 2009, McAllen had been a clear picture of what “bad” care looks like. Atul begins the review of what he wrote about McAllen by saying that the McAllen doctors were practicing inordinate “overkill”. In the same article he had looked at Grand Junction and El Paso and now he says, “The difference was that McAllen’s doctors were ordering more of almost everything—diagnostic testing, hospital admissions, procedures.”
The last five plus pages of “Overkill” chronicle what has happened over the six years since “The Cost Conundrum” was published. Now McAllen is better with much less expense and better outcomes. Big changes have occurred over the last six years. Primary care leadership, Medical Home thinking and ACO participation have lowered the cost of care and produced significant benefits to physicians through income earned through good ACO performance. Leadership emerged and new ideas of resource stewardship replaced the drive for large profits through revenue from overuse.
The article is an argument for spreading all of these tools and the continuing focus on the elimination of waste, but perhaps the most startling revelation is the power of transparency to initiate improvement. It is a true-life story of what happened when bad care is exposed and clinicians are able to see what parts of the problem they are or could improve. As practices everywhere wonder if they can make the changes that will make a difference, McAllen moves from an example of what “bad” looks like to what “good” can be like.
It Was A Good Week
Tuesday I traveled to Westborough, MA for the Annual meeting of VNA Care Network and Hospice. I am a proud board member. As I look back on my years of leadership at Atrius Health I have many fond memories, but nothing provides me more continuing satisfaction than the work done to bring VNA Care Network into Atrius and then the expansion of the strategy by helping VNA Care and VNA of Boston to come together to create a blanket of VNA services that was a perfect match for the Atrius footprint. The future of healthcare will be in the promotion of wellness and the management of chronic diseases. The capability of the VNA services to enable the ambulatory practice to diminish the use of hospital and post acute facilities is enormous and expanding. I live in expectation of the day when the hospitalization of a patient with an ambulatory sensitive diagnosis is a sentinel event.
There were two big topics under discussion at the meeting. The first was a very informative review of how to run a parallel home care service in conjunction with VNA services. Home health aides, homemaker services and companions are all part of the picture of the optimal care of the frail elderly and disabled patients of all ages. The ability to have a meal in your own home and sleep in your own bed becomes for many what seems like an impossible objective, but when we engineer the possible to be the usual then we are making progress. I was impressed with the understanding that has emerged and is ready for implementation when intelligent people look around for best practices.
Nalari Health made the second big presentation. Click on their name and check them out. They represent a true innovation. Utilizing their services we can manage a patient anywhere. An immediate application of their technology would allow better evaluation of patients in post-acute venues where there is good nursing care but no physician. It was terrific to try on a Bluetooth enabled stethoscope and imagining what it might be like to examine and manage a patient who is many miles away. Last week I commented that I was born too soon. The golden age of ambulatory care is upon us. New configurations of technology like the Nalari package will continue to transform practice. Imagining how to configure workflows and care delivery to take advantage of the emerging technologies will require Lean thinking and continuing innovation in healthcare finance. The work is challenging now because of many barriers that must be addressed, but I predict that these technologies will drive more and more practice innovation and the issues that seem insurmountable will become moot questions in short order.
Wednesday was the quarterly meeting of the Advisory Council to the Health Policy Commission of Massachusetts. The two hour discussion was far ranging but then in the last half hour focused most specifically on strategy development and deployment. At one point in the meeting I reflected back on how excited and hopeful I was when Chapter 305 had been passed and called for the entire state to shift in five years to global payment. I think that I was one of the few healthcare system leaders who thought that was a good idea. Those five years have passed and the major platform for healthcare finance in Massachusetts remains fee for service, but the need for new or “alternative payment mechanisms” or “APMs” as they are being called, persists and progress is being made slowly.
The key discussion for me in the meeting was the detailed review entitled “Enabling Policies and Supports to Facilitate System Transformation”. Six items were on the list and there were several slides to stimulate discussion and to explore policy development and strategies related to each one. The six items were:
- APMs that support transformation across provider types and stages of development
- Standardized and accessible payer data for population health management & resource stewardship tracking
- Address provider access gaps
- Enhance payer product design to promote delivery of high-value care
- Build and support provider workforce capabilities
As I thought about all of the politics and all of the process that must be endured to overcome these barriers to transformation they began to look like what we call a TPOC in Lean, a transformational plan of care. Commissions in state government are rarely given the authority to make change. They find facts, study issues and make reports, and generally are careful to manage the moment as they anticipate the needs of the future. As I thought about the list, an alternative approach that seemed worthy of consideration was the promotion of a market environment that drove competition and through competition fostered the pursuit of the Triple Aim.
I know that Blue Cross and other payers are experimenting with APMs without the goad of the HPC and just a little encouragement by the guidelines of Chapter 224 of 2012. Atul Gawande’s story of the six-year transformation of practice in McAllen, Texas is a manifestation of transformation being driven by transparency and was enabled by data coming from CMS. IT interoperability is key to waste elimination and more coordinated care. The stimulus from Meaningful Use and from insightful and innovative health IT vendors is producing some progress toward this third goal. I could imagine the last three objectives “drafting” on progress made by focusing on the first three objectives. Suffice it to say that I found the meeting and presentation to be thought provoking. Is it possible to expect much more than that from an “advisory meeting” of a relatively powerless state commission whose only real tool is a bully pulpit? Maybe that is enough if we can find more leadership and talent “from another planet”. I am hopeful. Massachusetts has led before and is likely to find a way to lead again.
Do You Still Care About Sports?
I am so disgusted by all that goes on in the NFL, and I am confused by the possible revelations that Tom Brady may not be from another planet and has the same vulnerabilities of mere mortals. Is that evidence that I do care? Perhaps I am just disgusted.
Out on the road and away from Fenway, The Sox are showing a little life playing teams that have more problems than they do. Maybe they will begin to gain momentum as they finish up their West Coast swing and return more worthy of our interest. They will always have my heart
The fishing has been great this week. The header on this week’s letter is the view of the sunset on my lake as I pedaled home in my kayak after I had caught three nice rainbow trout earlier Thursday evening not further than a few hundred yards from where I sit as I type this note. May I suggest that if a walk does not catch your fancy as a way to enjoy the wider world, take a friend to someplace like the Charles River out near 128 where you can rent a canoe or a kayak and have some fun on the water while getting great aerobic exercise. These days I feel gypped if I can’t figure out how to both be on the water and be on some road or trail everyday.
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