15 September 2017

Dear Interested Readers,


What’s Inside and an Update on the Bipartisan Efforts in Congress

For the past month we have been considering the question of whether the continuous process of system affiliations and consolidations, competition between systems of care within a market, or innovation within systems are effective ways to lower the cost of health care. Since I wrote to you last week I have discovered a recent report that the Commonwealth Fund has published, entitled “Health Care Market Concentration Trends in the United States: Evidence and Policy Responses.” The study examines the various consolidations of providers at every level between 2010 and 2016. The last sentence of the paper states:

As market concentration in the health care system accelerates, more consumers and employers across most of the country are left with higher prices and fewer choices. Regulators can take steps to scrutinize and restrict anticompetitive behavior.

That analysis suggests that if consolidation and competition are ever going to be effective agents that lower the cost of care, we have a lot of work to do to create an infrastructure of regulations and effective tools that ensure that consolidations, mergers and acquisitions create economies of scale that yield lower costs. The findings suggest that if we can’t be certain that a proposed merger will yield improvements that might lower the cost of care, we should be careful about approving it.

There is great news in a few areas this week. Massachusetts has achieved the lowest uninsured rate in the country, with only 2.5% of the population lacking coverage. Even more remarkable is that the uninsured rate for the whole country is down to 8.8%. That is encouraging and underlines the value in protecting the gains of the ACA. Another fun fact that I have heard but have not confirmed is that is that the cost of care in Massachusetts rose less than 3% percent over the last year. That means that the goal of keeping the increase in the cost of care below the increase in the state GDP has been achieved. In my mind that means that even with its limited powers the Health Policy Commission created in 2012 is finally beginning to be effective. The annual public hearings on the cost of care will occur next month and the goal for 2018 has been announced as 3.1%. The final piece of good news is that there seems to be a remarkable consensus in the Senate Finance Committee to renew the authorization of CHIP (Children’s Health Insurance Program) for 5 years!

I find that there is a moment to moment shifting of opinion on what is happening over in the Senate HELP committee where they are struggling to produce bipartisan healthcare legislation before September 27 when the insurers offering products on the exchanges must finalize their plans for 2018. The most optimistic and somewhat humorous comments come from Rachel Bluth of the Kaiser Health News Service.The common wisdom has been that some guarantee of the Cost Sharing Reimbursements (CSR) and the creation of some form of risk pool for high cost cases would be good short term bipartisan objectives. The cost of access through the exchanges and even through employer sponsored plans takes a huge bite out of the paycheck of most consumers.

The conversation in the Senate HELP committee began as an urgent bipartisan effort to stabilize the exchanges to preserve the benefit coming to the 17 million exchange participants. The other objectives of the Triple Aim, better care for everyone and the improved health of the community, would seem impossible without universal coverage. The new wrinkle this week seems to be that the guarantees of better care written into the ACA as benefit requirements are becoming a bargaining chip in the Senate process that is trying to become bipartisan. It is never said directly, but I sense that the current bottom line for the conscientious senators of both parties is not lasting legislation that quickly achieves universal coverage, but rather preserving the incremental gains of the ACA and making sure that those who have care now can continue to afford it.

Sustaining a bipartisan focus has been hard. The introduction of a final effort at “repeal and replace” that would deny care to millions by Senators Lindsey Graham of South Carolina and Senator Dr. Bill Cassidy of Louisiana is not a threat to be dismissed lightly. On Wednesday Bernie Sanders introduced his “single payer” legislation with the support of 15 Democratic senators and at least a third of the country interested. Those numbers suggest a growing support and the realistic expectation that “single payer” will be a big issue in the 2018 midterm elections and the 2020 presidential election. Some liberal commentators like Drew Altman, President of the Kaiser Foundation are not so sure this is the right conversation. Read his well written analysis of the pros and cons.

For me the most important question to be answered in the short haul is how successful the bipartisan efforts in the Senate HELP Committee will be. I pray that they will come to a consensus, and soon. The HELP committee is quickly moving toward another small “showdown” that will test the early confidence in the possibility of a bipartisan approach to solving the thorniest healthcare problems. The Republicans are bargaining for changes in section 1332 of the ACA which now limits the liberties that states can take with the benefit packages required by the ACA as they seek Medicaid waivers. Republicans are willing to approve a one year extension of the CSR payments. The Democrats want a multiyear CSR guarantee and would prefer to continue to hold states to the requirements of the minimum benefit packages of the ACA. We are getting close to crunch time.

This week’s letter is about patient engagement, a subject that is close to my heart and has nothing to do will the Senate. It is an essay of sorts. I have said before and will say it again in the essay that the Triple Aim will be much easier to gain when we learn how to engage patients in their own care. I do not present myself as a patient engagement expert but by practicing medicine for over forty years I have some opinions. I do not know how many unique patients I saw during those years, but I am sure that I had no less than one hundred and fifty thousand patient encounters. I am sure that in every one of those encounters, when possible or appropriate, I was trying to get my patient or their family involved in the work of improving their own health. I have been thinking about writing this note for a long time. I have delayed for fear of doing an inadequate job. I finally decided that it is a book length subject, and since I was not going to be writing a book I should just start writing with the hope of getting you into the conversation. What you think about patient engagement is more important than what I think. I hope that reading my thoughts might push you to express your opinion. So the effort is one that should be judged by whether or not it gets you thinking and talking about the importance of patient engagement. A measure of the importance of the idea will be your responses.

This week I spent some time in Cambridge at the IBM Watson Health offices. I should disclose that I do serve as a clinical advisor to the Lean consultants of Simpler Consulting. Simpler is now a part of IBM Watson Health and both IBM and Simpler are engaged in the predictable struggles associated with the introduction of any innovation. I reviewed some of the barriers to innovation in healthcare two weeks ago. As I was listening to the Watson presentations I was thinking about a host of ways that AI, cognitive computing or “augmented intelligence” could transform care. Beginning this week, and whenever possible in the future, I plan to touch on the potential ways that AI might change everything we do, including how we engage patients. AI represents a tool that should bring us great benefit, if we can effectively employ it, on our journey toward the Triple Aim. I would like nothing more than to be a young doctor once again who could look forward to the opportunities to improve care that innovations like Watson offer us. A challenge that we face is how to work these opportunities that invention and innovation present into our professional workflows. The work is hard because in some situations we will need to totally give up old ways of working if we are to take advantage of the new opportunities.

The letter concludes with an expression of thanks for the mitigated damage of hurricane Irma, the celebration of reunions, and a resolve to fully enjoy the beauty of the coming fall.


The Importance of Patient Engagement

Dr. Ebert told us that more money, more personnel, and more facilities were not the answer to the question of what “will provide optimally for the health needs of the population.” His answer was that the job of improving the health of the nation would require the organization of the personnel, facilities and financing into a [more effective] conceptual framework and operating system.


“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.”


The statement is beautiful and directionally correct at a high level. It states a hypothesis that I have treated like a law of nature. My esteem for its wisdom is manifested by the fact that I have quoted it hundreds of times. Dr. Ebert’s statement is cryptic and purposefully avoids specificity. It is a high level ambiguous answer that does not ever describe the optimal operating system and finance mechanisms that will do the job. I resolved that concern for myself by realizing that there are several management systems and finance mechanisms that answer the riddle. I have come to believe that as long as the operating system and finance mechanisms support the establishment of delivery systems that meet the criteria published in Crossing the Quality Chasm progress will be made.

1) Care based on continuous healing relationships.

2) Customization based on patient’s needs and values.

3) The patient as the source of control. Encourage shared decision-making.

4) Shared knowledge and the free flow of information.

5) Evidence based decision making.

6) Safety as a system property.

7) The need for transparency.

8) Anticipation of need.

9) Continuous decrease in waste.

10) Cooperation among clinicians. [“I to we” within practices, across practices, across systems and throughout the community.]


I have come to believe that management by process as facilitated by Lean, and value based payments that are built on budgets that support the principles of caring for a population get my nod as a step closer to the specificity necessary to achieve the Triple Aim which is a little more specific than provide optimally for the health needs of the population.

As I think about the list that was generated by Crossing the Quality Chasm in 2001, I would make one addition that I believe may bring us closer still to the Triple Aim. The operating system and finance mechanisms should support patient engagement. I know that some will push back and say that it is there in a combination of # 1-5 plus 7 and really is echoed in every descriptor on the list, but I think it should be a list of 11. The goal of the operating system should be an evolution that optimizes patient engagement.

I know that finance is a huge barrier to patient engagement. If a patient does not have access to care it definitely impedes engagement. If the finance system is so laden with copays and deductibles that it makes patients reluctant to access care, then we have a problem. Maybe Bernie and Elizabeth are right, single payer could reduce the cost of care. I am sure it would facilitate patient engagement.

Lean contributes to patient engagement through its philosophy of the primacy of the customer and the importance of its emphasis that systems should be managed to produce value for the customer. Ironically, even in a very commercial environment, creating value for the customer is the most reliable way to “increase shareholder value.” Lean supports providers in their primary objective of serving patients and better functioning systems derived through the wisdom of the people who provide the services that support care including patient engagement.

What amazes me is that our systems have been so focused on volume objectives that they are a barrier to the objectives that managers are trying to achieve and the relationships providers intuitively know are required to achieve those objectives. Ordering a $2500 MRI as a substitute for a fifteen minute conversation will rarely promote the objectives of the Triple Aim, and when it comes back as negative we may close the question but the patient is still concerned if the precipitating problem persists.

There are many ethical reasons to support efforts to improve patient engagement, but there are some practical considerations to mention to help motivate us to change in ways that improve our ability to effectively engage patients in their own care. An effective way to lower the total cost of care for a population would be to manage chronic diseases like diabetes, COPD, CHF, asthma, and chronic early renal failure so effectively that an admission to the hospital for any of these diagnoses would become a “never event.” That audacious goal can only be approached by much more effective patient engagement that enables either improved self management or augments outreach efforts like home visits and telemetry. Self management may not be possible for some severely compromised patients, but effective engagement of family or designated caregivers can be effective facsimiles.

I believe that systems should be engineered to support patient engagement. The first step is to engineer patient flow in ways that promote team based care and a redistribution of work that is designed to give clinicians the time necessary to promote the self management which is a primary goal of patient engagement. My friend and colleague at Simpler, Dr. Paul DeChant is probably the most articulate proponent for efforts to improve care delivery in ways that reduce clinician burnout. Burned out clinicians whose enthusiasm for patient care has been replaced by depression and a self protective wall of cynicism can not promote patient engagement and often refuse to engage when a patient clearly has a desire to know more to enable self care. Paul’s goal is to “return joy to patient care.” Paul has taught me that we will never achieve the Triple Aim unless we make it a Quadruple Aim and modify the IHI statement that we want

...Care better than we’ve seen, health better than we’ve ever known, cost we can afford,…for every person, every time,

...to include

…in settings that support caregiver wellness…

Fixing what causes over 50% of physicians to suffer from symptoms of burnout to the point of resenting what they are required to do to deliver care in a dysfunctional system ( over 40% of behavioral health docs on the low end and 59% of intensivists on the high end) is a good place to start in our effort to more effectively engage patients.

I chose healthcare as a profession because I wanted to help people be healthy and enjoy their lives. I was very fortunate to have had the opportunity to realize that objective in an organization that was created to prove Dr. Ebert’s theory. We had team based care before you could find those words in the literature. In practice we were a medical home from moments after the concept was first described in the pediatric literature in 1967. We had an automated medical record on day one of existence in October 1969. We always were financed based on the principles of value based reimbursement and the necessity to budget for the expense of delivering care to a population. We were early adopters of the principles of quality management and improvement science. In short, I was lucky to spend my years in practice in an environment where I could respond to the innate desire of my patients to be a participant in their own care working with colleagues who shared the same goals.

Our desire to practice in a new and unique way that embraced the importance of fostering patient education with the goals of engagement and self management did not protect us from the pressures of a competitive market, or the challenges coexisting with business partners who had different values, but the ideals did sustain us and create a resilience that was an effective counterbalance to our challenges. In our most difficult moments the vision of what was best remained as a motivation to find a way to overcome the challenges. Patients who had become engaged and appreciated the partnerships that they had established with us remained loyal to the mission as well and sustained us when we were struggling.

The interactions that promote patient engagement and partnerships between clinicians and patients are a great example of a “non zero” interaction that foster progress. Non zero relationships or “win-win” transactions were well described as essential to improvement by Robert Wright in his book Non Zero. The transactions between patients and their caregivers that foster patient participation and engagement “create capital” and are essential to the hope of ever achieving the Triple or Quadruple Aim. Dr. Ebert’s hypothesis calls for a “non zero” solution.

Perfection is not necessary in the clinician/patient effort to establish a collaboration that supports individual health and enterprise success. More often than not there will be problems and failures that can be captured and become the sources of insights that move the patient toward a more stable condition as the “failure” provides the insight for system improvement. Failure informs both the patient and the clinician and should inform the work of the system if there is an effective deployment of Lean principles.

As I look back on my practice years, what I remember most fondly are my collaborations with my engaged patients. I gave them information and they gave me information. I often learned that the care plan we developed was wrong, or that it was theoretically correct but practically implausible. They had an expertise that I could transfer to other patients. That is an example of a non zero interaction. At the end of my career I had the chance to practice in a shared medical appointment environment. It was an incredible exercise in patient engagement. Patient engagement is a learning process. Patients learning from other patients and the doctor at the same time is an enhanced learning process. I have had equally satisfying experiences of care facilitated through the electronic patient portal and I wish that I practiced long enough to enjoy the potential benefits to patient engagement that might be realized with new tools like “Watson.” The overriding point is that different people respond to different approaches to engagement. Our challenge is to continue to explore ways to bring more and more of our patients into an active role in their own care.

The search for innovations that optimize patient engagement will be facilitated by management systems and finance mechanisms that can adapt to exploring new ways of optimizing patient engagement which was possible but always difficult for both the clinician and the patient in the standard fifteen minute medical appointment. There is so much to learn. There are so many potential solutions. I wish I could start all over knowing what I now know. That is not going to happen for me, but I hope that you will be an advocate for yourself as a clinician or as a patient. Everything we try, as we attempt to find the answers that will provide optimally for the health needs of the population should be passed through the consideration of its impact on our efforts to enhance patient engagement.


In The Wake of The Storms

This last weekend was tense. It seemed like the same song second verse after Harvey. Many of us spent much of the weekend watching the track of Irma while talking off and on with family members who were dealing with the uncertainties of this monster storm. Last Wednesday the storm was predicted to hit Miami on Sunday. After much discussion, my son, his wife and daughter and their German shepherd made the decision to go to a hotel in Orlando for the weekend. Normally the trip takes four hours. On Thursday afternoon it took them twelve hours including more than an hour in a line for gasoline. As we all now know, Irma went up the West Coast.

In the end my family’s decision was still a good one because Coconut Grove, their neighborhood, was flooded by the storm surge and the area was without electricity until late Wednesday afternoon. They were doubly fortunate because their home sits about ten feet above sea level (one of the highest spots in Miami) at the top of a little rise coming up from Bayshore Drive which was flooded with several feet of water from Biscayne Bay.

My granddaughter’s high school literally sits on the bay. The football field extends out on a point into the bay and field goal kickers can put the ball through the uprights and into the water. The first floor of her high school was under water. The picture in the header today shows what things looked like after the water receded. It seems that a sailboat that was moored in the bay ended up in the end zone closest to the school gym and swimming pool that is behind the end of the field. Field goals kicked on that end of the field apparently end up in the swimming pool. The picture also reveals that the artificial turf needs replacing. It amazes me that they had a rug. If you can’t grow grass in Miami where can you grow it?

My initial thought as I was deciding to use this picture was that this would be the first time I used a picture that was not an attempt to capture some natural beauty. Reflecting on the idea for a little longer changed my mind. There may be no “beauty” in the picture, but it was beautiful that so many people followed the advice of the authorities and that everyone seemed to be trying to work together to make it through a difficult time. Millions of people on the move in an orderly fashion and in the face of uncertainty seems like something that deserves a celebration or a prayer of thanks.

Now that that Irma no longer threatens us and as the clean up begins, it’s time to take a deep breath and promise myself that I am going to give fall a chance to be a great season. There is no election looming for late fall. My agenda includes enjoying weekend visits of some old friends and family and welcoming a new grandson whose ETA is early in October. If the Sox go deep into the playoffs or make it to the World Series, it will icing on my cake.

Be well, take care of yourself, stay in touch, and don’t let anything keep you from making the choice to do the good that you can do every day,

Gene