16 December 2016

Dear Interested Reader,

Comments From Readers

Last week’s letter generated a few more comments than usual. The letter has been abridged and perhaps improved and is available now as “Population Health, Sustainability and the Triple Aim” on strategyhealthcare.com. I hope that you will check it out if you did not have a chance to read the longer “Musings” version. I appreciated all of the comments! A few moved beyond kudos and expressions of post election angst into further comments on the “state of things”.

Insights From Comments by Paul DeChant

Paul DeChant and I first met several years ago when we happened to be visiting ThedaCare at the same time. Paul, who is a family physician and medical executive, was then the CEO of Sutter Gould Medical Foundation in Modesto, California, and like me, he was trying to lead a Lean transformation within his organization. We immediately discovered that we saw the world in much the same way, and over the years have enjoyed sharing ideas through the frequent exchange of letters and as often as possible visiting at conferences and meetings.

Paul is now the Executive Director, Clinical Operations and Innovation for Simpler North America and the co author, along with Diane Shannon, MD, MPH, of Preventing Physician Burnout: Curing the Chaos and Returning Joy to the Practice of Medicine, A Handbook for Physicians and Health Care Leaders, which is available this month. I have had the privilege of reading much of the book in its pre publication form and highly recommend it to you. Paul is passionate about the practice of medicine and extends that passion into a concern for all practitioners as they endure the challenges of the adaptive changes forced on their work lives by the instability of health care finance, the complexity of medicine today, and the challenges of healthcare transformation.

Paul’s signature concern over the past three years, if not longer, has been burnout. He is not alone in this concern. I was delighted to read an article on burnout just yesterday in Stat, the online healthcare journal of the Boston Globe, co authored by Steven Adelman, another “Interested Reader”, and a former colleague at Atrius Health, who is now the director of Physician Health Services Inc. (an organization of the Massachusetts Medical Society) and a clinical associate professor of psychiatry at the University of Massachusetts School of Medicine.

I highly recommend the article by Steve and Harris Berman, MD, who is the Dean of Tufts Medical School. The article has a link in it to a study that they presented at the International Conference on Physician Health this fall. The conference was focused on “Increasing Joy in Practice.” Their study was a focus on eight things that could be done to improve burnout and presumptively, as Paul DeChant is fond of imagining, returning joy to the practice of medicine.

Paul was writing me last week after reading my letter on population health, sustainability and the Triple Aim. He also included some observations from the 28th Annual IHI Forum which he had just attended:

I’ll share a couple of observations from IHI...I had the pleasure of attending an all day workshop on team care by Bellin Health from Green Bay. They started developing their model to relieve burnout, and found that it not only did that, but also drove population health success. Perhaps the only way to achieve the Triple Aim is by pursuing the Quadruple Aim. Should we consider changing Care better than we’ve seen, health better than we’ve ever known, cost we can afford,…for every person, every time… to Care better than we’ve seen, health better than we’ve ever known, cost we can afford, in settings that support caregiver wellness,…for every person, every time… ? Just a thought…

My response to him was:

I am in total agreement with your thoughts and actually share them. I was trying to begin a conversation and not finish it. The Era 3 recommendations are at 100,000 feet. You are bringing the conversation down close to the ground. I plan to take it closer to the patient because that is where there has never been greater need on either side of the transaction. On the clinician side it is an undoable job without reengineering and on the patient side it is an insurmountable cost and access issue. Lean is agnostic to the ACA. It was a good idea before the ACA and an even more important option after the ACA in what will surely be an era of more downward pressure on revenue.

May I quote you next week?

I think that Paul is right and the evidence lies in his book, and in work like Steve reported in Stat. The importance of the problem has been quantitated in a frequently cited study from the Mayo Clinic. We can only imagine that the disturbing statistics that are suggested in the Mayo report are getting worse and will continue to deteriorate as we live through the stresses that will arise from the “repeal and replace” strategies of the Trump Presidency.

The term Triple Aim has become deeply imbedded in our literature since its introduction in 2007 and was further elucidated in the classic article in HealthAffairs by Berwick, Nolan and Whittington in May 2008. Over the last few years insightful leaders and thinkers like Paul and Steve have recognized that it is impossible to achieve the Triple Aim with a workforce suffering from staggering and increasing levels of professional burnout. Many students of practice, including Tom Bodenheimer and Christine Sinsky, have suggested that because of physician burnout the core concept must be “the Triple Aim Plus One” or the Quadruple Aim where the “Plus One” or movement from “triple” to “quadruple”, is a reference to improving the working conditions of those who deliver the care. Paul loves to use the phrase, “Returning joy to practice…”

I have always been aligned with Paul’s thinking but thought that “Triple Aim Plus One” or Quadruple Aim, if you prefer, needed a lot of explanation, even more than “Triple Aim”. I was very delighted a few years ago when the IHI Leadership Alliance came out with a more poetic “poetic expression” of the Triple Aim as

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

And now it seems totally logical to me to accept Paul’s further evolution

Care better than we’ve seen, health better than we’ve ever known, cost we can afford, in settings that support caregiver wellness,…for every person, every time…

Paul did ask me to consider wordsmithing his effort, and at first I was reluctant to do so, but while writing to you it occurs to me that I might offer a minor adjustment by putting our patients first. I am offering no more words, just a slight change in syntax.

Care better than we’ve seen, health better than we’ve ever known, cost we can afford,…for every person, every time…in settings that support caregiver wellness.

Now it’s over to you. What do you think? Is the statement one worth keeping and quoting to add meaning to the “Quadruple Aim”? Creating change requires conversation and discernment to draw together a coalition that has a shared understanding of the “reason for action”, the deficiencies of the “current state”, and a vision from an “improved or ideal state.” It is my hope that the new slogan will contribute to a broader understanding that the straightest road to returning joy to the practice of medicine is a route plotted utilizing the sort of strategies for system improvement, like Lean, that bring greater value to those who need care in environments that preserve those who provide care.

Insights From Comments by Stefani Daniels

Stefani Daniels, RN, MSNA, CMAC, ACM, is President and Managing Partner of Phoenix Medical Management Inc., a national advisory firm exclusively devoted to hospital case management strategic planning, program improvement projects, and education. She is also the co author of the only textbook on hospital case management, The Leader’s Guide to Hospital Case Management. Stefani is an Interested Reader and has given me her insightful comments on other occasions. I was delighted when she wrote this week to say:

I attended the Pop Health Colloquium last year and was impressed with the scope of involvement on a macro level. But I'm all about hospital operations and Pop Health on a micro level is just not happening in the average the community hospital. The Bundled Payment initiatives were perfect experiments for the small or mid-sized community hospital to start thinking in terms of the Triple Aim and outcomes for a defined population. They could have reviewed practice patterns to see where savings were possible; they could have reached out to post acute providers and reached consensus to form partnerships that would benefit all; and yes, they could have helped their communities understand the new healthcare environment and what the hospital must do to preserve its fiscal integrity in order to continue to serve. In my travels around the country, I'm not seeing it. Instead, I'm seeing execs who are still working hard to protect their FFS volumes; who won't jeopardize their referral patterns from community physicians by questioning inefficient practice patterns even when demonstrated by comparative data; and who find it easier to present community programs on 'how to cope with your COPD' than 'what you need to know to understand the changing healthcare market.'

My primary role as a consultant is to help hospital leaders assimilate new information about 'best practices' regarding care management in the hospital and across the continuum. That means that there are going to be populations of hospitalized patients who would benefit most (80-20) from having a 'neutral' care manager coordinate care across settings while influencing delivery of safe, efficient,and high quality care.

Many hospitals are dropping out of the 'voluntary' bundled payment projects because they cannot efficiently manage costs and outcomes. But as more mandatory bundles are implemented, they are going to have to step up to the plate and challenge resource utilization, delivery of care, and care coordination activities for selected high risk patients if they want to be successful.

My response to that piece of terrific writing and straightforward reporting of what she sees in the “gemba” of the community hospital world was a huge thank you.

Stefani,

I totally agree with your observations and analysis. I think that you may have made the point more succinctly than I did.

A question that I did not approach was whether CMS and CMMI could have done more to shift the focus of these hospitals that are just not understanding that not only does CMS want to change the way they are paid but so do the commercial payers.

I think that what you describe is a form of collective resistance that is understandable. People with established business processes rarely are enthusiastic about change. At a minimum it puts them on a new learning curve and that takes energy that they would rather spend some different way...

I think that the driving force is sustainability. Sustainability is really not a political issue; it is a fact of the physical world. Something that can't go on forever will eventually end. Our challenge is to recognize when something is near the end of its life and transition to a new curve.

The "second curve" in healthcare was predicted by Ian Morrison some time ago. Peter Drucker described the fact more than 50 years ago that many ventures and product lines failed because managers failed to recognize that their product was not sustainable, and they either needed to change or accept their failure. Kodak is a great example of that sad reality.

Thanks so much for responding. I think that your thoughts merit sharing. May I quote you next week?

As is true with any great conversation, we continued to exchange ideas. She wrote back:

It's not the 'hospital' that's to blame, let's be clear…a hospital is brick and mortar. It’s the Board and the Execs that have their heads in the sand. I disdain using the generic 'hospital' - even when CMS does it. The hospital culture, structure and operations are based on Board and leadership direction, and responsibilities and accountabilities should be specific. Whenever feasible, I always refer to the people who are in charge - not the building.

Our conversation continued:

Stefani,

Great point. I get it. We give people cover who should be more responsible when we sum up or locate the failure as the “hospital”. The same thing is true when we talk about the “church” or the government. If we are going to say that guns don’t kill people, people do, then we should also say that hospitals and governments do not fail us but rather it is within those people who are the fiduciaries and functionaries of those enterprises where change and insight needs to occur.

Stefani had the last word:

Precisely……
In my field of care management, my toughest challenge is to remind the CNO that discharge planning is a core competency of professional nursing practice and why is it that bedside nurses have been 'allowed' to distance themselves from that responsibility....

Right now hospital execs and case management program leaders expect a few care managers to develop a plan for every single hospital patient. Its outrageous and impossible which is why there are so many problems with discharge delays and the throughput obstacles....You might find this guest editorial of interest.

I did read her editorial, and it is clear that the we have a long way to go as we work on one of the most obvious sources of waste in healthcare, the discharge process. Stefani’s notes took me back to the many positive interactions that I had with the case manager nurses that my practice employed in the hospitals that we used. Hospital case management was always a critical focus at Harvard Vanguard and Atrius Health. It was always a process in evolution and yet I fear that we did not adequately support the dedicated professionals who were charged with the responsibility.

Her comments point to a huge opportunity for gains in every aspect of the Quadruple Aim and suggest to me that there may well be high levels of burnout in the medical professionals who are trying to improve the discharge process despite a lack of adequate support. I would expect that any dollars invested in improving the hospital case management process will be returned in multiples in the age of value based reimbursement. As Stefani’s comments suggest, case management is a population health competency that is critical to the sustainability of efforts for the Triple (or Quadruple) Aim.

Where Do We Go From Here?

Dan Burns, is an Interested Reader, a former colleague who served on the Harvard Vanguard and Atrius boards with me, my dermatologist, and the person who became CEO of Harvard Vanguard after I retired three years ago. I most recently saw Dan, and we had a brief conversation during a visit I made to the Wellesley practice of Atrius Health. I was there for advice from orthopedics regarding a recent shoulder injury. (I injured my shoulder in a fall while going door to door for Hillary.) A few days later I was surprised to see a text from Dan asking if I had time for a call.

We had a great conversation. Dan made his concern known immediately when he said that he was quite worried that all that had been accomplished since the beginning of the Quality Movement was now in jeopardy with the uncertainties that were introduced by the election of Donald Trump to the presidency. His concerns had mounted as Mitch McConnell has reiterated the goal of initiating the repeal of the ACA on day one of the new administration. I quickly told Dan that I understood and shared his concerns. I found the conversation to be helpful for me and asked Dan if I could transmit his concerns to you. I told him that many of you had shared the same concerns with me.

In the course of the conversation we considered several strategies. It occurred to me that up till now most of us have been in a state of shock. The outcome of the election itself was a huge and unexpected surprise for many. The President Elect even seemed a little surprised that he had won an election which he had said was fixed.

Following the collective “this can’t be”, there have been moments of hope as the realities of the loss sink into our disbelieving minds. I really felt better after the dramatic visit between the President and the President Elect. Trump seemed sincere when he said after that visit that there is much in the ACA that is worthwhile and should be protected. Then in the background over the next few weeks both Paul Ryan and Mitch McConnell have reiterated that the ACA will be completely repealed, and then replaced with something better. It is unclear what they mean, especially when yesterday the Republican leadership said that their goal is to give every American an opportunity to chose to have healthcare. The cynic in me says, “Watch out. Read the fine print.”

“Our goal here is to make sure that everybody can buy coverage or find coverage if they choose to,” a House leadership aide told journalists on the condition of anonymity at a health care briefing organized by Republican leaders.

What does “if they choose to” mean?

My junior high school football coach taught me that to make a tackle you must always watch the runner’s belt buckle and not his eyes or upper body. The runner always goes where his center of gravity is headed. The eyes, arms and upper body can trick you. With his cabinet appointments, which must be an indication of where his momentum is headed, this President Elect has already taken enough steps to suggest that his center of gravity is headed in a way that will be problematic for the journey toward true universal coverage. I am sorry but I do not trust that “everybody can buy or find coverage if they choose to” means universal coverage. I see Mr. Trump’s center of gravity expressed in his choice of Representative Dr. Tom Price to be the Secretary of Health and Human Services and Dr. Seema Verma to be the administrator of CMS. The choice of Rick Perry as Energy Secretary is another startling revelation of Mr. Trump’s amazingly consistent approach to dismantling the progressive agenda.

I was in total agreement with Dan. A “wait and see” approach, coupled with prayers that the President Elect will suddenly see the light, seems like a strategy for continuing disappointment and loss. We began to consider a few peripheral questions.

Massachusetts had virtual universal coverage before the ACA. Would the state expend the resources to maintain what had been accomplished if the ACA was repealed or if its replacement resulted in huge reductions in federal aid? How secure was the recent 52 billion dollar Medicaid waiver that was granted to Massachusetts to put all Medicaid patients into an ACO? Would Massachusetts taxpayers who were already spending $0.42 of every tax dollar on healthcare be willing to make up what Donald Trump’s administration might try to rescind? Interesting questions.

Dan and I found a little bit of consolation in MACRA (Medicare Access and Reauthorization Act of 2015) and the fact that the passage of MACRA suggested a strong bipartisan support for shifting Medicare reimbursement toward payment for value. I still believe that the most important fact arising from MACRA is that it is providing encouragement to commercial insurance to follow CMS’s lead into alternative payment models. Is that enough to form a foundation for a strategy? Perhaps the alternative question would be, could MACRA be undermined and its implementation delayed by an administration that wanted to play to providers who saw only stress in further transitions that moved them away from Fee For Service payment?

Before the conversation had gone very far, Dan and I had concluded that the greatest hope for the preservation of what has been accomplished and for further progress toward the Quadruple Aim,

Care better than we’ve seen, health better than we’ve ever known, cost we can afford,…for every person, every time…in settings that support caregiver wellness…,

would be an offensive strategy. It is preposterous perhaps to imagine, but those who see value in what has been accomplished need to come together in an all out coordinated effort to preserve and improve, not repeal and replace, the ACA.

History demonstrates the path for success for unlikely processes of change can sometimes lead to surprising successes. John Kotter teaches that foundational to effective change is the formation of a guiding coalition. Actually, the first step is to have a cause, but the first action is to form a large volunteer army from up, down and across the organization (or the nation) to serve as the change engine.

Here are the eight steps in Kotter’s accelerated change process. Can the steps be followed as a framework for a strategy to preserve the work of a quarter of a century, the investment of billions of tax dollars and the commitment of huge sums of investment capital? More importantly how hard should we fight for things as important as the health of all and the preservation of the climate that we share with the rest of the world?

1. Craft and use a significant opportunity as a means for exciting people to sign up to change their organization.
   
2. Assemble a group with the power and energy to lead and support a collaborative change effort.
   
3. Shape a vision to help steer the change effort and develop strategic initiatives to achieve that vision.
   
4. Raise a large force of people who are ready, willing and urgent to drive change.
   
5. Remove obstacles to change, change systems or structures that pose threats to the achievement of the vision.
   
6. Consistently produce, track, evaluate and celebrate volumes of small and large accomplishments – and correlate them to results.
   
7. Use increasing credibility to change systems, structures and policies that don’t align with the vision; hire, promote and develop employees who can implement the vision; reinvigorate the process with new projects, themes and volunteers.
   
8. Articulate the connections between the new behaviors and organizational success, and develop the means to ensure leadership development and succession.
   

Dan and I focused on items #2, #3, and #4. Our conversation included developing a combined list of people from around Massachusetts and around the country who we believed shared the worries and concerns that we feel.

Objective #5 makes me think that the proximate battle ground for the defense of what has been accomplished so far will be in the Senate. If one reviews who populates the slim majority that Mitch McConnell controls, it is possible to construct a list of Republican senators that might disagree with radical appointments and proposals. The list includes some interesting names. On my list John McCain and Lindsey Graham are on top. How might Susan Collins of Maine vote? Are there any who remember the fate of Kelly Ayotte? Is there leverage in the 2018 mid term elections?

Dan and I ended our conversation with the idea that doing something effective would be difficult, perhaps impossible, but we also agreed that not to try to see if there were others who shared our concerns would be irresponsible. Is it possible for healthcare professionals to appeal to the concern of those who have the constitutional responsibility to provide advice, and when appropriate, consent?

There is a very confusing statement that I have heard from Buddhism. It is essentially, if you meet the Buddha in the road, kill him. This is one statement that is not meant to be taken literally. If you type it into Google you will get several different reflections on its meaning. Over the years I have come to my own interpretation. The Buddha represents all knowledge. No human being is so smart and so all knowing that their opinion should be accepted without consideration, and therefore anyone who claims all knowledge should be rejected or avoided.

Thoughtful people know the folly of following a con, and avoid people who claim they are all knowing and all powerful. In the metaphor rejection is expressed as “kill him”. We call these “Buddhas” “no it alls” and we usually avoid them. There is a reality that sometimes in groups we can collective be led to do things that most of us would have the wisdom not to do individually. I think that happened this year.

What do you consider your options to be?

It is Cold!

As I write this letter, the temperature is minus two. Overnight we will fall to minus seven. By the time this letter goes out it will be a balmy eight degrees. Earlier this week I snapped the picture of the fog that covered the frozen surface of my lake. The picture doesn’t come close to revealing the beauty I observed. We have accumulated six to eight inches of snow cover through several small storms. The fresh snow has made it possible for me to do some snowshoeing with a couple of friends in lieu of one of my walks this week. It is a joy to go crunching through snow where the only tracks are from the deer and other little critters that know how to live there in the cold, cold woods.

I hope that you will bundle up and be out and about this weekend. Nothing beats walking in brisk weather while having a great conversation with a friend. A hot cup of tea or cider after the walk is an extra delight!