18 August 2017

Dear Interested Readers,


What’s Inside Plus Reflections on a Very Volatile Week

Did you, like me, hope that in what was left of August we would have a break from the tweets, the taunts, and the daily emergence of yet another controversy that have become the focus of our political process? I do not like the way the continual feed of breaking news has transformed me. I am a little like one of Pavlov’s dogs. He rang a bell to get the dogs to drool in anticipation of the next feeding. I have an iWatch as the source of my conditioned stimulus. I feel a little buzz on my wrist and hear a faint ding that releases a little dopamine in my brain as I eagerly read the message that appears on the little screen that introduces the next event in the careening decline of our president.

My conditioned response to the stimulus is usually followed by yet another fulfillment of the cliche, “You can’t make this stuff up.” In the end I am left with the self loathing that is the aftermath of my conditioned response. Am I a junky to the turbulence the president has created? It is true that each weekday evening my excitement grows as we approach the time when Stephen Colbert will deliver his monologue. Sunday evening I substitute John Oliver for my Monday to Friday Colbert fix. Before it finished its season I was sure to have my itch scratched by “Saturday Night Live.” But is this right? I don’t think so, which is why I so eagerly embraced the idea of Washington being on vacation in August. I had so hoped that having Congress on vacation and the president out of town playing golf at his Bedminster Club until after Labor Day, I would have an opportunity to detox. Not so.

What is also amazing is how fast we move from one episode to the next of the “You can’t make this stuff up” reality show. Did the president warn the North Koreans of “Fire and Fury” as recently as just ten days ago? At the current pace of events that eruption and the subsequent “Locked and loaded” comment seem like they occurred several months ago. Did the announcement about no transgendered people in the military come before or after the departure of Sean Spicer and Reince Priebus and the subsequent firing of Anthony Scaramucci? It is hard to be sure. Robert Mueller never speaks, but whatever he might be discovering seems to have the president oscillating from trying to figure out how to fire him to harassing Jeff Sessions whose recusement on the issue of Russian interference with the election created the need for a special council. Ten years from now will the sequence and the facts behind the events really make a difference beyond the content of some doctoral dissertation in political science to be written long after this food fight over fake news becomes a joke in history?

The thumbs down gesture of John McCain that signaled the failure of the “skinny repeal” still seems like an event that will have persistent historical significance, but that act and the whole healthcare debate is easily lost in a blur of other attention grabbing episodes that are hard to remember in sequence as we look back to that bizarre Inauguration Day in January and the false and pointless claims about crowd size.

The controversy over the events in Charlottesville and the evolution of the president’s response from late and off target, to later and on target but prepared by others for him to read, to the current status of “ ‘Holy smoke’ did he really say and mean that?” may actually end up with a longer page in history than the other events that have kept me going up and down over the last six months. Has he finally found a piece of rope long enough to hang himself? This is an important question because unless the president ties his own knot, or unless Robert Mueller ties it for him, it seems doubtful that Republicans in Congress will ever get beyond individual comments on Twitter and will never come together to relieve us from the torment of the beast that they were complicent in feeding and unleashing. They have three options. Option 1: They can just sit a wait with the rest of us until some disaster occurs. Option 2: They can exercise the options of the 25th Amendment section 4 and make the considered judgement that this president who wants to be seen as exceptional is in fact exceptional compared to the most spectacular of our previously compromised occupants of the office and should be compassionately removed from the stress of his office. Option 3: Begin to seriously consider impeachment.

The best high level comment that I have read on the deeper meaning of the events in Charlottesville and the subsequent controversy that was initiated by the series of comments from the president came from Tom Friedman in an opinion piece in the New York Times entitled Charlottesville, Isis, and Us. Friedman’s thesis is that despite our current confusion and fears about immigrants and terrorists, our nation’s current strength and its past and future greatness are a function of our embrace of pluralism which is antithetical to concepts of supremacy of any race, gender, sexual preference, and the exclusive rightness of any religion. The benefits of pluralism are at risk in the moment, but can be renewed by an assertion of our concept of “out of many, one,” which you can see expressed in Latin as e pluribus unum, if you look at a penny or any other coin you may have in your purse or pocket.

The healthcare discussion has not been on vacation either. It has continued in a subdued and muffled way. The CBO reported this week, in response to a request from Congressional Democrats, that undermining the exchanges by denying payment of the CSR, as the president threatens, will create an almost $200 hundred billion dollar expense over the next ten years. Who knew? Clearly not the president and perhaps not Tom Price and Seema Verma over at HHS and CMS. This week they did their own surgery on orthopedic and cardiac bundles that were being piloted as forms of value based reimbursement. Perhaps they have other, better plans to promote a shift toward value based reimbursement. We will need to wait and see. We are also waiting to see what the Senate’s next move will be after the failure of the “skinny repeal.” For some time now Senator Bill Cassidy, a gastroenterologist in his previous life, and Senator Susan Collins of Maine have been looking for bipartisan support for an effective healthcare bill. Will that happen? Will Lamar Alexander get things going in the Senate HELP committee. “Uncertainty” is the word of the day.

The challenges that faced healthcare more than fifty years ago in the mid sixties were surprisingly similar to our current dilemmas and may offer us insight as we creates strategies for the future. I have always been convinced that as you proceed forward it is good to be looking back to see what lessons have been learned that might make the road ahead a little smoother. I will continue that thought in the main section of today’s letter which will begin a multi week discussion of the ways in which individual organizations might improve care and lower their costs of delivering care to sustainable and survivable levels.

A high level overview of the subject reveals that there have been many suggested strategies. If you set aside single payer, in its various proposed forms, and follow this country’s historical confidence in competitive markets and entrepreneurial efforts, it is easy to conclude that we believe in the power of markets. Our belief in the power of markets leads us to consider some mix of consolidation, competition, and innovation while improving quality and diminishing waste, as the best strategy for a better future for consumers, providers and payers. The prescription is easy to write, but it seems hard for organizations to fill the prescription or take the pills. Why? I do not have certain answers, but my experience as a healthcare leader, as a physician, as an observers of other leaders and practitioners, and now, as a more frequent consumer of care, I do have opinions. As the discussion continues over the next few weeks, I hope that you will send me your thoughts and experiences.

The letter concludes with the usual description of the small joys and amusing observations and adventures of the retired life. As you might expect from the header this week, there is probably more than you want to hear about fishing.

The new format and distribution of the Tuesday postings of Strategy Healthcare has been up and running for several weeks. I hope that you are finding some use for it. If you have time either leave me a comment on the site, if you want to share your idea with others, or send it to me directly if you would prefer not to make a comment for others to read.


Are Consolidation, Competition, and Innovation the Answer? Part 1

By the mid sixties many healthcare leaders and liberal politicians had been concerned for sometime about our lack of universal access to quality care at an affordable cost. Studies were beginning to emerge that documented the experience of thoughtful and observant clinicians that maintaining health and carefully managing chronic disease could produce superior outcomes and a lower total cost of care, compared to the usual practice of getting medical care only after illness or injury had occurred. Through his own observations and vast experience coupled with a vigorous exchange of ideas with colleagues across the country, Dean Robert Ebert of Harvard Medical School succinctly summarized his conclusions in a letter written in 1965 to the president of the Commonwealth Fund. The letter was a request for funding to further explore the implication of his theories in the laboratory of a “teaching practice” designed to pilot new forms of care and to produce a new generation of socially responsible physicians. I have published his words in dozens of letters. You have most likely seen them before.

“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.”

Now 52 years later we are still searching for those elusive effective operating systems and supportive finance mechanisms, but perhaps we have made a little progress as we have done more with the conceptual framework as we have adopted more universally accepted principles of quality and safety even though they are imperfectly operationalized. What seems clear to me is that local variation will drive the need for multiple operating systems and finance mechanisms that vary for local reasons. This was addressed in Crossing the Quality Chasm in 2001. By that time pursuit of Dr. Ebert’s concept had led us to understand that the desirable properties of effective organizations could be accomplished through a variety of operating systems and finance mechanisms. In case you have lost the list here again are the ten properties of an effective delivery system.


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 will contend that clarity about how and when to effectively consolidate service into larger systems of care still elude us. Part of the problem lies in the uneven distribution of medical assets and the variation in market realities across the heterogeneity of the country. What works in Boston does not always work in Maine and is hard to reproduce in Wyoming or Alaska. Conversely what does work in Alaska may well work with specific populations in New York City or Los Angeles but transferring the experience or methodology is not easy. We will come back to these issues in a subsequent letter.

The same sense of variation in opportunity related to location and context also mightily impacts how market competition can be used to lower the cost of care. With three medical schools and even more world class academic medical centers in Boston one would expect competition to be a powerful determinant of price, and as a derivative of price, cost. Trust me, it does not.

Just as now, back in the early sixties the conversation in Washington was a confusing oscillation between what was needed and how to pay for it. Just as now, people were talking past one another as some earnestly talked about “why” we needed to extend care to the elderly and the underserved, and others were worried about “how” we would pay for it. Just as now, there was not a consensus about what the role of government should be or what was the proper attitude was of a patriotic American. Then as now there were those who thought we were a great country because we are a collection of self reliant individualist capable of pulling ourselves up through effort. Then as now there were many that believed we could be a greater nation if we could use government to help everyone achieve their potential. Then as now, we were confused about how to negotiate a consensus on these complex issues that would allow us to evolve and operationalize a solution.

Much of the language of primary care, quality assurance and population health had not yet evolved in the mid sixties, but some thought leaders had an intuitive appreciation of the principles. In the mid sixties America was still several decades away from reclaiming the continuous improvement concepts of Deming and Juran from the Japanese. We had some start up examples of new models of care like Kaiser Permanente in California and Group Health Cooperative in Washington. At these organizations and in other places and in academia there were healthcare thought leaders like Dean Ebert who were beginning to consider the systems thinking that would evolve toward new concepts of care and wellness like health maintenance, preventive care, and integrated multispecialty group practices financed by affiliated insurance products or accepting prospective capitations for large populations. By the mid sixties there were a few visionaries who realized that their hopes for better care were incompatible with the “overuse” tendencies inherent in fee for service payment.

Another similarity to these times is that Medicare and Medicaid emerged on the legs of a shaky and time limited bipartisan consensus after two decades of intense disagreement and political gridlock. Healthcare access and finance improved against resistance. It was an era when there was a growing consensus that we needed to squarely face a collection of chronic social and political problems. I was witness to much of what was happening, although I could not fully appreciate it because I was in the midst of my own education and just becoming aware of how what was happening in the larger world might impact my provincial universe.

What seems different in retrospect was leadership. Truman, Eisenhower, Kennedy and Johnson were all engaged and all were contributing participants to the process of discerning the way forward toward a solution. Ironically the AMA was against everything that hinted of any change. The final reality was that it took a focused and experience legislator and president in the form of one man, Lyndon Johnson, to make it happen. We do not have such a leader now. Ironically, we imagined that we would be better off electing the proprietor of a family owned business rather than an experienced public servant who understood political process. If success is a function of well processed failures, then this misstep may offer payoffs later.

If you did not live through the sixties, or were too young to notice what was happening, or were engaged in other activities like welcoming the Beatles to America, I would highly recommend Robert Caro’s four volume biography of Lyndon Johnson. I hope that the fifth and final volume Caro’s monumental exploration of the life of Lyndon Johnson that will cover Johnson’s politically fatal errors involving Vietnam will be in my hands within the next two years. I have already benefited greatly from reading the first four volumes covering Johnson’s early years and then his political activities from the thirties, through the first half of the sixties. Caro’s description of Johnson and the interaction between his personality and the times have given me a richer framework against which to consider the challenges of today.

Books like An American Sickness by Elisabeth Rosenthal and Mistreated by Robert Pearl give us excellent views of where we are now and some information about how we got here, but the greatest insight available (from my experience) on the political journey to the moment when the ACA was conceptualized comes from Blumenthal and Morone in their 2009 book, The Heart of Power. I have recommend all three to you on many occasions, but now more than ever offer them as a source of perspective as we consider the opportunities that might lie ahead if we have the energy and commitment to pursue a truly bipartisan process with everyone eagerly engaged with the goals of the Triple Aim as the simple statement that describes a destination that we all want to reach.

...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…

Before we discuss the pros and cons of the consolidation of systems, and the benefits or futility of market based competition, I want to discuss innovation and associated ideas of patient engagement, organizational evolution, and healthcare applications of the principles of the “experience” economy. At this time I would say that if your plan is to succeed and lower the cost of care in the future through ill defined and poorly considered “innovation,” I have a bridge for sale. Innovation, as most of us think of it, will be “necessary but insufficient” to sweep us to a future of Triple Aim nirvana.

As a preview of next week’s discussion of innovation, let me give you a few of the barriers that impair effective innovation and must have solutions if we are to harvest the benefits that we can optimistically imagine from “innovation.”

• Satisfaction with the status quo 
  
• Complex systems where one unit can exist comfortably for a while as others suffer
  
• Apprehensions of middle and upper management
  
• Today’s work
  
• Effort versus benefit
  
• Matching what can be done with what needs to be done
  
• Funding in an era of external pressures on finance
  
• Incorporating potentially effective innovations into work flows
  
• Aging professionals and emerging workforce shortages
  
• Red ink and the need to cut the budget
  

I believe in innovation. I believe that organizations without continuous improvement, cultures of learning, and effective programs of innovation will eventually fail. I hope that you will be back next week for the next installment.


Surprises and Variability at the End of the Season

It’s beginning to feel like fall. The water temperature is making my daily swim a challenge. On some days the air temperature is below the water temperature. I can see a few early pockets of color in the trees along shore of my lake. It is hard to avoid the idea that Labor Day is less than three weeks away, and we all know that fall really starts at sundown on Labor Day.

My response to the fleeting summer is to try to begin to think more positively about fishing as the trout rise closer to the surface in the colder water. This is one of those years when baseball will make the coming of fall seem a little easier to tolerate. Oh, and it’s time to begin to pay a little, but not much, attention to football. Most summer evenings you can find me on the water in my kayak or in my old (1972) fishing boat with its ancient motor touring the lake, essentially the same way every evening with very little variation. The path is a constant but the outcomes vary.

This week my fishing gave me the usual daily pleasures and one big surprise. Fishing is a contradiction to Einstein’s definition of insanity. Fishing requires doing the same thing over and over again while hoping for a different outcome. Today’s header is evidence of the fact that fishing can sometime give a different and unexpectedly pleasant result as an outcome of doing the same thing over and over again.

Monday evening was pleasant. I spied an eagle high in a pine that did not move for more than a half hour which is as long as I could keep him in my sight as I made my usual rounds. Tuesday evening I was on my usual route when I was thrilled when my fly rod zinged to announce that something had hit the fly that I was dragging. I was dragging a weighted fly line that was down around fifteen or twenty feet. Our lake is a shallow glacial lake. At its deepest point it is less than forty five feet deep. I was trolling my fly for rainbow trout in a part of the lake that was about twenty feet deep. I assumed that the fish that began to give me a fight was a rainbow trout. The lake has rainbows, largemouth bass and smallmouth bass as its principal game fish.

When I netted the fish I was quite surprised to find that I had caught a landlocked salmon. According to the website of the game and fish department of the state, New Hampshire has landlocked salmon in fourteen lakes. Two, Lake Sunapee and Pleasant Lake, are in my town. Both lakes are very deep glacial lakes. So why was this fellow on my line? Wonders never cease.

Tuesday was an amazing evening. Shortly after I returned to shore, I was checking out the progress of the Red Sox against the St. Louis Cardinals when I had a second pleasant surprise as I watched the hometown team turn a rare triple play! How good does it get? Who knows what adventures lie ahead this fall? Trout season lasts until October 15, and shortly after that we may have a team in the World Series.

I am hoping that there are pleasant surprises ahead for all of us this fall. We need some relief. One of my old football coaches would preach that good things can only happen when you are in the game. I hope that you will be out and about this weekend looking for good things to happen as you enjoy the company of good people.

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