Subject: [SHC] Dr. Gene Lindsey's Healthcare Musings Newsletter 18 December 2015

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18 December 2015

Dear Interested Readers,

Inside This Week’s Letter

This week’s letter has only one subject. It is an essay on the appeal of hope over optimism. In the essay I go back to the IHI speech given just a little more than a week ago by Don Berwick. His words were so helpful that they deserve a second look. I also used the essay to try to extricate an issue that has been stuck in my craw since it popped up earlier this fall.

I hope that you will cruise by strategyhealthcare.com from time to time. Send your friends to the site also so that they can sign up to get these letters. I had a weird experience this week. I was doing a little online research for a talk that I will be giving in January on healthcare finance and I ran into a citing from strategyhealthcare.com! I quickly moved on to other articles.


Next Steps. Head Forward with Optimism or Hope?

An “Interested Reader” who comments frequently, wrote me a quick note following last week’s letter:

Gene,

I continue to admire your optimism. I don't feel it...



I responded quickly:

..You read me wrong. I am not optimistic. I am hopeful. Optimism is about false certainty and frequently leads to huge doses of disappointment. It's like being sure that the Patriots would beat the Giants a few years ago and then have them loose on a fluke catch.

I am hopeful. A person with leukemia can be hopeful. Realistically they may expect to die but hold on to a hope that a way out might be found or that at least they will have a long run with chemo. A hopeful person is looking for small indicators of possible progress. I think that there is a high likelihood of significant short-term disappointment in healthcare and even some possibility of a reversal of the little bit that has been accomplished.

My life's experience as a kid growing up in a segregated and racist South encourages me. We are still racist but we are not as segregated… Change has occurred, but not perfection. That gives me hope. I do not despair. At the end of the piece I tried to indicate with my comments about McGovern in ‘72 that a collection of healthcare enthusiasts in Orlando who can point to a few small successes does not mean the game has been won...

All the best,

Gene

A friend and former colleague, Diane Gilworth, NP, brought the nuanced difference between optimism and hope to my attention several years ago. Diane is, I am happy to say, an Interested Reader. For many years Diane was at the epicenter of innovation at Harvard Vanguard. She was a leader and innovator in our efforts to develop programs of chronic care in cardiology, renal disease, pulmonary disease, and diabetes. She then served for several years as the Vice President of Nursing before leaving us to assume the role of Medical Director in a relatively new organization that was focused on home care. As a nurse practitioner working at “an uneven table”, trying to get her innovative ideas into pilots or programs, Diane had many opportunities to personally explore the difference between optimism and hope.

In a nutshell, she would always say that she was hopeful about the future, which to her did not mean that what she desired was likely; but it was possible, if she could keep the idea alive. Diane was always reluctant to say that she was optimistic because to her optimism assumes that what is desired is very likely to become a reality. She believes that a hopeful person accepts that there are many bridges to cross, hearts and minds to win, and battles to be survived, if not won, between this moment and the dream. A person with hope is less likely to be deterred by a loss or a setback.

Hopeful people orient themselves to the future as they work in the moment. They live and work for their dreams and hopes as they continue to struggle with how to make the dreams come true. They live a life that is one big heuristic exercise. The spirit and reverence in the song, “We Shall Overcome” and the spirit and expectation in Dr. Martin Luther King’s famous “I Have A Dream” speech come to mind as embodiments of Diane’s concept of hope.

Hope endures even in defeat or when it faces obstacles. The desired outcome may be a long shot or perhaps a theoretical impossibility but the dream lives. Hope has patience and expects delays. Hope takes a long view. Dreams plus hope suggests an “audacity” that defies conventional thinking as the title of Barack Obama’s book, The Audacity of Hope, implies. Diane taught me that when defeat looked inevitable it was not unreasonable to still hope that a Malcolm Butler could intercept a pass.

Optimism is founded in the expectation of victory or success. The money is in the bank. The data is predicting a certain positive outcome. The stars are shining bright. Victory is inevitable. “It’s as good as done”. The sale will happen because “The check is in the mail”. This game is in the win column. We will be the champs!

Unexpected expenses could arise suddenly to wipe out what is in the bank. A new and unexpected piece of data can turn the analysis around 180 degrees. Clouds can suddenly roll in to obscure the stars. Sometimes the mail gets delivered to the wrong house or is lost. Fluke catches can cost you the Super Bowl more than once late in the fourth quarter (2008, 2012) and you get to watch the Giants hoist the trophy. Do not forget the ball in ‘86 that bounced between Buckner’s legs and with it went a certain World Series victory.

Whenever the unexpected occurs, the optimistic person who is expecting success that suddenly has evaporated is likely to be devastated by the surprise. The emotional work of processing the grief associated with the loss when victory was expected puts everything that has been accomplished at even greater risk or prevents extraction of any good from the shambles after the disappointment. The hopeful person rolls with the punch and quickly incorporates the lessons of the defeat into the strategy for the next attempt at the summit.

Diane’s lesson has stuck with me and it is the reason that despite the fact that I have real concerns about the future, I appear to some to be optimistic. They did not get the lesson from Diane and so they misinterpret me as “optimistic” about the future of healthcare. Our points of view are more similar than different.

Trust me, I can list plenty of reasons to be apprehensive about the future. I know that the ACA is constantly under attack. Marco Rubio has successfully created legislation that prevents subsidies to insurers who are facing big losses. I know that consumers and providers are bearing more and more risk even as some insurers and many pharmaceutical companies are enjoying big profits. I know that the the cost of care is rising again. In know that last year we spent over three trillion dollars or over $9500 for every person in the country. I read that hospitals and health systems continue to invest in expensive robotic surgery and other machinery as they continue to compete for volume-based revenue. I know there are a large number of physicians and other clinicians who remain angry or have such a sense of loss that they show up in dissatisfaction surveys as depressed or burned out. These few factors plus a host of others give the continued path of healthcare reform an uncertain future, but I am hopeful.

Perhaps on the list the biggest barrier to the Triple Aim is the state of the professionals that provide care. “Burnout” is a popular topic but it is a symptom and not a disease. We need to fix the root cause issues. As a symptom burnout requires deep reflection and deserves immediate action. Unless we fix its causes it has the potential to undermine much of what has been achieved. The achievements we have experienced could be undermined by a disaffected workforce.

The optimists among us might have a hard time even reading the Boston Globe on a regular basis. As I reported in October following the Annual Cost of Care Hearings in Massachusetts, Dr. David Torchiana, the CEO of the largest system in Massachusetts continued to contend that the cost of healthcare was not a problem if one would just understand that the cost needed to be considered in the context of the high average income in the state. I also reported at that time that it was disturbing that Governor Baker used much of his testimony to say the same thing.

On December 3rd the Globe reported Dr. Torchiana saying the same thing again at a meeting of the Chamber of Commerce. The cost of care is a problem no matter how many times Dr. Torchiana says that care in Massachusetts is “very affordable”. His argument is built on studies that show when the total cost of care is divided by total income it is only 18 percent of the income of the average family in Massachusetts compared to a national average of 21 percent.

Average doesn’t mean “all”. There are many families with less than an annual income of $68,000 (median income compared to national median of $53,000, and median means that half have less but their cost of care is still the same). Even if the cost of care consumed “only” 18 percent of the income of those below the median income, it is still a huge problem. Even with expanded coverage the out of pocket expenses continue to rise. Most people would like to spend some of those dollars in other ways. I agree with my Reader that those kinds of statements are “optimism killers” when they come from powerful people like the CEO of Partners or the Governor of Massachusetts.

Reading a little further you can still have a little hope when you read that Amy Whitcomb Slemmer, executive director of Health Care for All, is speaking out against Dr. Torchiana’s analysis. In other places I have also read that Stuart Altman, the well known economist and the chair of the Health Policy Commission has disagreed with Dr. Torchiana’s logic. I have hope that this issue will get some traction. My hope is bolstered by an article in the Globe yesterday entitled “Escalating health care costs seen outpacing Massachusetts incomes”. To quote the article:

Rising healthcare costs have outpaced the incomes of Massachusetts families over the past decade, despite efforts by the state to control medical expenses, according to a report released Wednesday.

The cost of health insurance grew at twice the rate of incomes, jumping 55 percent from 2005 to 2014, compared to 23 percent for income, according to the report from the Health Policy Commission, a state watchdog agency that monitors health spending. Health insurance costs averaged $19,300 per family last year, consuming about one-fifth of the average family income of $88,000.

For many Massachusetts residents, the costs of care are unaffordable, the report said. About 17 percent of residents reported forgoing medical care because of the high expense.


The number that really needs emphasis is not the average or the median income of families in Massachusetts compared to the cost of care, but rather the fact that 17 percent of residents did not get the care they needed because of the cost!

If I were an optimist the position and logic of the leadership of Partners coming out of the mouth of the Governor, or the scene of the CEO of Partners presenting his logic to the Chamber of Commerce, would sink my mood for a while. Being hopeful I can say that I am delighted for the emerging transparency coming from the Globe and the willingness to express a different opinion coming from the Attorney General and citizens like Amy Whitcomb Slemmer. My hope gained momentum when I read the quote from Lynn Nicholas further down in the article

Lynn Nicholas, chief executive of the Massachusetts Hospital Association, said hospitals have taken many steps to control costs. She said replacing the traditional fee-for-service payment system, which rewards providers for the number of procedures they do rather than the quality of care they provide, is critical to reducing costs.

“The greatest potential catalyst to [cost control] is moving away from fee-for-service to alternative payment models,” she said.



I do not know if she was expressing her support for greater efforts to reduce the cost of care. Perhaps she was defending hospital costs as something out of their control or she could have been mounting a defense for continuing high costs by looking to shift blame to the payment system. Perhaps she was saying that despite efforts, costs were high and would stay high until we got rid of FFS. It is hard to judge intent but her words did support my hope.

I am actually delighted with the campaign of enlightenment that Dr. Torchiana seems to be waging. He is demonstrating every time he speaks just how disconnected and distant from the experience of “average”, or should I say less than average, people he and his organization have drifted. I hope that he gets more airtime and print. It may well be that the continued reports in the Globe and elsewhere of the blatant insensitivity of the Partners leadership to the impact of high healthcare cost on Massachusetts citizens will become the source of change. There is a lot of hope in the fact that smart people make mistakes. I wonder what was really going on in Pete Carroll’s mind when he decided to make Malcolm Butler an instant folk hero.

The hope interpreted as optimism that my “Interested Reader” saw in my letter last week was derivative of all that I experienced as the faithful gathered in Orlando, but the intensity of my rapture was probably mostly attributable to Don Berwick’s wonderful speech. Don’s speech is the antithesis of the excuses and the specious arguments that were the subject of my disdain at the Cost Hearings and which seem to be continuing in the hope that if they are repeated frequently enough someone will say, “Oh you’re right Dr. Torchiana. How silly of us to think there was a problem.”.

My belief is that Don Berwick’s speech at the 27th IHI Forum last week was as much a call for understanding where we are as it was a call for moving forward. My excitement that was interpreted as optimism was actually a sigh of relief that Don was suggesting a dual process analysis. The first step toward understanding why the “joy of practice” is vulnerable is to look at what has been the basis of the status quo, or a review of from where we have come and why we have not gotten to our goals. We also need to understand why what he called “Era1” and “Era 2” were positive at one moment in time and then their competencies and attitudes became inadequate for these times. For those who missed the letter last week and because learning occurs with review, read what I wrote about Don’s speech at the end of the IHI Forum last week. I have added some bolding and left out a little of my original verbiage.

And Then Don Spoke

Don Berwick was the last keynote speaker. His “message” closed the 27th IHI Annual Forum as it has done many times in the past. I would have flown to Orlando and waited two days doing nothing just to experience the joy of being present among the 5,000 plus attendees to hear what he has been thinking about over the last year. What amazes me is that he has been thinking about the same things continuously for over a quarter of a century and the insights just keep getting more and more profound.

It is as if he has been climbing a mountain, and the higher he gets the better the view and the clearer the air. He did use a mountain metaphor as the core of his presentation. He has climbed Mount McGregor in Washington twice in his life. The first time he had a guide who knew the trails. The second time he took a friend and thought that he could find his way. There are many confusing trails near the summit and all but one end in a dead-end and you must come down or back track to find the right trail to get to the summit. Don and his friend followed many false trails trying to get the summit. Each time they realized they were on the wrong trail they were willing to go back and start again on another trail. After many wrong turns they eventually found their way to the top.

Don postulates that healthcare in general, and physicians in particular, have been on some dead-end trails. He described two eras in practice. Each era was positive for a while but eventually the trail came to an impasse. Giants like Hippocrates and Galen characterized Era 1. In Era 1 physicians had noble intent and specialized knowledge that no one else had. They were beneficent. Like all professions they were self regulating, a rule unto themselves. He quoted Eliot Freidson,

“A profession is a work group that reserves the right to judge its own quality”.

Freidson turns harsh,

“While the [medical] profession’s autonomy seems to have facilitated the improvement of scientific knowledge about disease and its treatment, it seems to have impeded the improvement of the social modes of applying that knowledge.”

Despite the fact that in Era 1 we failed to learn how to effectively apply our knowledge to everyone’s benefit, it had the positive characteristic of trust. Patients and the community trusted their doctors. Doctors had a prerogative that allowed them great clinical autonomy. They were focused on science with inquiry and research and they practiced great mentorship to those coming up in the profession.

Don thinks that Era 1 ended thirty or forty years ago and Era 2 has had harsh accountability, increasing scrutiny, and excessive measurement of many things that do not add value. There has been an intense attempt at a carrot and stick approach to motivation with the duality of accountability and scrutiny confused by complex incentive schemes. All of this has induced doubt in the minds of physicians and apprehension in the consciousness of their patients, other healthcare professionals and the public in general.

Don anticipates a new “third era” where we come back down the trail from our most recent dead-end and then make a new attempt on the summit. The summit is a good metaphor for the triple aim, which he articulates in its new form as I introduced before as:


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

As we come back down the trail we will need to:

  • Stop excessive measurement
  • Abandon complex incentives
  • Decrease the focus on finance
  • Avoid professional prerogative at the expense of the whole
Going up the new trail as we start again we will need to take the following positive steps:

  • Recommit to improvement science
  • Embrace transparency
  • Protect civility [He spent some time talking about how we treat one another as well as our patients. Our society seems to be moving to a deficit in civility. Think again about the political campaign.]
  • Listen. Really listen
  • Reject Greed
Yes, he did talk about our greed…

Don pointed out that there are things that we should retain from Era 1

  • Professional pride
  • Commitment to science
  • Beneficence
From Era 2 he would hate to lose

  • Transparency
  • Sensible payment mechanisms
  • Patient engagement
… When he finished the speech, I agreed with him that to implement his ideas would require a “movement”…Don was preaching to a very small choir. [Despite the crowd, the audience was less than 0.05% of all healthcare professionals]. It must therefore fall to those who heard him and agree with his spirit, direction and analysis to do a lot of work spreading the ideas that he has so profoundly articulated. Just as our environment remains vulnerable to the shrugging of our shoulders when the subject of climate control comes up, I believe there is a deeply ingrained sense of futility that is part of a larger loss of professionalism in healthcare. So as Don suggests, it is easy to take the money and keep on going to work every day with your head down as long as the gig lasts.

I am gullible when it comes to numerators and denominators. In 1972 I was wildly enthusiastic about the candidacy of George McGovern. All my friends and even people I met on the street in Boston seemed enthusiastic about him. He seemed a sure bet for the White House. We all knew that Nixon and his henchmen were crooks. As you remember, George did carry Massachusetts in a landslide. It was the only state he carried. It feels the same to me now when I talk with people about the exciting possibilities in the future for healthcare. All my friends at IHI and GPIN and the places I go agree, but then I remember George and I am not so sure about the future and I realize that there isn’t very much any of us can do alone.

It will take a movement and every one of those people who heard Don needs to recruit and educate several hundred other people. You can occasionally see a few stars twinkling on a dark and mostly cloudy night and Don did give us some examples of practices and hospitals that get it and are making a difference as they twinkle to our amazement but there aren’t many of them yet in our dark sky. There is a lot of work to do…


As I have reflected again on Don’s words and my “Interested Reader’s” skepticism, I realize that my hopes for the future are pinned on ten emerging realities.

  1. Most healthcare professionals have (even when burned out) a core desire to do the best job that they can for patients. I have never heard anyone call the Triple Aim a bad idea in any of its iterations; nor have I heard that it is not the goal for all that we are trying to accomplish.
  2. The regulatory structures and programs that have promoted and initiated the shift from volume to value are gaining traction outside of CMS. They are being adopted by the world of commercial insurance.
  3. The shift of risk to consumers plus the necessary associated increase in transparency is beginning to create a “need to learn and know” engagement by consumers. Sadly, as the cost of care rises because of inefficiency, overpricing and waste, the cost to some is becoming an unbearable burden. This is creating short-term pain that may become the origin of more legislative response. I cannot believe that there are still large systems of care like Partners in Massachusetts that contend that the cost of care is really not excessive.
  4. The digitalization of medicine will be followed by a necessity to change the flow of work. (As presented by Dr. Robert Wachter at IHI.)
  5. The emergence of disruptors continues. They will create increasing necessity for the status quo to respond to the challenge of producing greater value, which is a function of access, quality and cost. The emerging delivery system driven by disruptors will make getting care simpler and more “user friendly”.
  6. Expansion of the market as we move toward true universal coverage plus the aging of the population will make current models of delivery inadequate and economically unsustainable. We will finally evolve the “conceptual framework and operating system that will provide optimally for the health needs of the population”. There will be a substantial redefinition of “standard work” for everyone. It is a process that has begun as the PCMH. Value based reimbursement will speed up the transition as professional shortages force reconfiguration of delivery.
  7. Understanding and using “Improvement science” and the tools and culture that are at the core of its efficacy will be recognized by physician groups, hospitals and health systems as foundational to their ability to survive and negotiate the changes that the six previous “emerging realities” will force.
  8. As we learn the lessons of adaptive change, focus more on the needs of patients and families, improve systems performance, simplify the work of care delivery with less wasteful “standard work”, and complete the digitalization of healthcare we will return “joy to the practice”.
  9. We will finally understand that good health is not a silo and requires effective attention to other social issues including education, full employment, cultural enrichment, improved infrastructure, and social equality.
  10. The practice will successfully negotiate the transition from volume to value and to Era 3 as it accomplishes the “adaptive change” necessary to achieve the Triple Aim.
I can understand the view of those who feel that short-term optimism is unwarranted. The near future may hold many instances of personal and institutional loss. I am already reading multiple lists of “the ten biggest issues for 2016”. Anyone who wants to predict a disaster, or at least continuing angst and more “burnout”, can make a pretty good case for trouble ahead. I prefer the long view and remain hopeful that what I see coming over the horizon looks a little better than it did not so long ago.

Can You Believe the Weather?

I am concerned. It’s just not right. The weatherman says that we are averaging about ten degrees above usual for December. I am beginning to think that I put away my fishing gear and kayak too soon. This last week we were in California visiting our grandson since he will be with his other grandparents for the holidays. The weather there was a blessing since their rainy days are breaking the drought. There were some days with a clear blue sky. I had not seen green grass along the coastal highway in quite a while.

I took walks in the rain in the redwoods and walks along the shoreline above Santa Cruz on a clear day. The header on today’s letter is from one of the beautiful trails in Wilder State Park a few miles north of Santa Cruz. Wherever you are this weekend enjoy the weather while it lasts. I hope that you have great plans for the Holidays and that they will include long walks with family and friends.

Be well, nurture hope, continue to try to make a difference, and let me hear from you every now and then.

Happy Holidays!

Gene

Dr. Gene Lindsey
http://strategyhealthcare.com
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