| 18 November 2016Dear Interested Readers,About This Week’s LetterThe main subject of this letter is a continuing analysis of what might happen in healthcare during the presidency of Donald Trump. My in basket is filled with opinions from online media sources, white papers written by consultants and law firms looking to capture business, and letters from friends and colleagues who are deeply concerned and want to share ideas about what is to come.For this letter I have drawn on the opinions of many healthcare pundits and insiders who are giving speeches and writing about what they think will happen. There is a consensus that is emerging from these expert guesses. After blending those predictions with my own thoughts about what a person who has proven to be very unpredictable might do, I move on to suggesting strategies in response to those actions. I have never seen such a vigorous discussion of the benefits and failures of the ACA. It is amazing how clearly you can see the value of something that you are about to lose. We have arrived at a strange place. There is some benefit in trying to try to figure out how we got here. If the ACA was a huge Lean A3, it is now time to do an A4. “A4” is Lean terminology for what you do to develop counter measures after the solution developed with the initial A3 failed to produce the target or ideal state. It is time to harvest what we can learn from the experience of the original attempt at a solution, and think about where we go from here. We must examine whether we really have a consensus that as a nation we are committed to universal coverage with an improved experience of care for a cost that we can collectively bear while addressing many other competing public and private priorities. I had the good fortune this week to be at a two day conference on access to care presented by an emerging software company, Kyruus. The company was co founded by Graham Gardner, a former BIDMC Chief Resident, and produces remarkable software products that facilitate effective appointment and referral processes in large delivery systems and CINs. I am proud to be a member of the Kyruus Clinical Advisory Board. For the last three years Kyruus has sponsored an exciting conference in Boston to explore the challenges to better access for patients and better deployment of physician resources. I am trying to contribute what I have learned over my career to their development process. I hope that their products will enable the more efficient and effective use of our professional expertise. The conference was a great venue for the discussion of the uncertain future of healthcare. The speakers were excellent and many were able to restructure their presentations to fit the unexpected outcome of the election. I am eager to share some insights from that meeting. Those insights are marbleized through this letter.It was a full week. I also attended the Advisory Council of the Health Policy Commission of Massachusetts where all of the continuing concerns were recast in the context of the outcome of the election. I finished the week with a trip to Pennsylvania for two board meetings of the Guthrie Clinic where I can assure you that the election was an elephant in the room and an item of discussion and concern among informal conversations with the trustees. I am certain that if this week I had walked the halls where you work, I would have heard discussions and debates about what the election will mean to the future of care delivery and the experience of care where you live and work. The goal of this week’s letter is to be a resource for you as you go through your own strategic considerations.I received several acknowledgements of appreciation following last week’s letter, along with one request that I write with shorter paragraphs and more headers to break things up. I think that is a good idea. Let’s see if I can show a little continuous improvement. Several who responded said that the letter made them feel better about the future. Some even commented that it was a relief for their anxiety and depression. I hope there may be some similar therapeutic benefit in this letter. If you did not read last week’s letter, you can read an edited and less dense version now on strategyhealthcare.com. I hope that you will pass that note on to friends and colleagues. Moving From Depression to Acceptance and ResponseOne Huge A3Before guessing what President Elect Trump might do and what will happen in response to his future actions perhaps it is good to ask the question that has become a cliche, “What problem have we been trying to solve?”. The next question to ask is, “What problem is the President Elect and his allies in the Republican party trying to solve.”My letter last week was built on the trust that all thoughtful Americans agree that an ideal state would be:
Care better than we’ve seen, health better than we’ve ever known, cost we can afford…for every person, every time.If we were doing a national A3 on healthcare I believe that there would be consensus on the reasons for action, the current state and the ideal state as expressed by the Triple Aim. Where Does The Real Controversy Lie?Our differences lie in the search for solution. Republicans put great trust in the power of the market and competition. They believe in “privatizing” care by giving public support to the needy and elderly to blend with their own resources to use in the marketplace to make as good a choice for themselves as the combination of public and personal resources can buy if they do not have access to employer sponsored care. They believe that state governments are closer to the site of care and should be where resources and regulations should be managed. Not only do the parties differ on the subject of private versus public determinants of care, they have philosophical differences about how change will occur. They see priorities differently in a world of scarce resources and competing needs. They have different opinions about the urgency of universal coverage and the liability of accelerating costs. The conversation about healthcare is occurring in a cacophonous environment where there are other issues that contribute to fear and anger. It is easy to forget that the core issues are access to care and its costs. All the peculiarities of Mr. Trump’s background and preparation for the role of president have been trumped by his ability to hear and speak to the issues that frighten enough people in enough states to win a majority of electoral votes. Both Donald Trump and Bernie Sanders recognized the desire for real changes that would decrease income inequality. I doubt that Donald Trump has any knowledge of the goals of the Triple Aim and how it intersects with the economy, but when I read what he and Paul Ryan have written and what they pledge I see different words that add up to the Triple Aim. The differences are all in the solution space.Predicting what Donald Trump will do has become a growth industry. It has become an obsession for me. I think that it is not too early for the leadership of healthcare enterprises to begin to contemplate how they will respond to the predictable actions that he will take. As I wrote in the first section, two of the speakers at the Kyruus conference on access abandoned what they had planned to say on the basis of the expectation that Hillary Clinton would be the forty fifth president and recast their presentation to a series of guesses about what a Trump presidency might mean. I also attended the quarterly meeting of the Advisory Council of the Health Policy Commission of Massachusetts this week. The “feel” of the Advisory Council agenda was substantially altered by the uncertainty of what a change of direction in Washington will mean in Massachusetts. My third meeting of the week was the board meeting of the Guthrie Clinic which serves a community and region where many of the patients voted for Donald Trump with virtually no understanding of how their vote might modify their future access to care.What Do the Experts Expect?All of the speeches that I have heard and white papers that I have read begin with one certainty; Donald Trump will absolutely support the repeal of the ACA, and will do anything that is within his administrative power to limit its effectiveness on “day one” of his presidency as he has promised. The “mandate” is what Republicans object to most. A mandate is structurally necessary for any attempt to use insurance as a pathway to universal coverage without reference to prior medical problems and with no lifetime limits. How the conflict between abolishing the mandate and preserving universal access to insurance will be resolved remains to be seen. Beyond the certainty that the ACA will be repealed, opinions diverge somewhat as to how the drama will play out. Repeal of the whole bill is probably impossible because the Republicans do not have the sixty votes in the Senate that would be required under the Senate’s current rules to bring the bill to an up or down vote. The ACA was passed by a “reconciliation” process and the same process could be used to repeal the majority of the bill and render what it does not repeal relatively ineffective. Last year a repeal bill was passed and vetoed by president Obama. Most experts suggest that last year’s bill will be refiled on “day one” of the Trump era. It is important to remember that there has been an incredible amount of investment in the ACA made by the federal and state governments and also by private investors and corporations. The estimate is that it will take a year and a half to bring the ACA to a halt after it is repealed. There will be confusion during that period. I assume that many organizations will be busy deconstructing their efforts to comply with the ACA and focusing on new strategies to try to figure out how to survive without the income they were enjoying from newly insured patients. Lastly, as you will see the “play out” of the shift in healthcare finance that will begin on “day one” may result in dramatic changes in who and how Medicare and Medicaid covers. There will be millions of people who either voted for Donald Trump or did not vote for Hillary Clinton (more than 42% of eligible voters, almost 100 million people did not vote) who are at risk of losing their access to care as the fallout of Trump’s fulfillment of his promise to abolish the ACA. How they will express their surprise and anger could be a big issue in the 2018 election. Mitigating the damage to the members of their base who will lose care that they want will be a political problem to be solved by the Republican leadership. Beyond Repeal to ReplaceThe repeal part of President Elect Trump’s promise is the easy part. The “replace” part is less certain. I have reviewed the scant writings that give us an overview of his principles. Many experts have suggested that Paul Ryan’s, “A Better Way” will be the core of the bill written to replace the ACA. If you do not want to read the 37 pages you can listen to Speaker Ryan explain his ideas by clicking here. I suggest studying the document if you have a governance or managerial responsibility. We all know now that Trump has also indicated that several of the provisions of the ACA will be retained. He likes keeping young adults on their parents plans until age 26. That benefit costs employers about $1200 per person covered. That’s a pretty good deal. He also likes the abolition of lifetime limits of payment and the ban against exclusion because of a pre existing condition. He has not indicated that he understands that removing the mandate for patients and employers to participate creates a huge potential instability in the insurance market when retaining these benefits. Without a new solution most people expect chaos. What will really happen remains unknown but the reality does create the possibility for bipartisan dialogue during the repeal debate.The Ryan plan shifts responsibility for Medicaid to the states through grants. It abolishes the subsidies that support low wage workers in the exchanges and replaces them with tax deductions. Ryan favors big changes in Medicare. Trump has said conflicting things but Medicare will be another place where productive conversations may occur. Medicare could be modified by combining parts A and B or alternatively privatizing it and giving vouchers to the elderly to assist in their purchase of insurance. It is also possible that the age of eligibility will rise from 65 to 67. The good news is that Medicare Advantage and its risk based finance are very popular with Republicans. There is much debate about selling insurance across state lines. Even though it is now possible in a few states there are many who are convinced that it is an empty box offering no real benefit. I think it will be part of the package that will be passed but then it will be ignored. The sum total of repeal and replace will likely be a direct reduction in revenue for most hospitals and provider groups if for no other reason than that there will be fewer customers in the market place. It is unclear what it will do to the business investments that have been made by the industry and its suppliers. Political PontificationDemagogues gain power by promising simple solutions to complex problems while identifying those who are easy to blame and creating misconceptions about potential dangers. As a society we have been looking for over seventy five years for solutions to the complex challenge of providing everyone with quality healthcare at a cost we can collectively bear. Now our President Elect is prepared to lead us in a different direction without much more assurance than the unfounded claim that he can “fix it”. In healthcare what needs fixing is cost, access and quality. He has made similar claims in all areas of presidential responsibility. He understands how to get better trade agreements. He knows more about ISIS than the generals. He can return jobs to factories that no longer exist. He can insure safety from all threats foreign and domestic. It goes on and on. He asks for trust when the record is full of his business failures and his record of stiffing business partners, contractors and suppliers. He says that he can bring us together when the rhetoric that got him elected was built on half truths, bald faced lies, blatant misogyny, and an appeal to the basest of xenophobic fears. Much has been written about the President Elect’s personality. Many explain the conundrum of his behavior as a manifestation of narcissism or say he has a borderline personality. Whether those concerns are real or not, his own presentation of facts and his analysis of his ability to contribute to solutions to the problems that he will recognize suggests that he demonstrates the Dunning-Kruger effect. I learned about the work of Dunning and Kruger while reading about behavioral economics. They did experiments that documented that people with limited abilities often think that they know more than they really do. Some have suggested that those who believe in people who overestimate their own abilities have some derivative of the Dunning-Kruger effect. I guess we could call it Dunning-Kruger “by proxy”. I anticipate that things that will not work eventually won’t work. I asked myself and the other attendees at the the meeting of the Advisory Council of the Health Policy Commission what Massachusetts would do when the support from the federal government for Medicaid fell even further below the true cost of care than it is currently. At this time the shortfall in Medicaid and Medicare resources is covered in most entities by cost shifting from commercial insurance. Will that be possible in a collapsing insurance market? Will the taxpayers and employers of Massachusetts pay more to continue the spirit of universal coverage when the Ryan/ Trump ideas reduce resources? It will test our priorities.What Can We/You Do?At a collective effort we can encourage thoughtful consideration and debate of unintended consequences. Continuing to question the managerial and governmental capabilities of a Trump presidency is an absolutely responsibility of a “loyal opposition”. We must move past the time when “progress” can only occur on any issue if one party controls the Presidency, both houses of Congress and the Supreme Court. The Constitution envisioned debate and discernment. I believe that as we look into the abyss of the alternative, the leadership of both parties must participate and compromise while using all the skills of interest based negotiation. After the knee jerk repeal of the ACA there will be a real opportunity to focus on what replaces it without causing a collapse of healthcare.Never before has there been a greater need for all of us to focus on how we lower both our operating costs and our prices. Money will becoming out of the system. Unless we replace the certain reductions with efficiency, the burden of cost on individuals, state government and employers will result in empty beds and empty offices for the wrong reasons. MACRA was passed with more than a 95% bipartisan majority. President Trump probably doesn’t know what an APM is, but Ryan does and he seems to like them. Commercial insurers and employers like them. We all need to enhance our competencies in them. I think that within the various medical specialties we need to understand the no one specialty can survive and thrive at the expense of others, if we are to preserve what our patients need and improve our experience of practice. Physicians need to be willing to collaborate in ever more creative and effective ways with other healthcare professionals. Don Berwick has given us great advise for these times with his call for Era 3 in healthcare. Read it and begin to try to live it. Give it to your colleagues.I am convinced that there is a long list of real things that we can do to promote better care after the ACA is repealed. I believe that the flame of commitment still burns in the hearts of most people who dreamed of being in healthcare when they began to plan their lives. There is nothing like a threat to what we hold dear to rekindle the flame. Walking Into The FutureI know that many people who read this letter each week are continuing to have a hard time imagining how they will get through the next four years. I am reminded that hope always has its eyes on the future. Hope is always rooted in faith in some belief or set of principles that range from some concept of spirituality to the hope that is offered in a world of great human understanding buttressed by science and technology. Hope needs sustaining sources of energy. When events disappoint or surprise us our hope can take a licking that sends it reeling for a while and that is painful. It is when your hope takes that punch in the stomach and it feels like you will never stand up straight again that you need to reach out of your pain and grab onto those sustaining sources. For me those sustaining resources lie in a few specific places. Number one is a desire rooted in my spiritual life for a better world grounded in love and respect for everyone and our planet. That hope is sustained by the trajectory of history and my personal experience that mankind is on a journey to a more stable state, despite events and circumstances that temporarily suggest otherwise. I am reassured in my belief that there is a very long term resilience inherent in all living things and in the physical world. Short term I primarily find support in family, friends and community. The hardest part of getting through a dissapointment is waiting through the time it takes to feel healing as that inherent resilience is slowly realized. I have several ways of coping through the time that it takes to feel better. Contemplating the lessons and accomplishments of the past is sustaining. Immersing myself in natural beauty has a calming benefit. Art as expressed in literature, music, theater, and the visual arts is much better than any drug. Making plans for a better future is enormously beneficial as a way to speed up the transition from despair to a renewed sense of possibility. There is a formula for sustaining health that suggests that to be healthy we need someone to love, something to do, and something to look forward to. I have found the formula to be personally useful and also to be a good guide as I assessed my patients. A good walk with a friend is a reasonable short term facsimile for the formula. A walk alone with one’s thoughts is also a good time to think about those you love, what you can do, and what plans could draw you into a better future. There has long been the suggestion that exercise was good for depression. This week the New York Times published a piece about the therapeutic benefit of exercise. I know that my first response to disappointment is to think about getting outside to move my body through the beauty around me. This week I found beauty walking on the Boston Common and around downtown Boston, and then driving through Western Massachusetts and across the vast rural areas between Albany and Sayre, Pennsylvania. The picture in the header shows a beautiful corridor of trees along Huntington Avenue as it runs past the Mother Church of the Christian Scientists as one walks from the Prudential Center toward Symphony Hall and the Museum of Fine Arts. My walk took me to the MFA where I met my wife and friends to enjoy the exhibition of the art of William Merritt Chase after which we backtracked to Symphony Hall where we heard a very vital eighty five year old Rita Moreno talk and sing for ninety minutes about diversity, opportunity, and the power of commitment to purpose and persistence. I hope that this weekend you will have a chance to focus on the things that sustain your hope for the future as we all look forward to the Thanksgiving holiday. |
| 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
Dr. Gene Lindsey
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