| 19 August 2016
Dear Interested Readers,
About This Letter
This letter may not have the “in the moment” feel of my usual letter. It does not contain reference to anything that has happened since August 11, when it was written. I wrote the letter last week because it needed to be “loaded” for distribution by August 12 before my “IT guy” was heading out for a well deserved vacation to the backwoods of Maine with no Internet access. I should take this opportunity to publicly thank Russ Morgan who has made this letter to you every week possible for over a year and a half without a break. He is overdue for a week off!
Readers who have been with me for a while can remember what an amateur appearance these letters had before my serendipitous introduction to Russ. Russ has taught me a lot. The learning process continues and perhaps some day I will be able to get the letter out myself; but even if I am eventually “IT competent”, I hope that my relationship with Russ goes on for years and years. He has become a true friend who always contributes much more than he takes. Russ cares about the world and as best I can tell from what I know of his very interesting personal history, he has always worked hard to make his community a better place for everyone. He is definitely one of my heros!
This letter is the conclusion of the two part journey of reminiscence back to Harvard Community Health Plan when it was an innovation struggling to take its place in the medical community of Boston. The letter last week was a personal travel log of sorts that covered the first ten years of HCHP’s existence. I observed the first five of those years from the perspective of a trainee as I progressed from a medical student, to my years as an intern and resident, and then finally as a fellow in cardiology, all at the Peter Bent Brigham Hospital. My personal journey as part of HCHP began on July 1, 1975, a little more than five and a half years after it had opened its doors in early October 1969 after more than five years of dreaming and planning by Dr. Robert H. Ebert who was then the Dean of Harvard Medical School.
As you may remember from last week’s letter or from looking at the SHC website this week, this two week project was undertaken in response to my visit to the home office in Boston of Iora Health, a remarkable and exciting primary care “greenfield” startup earlier this month. I saw many similarities between Harvard Community Health Plan’s early history and the first few years of Iora. This week (on the Monday after this letter was written and the Monday before you read it) I will accompany Dr. Rushika Fernandopulle, the cofounder and CEO of Iora to visit the Iora practice in Hanover, New Hampshire that was established as a partnership with Dartmouth College. You will hear all about that visit in next week’s letter. The set of four letters is meant to be a partial review of the issues that face innovators in healthcare. Many innovators feel like they are swimming against a tide of resistance. As I noted last week with the over 500 year old quote from Niccolo Machiavelli, resistance is a reality that faces most innovators.
There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things. For the reformer has enemies in all those who profit by the old order, and only lukewarm defenders in all those who would profit by the new order, this lukewarmness arising partly from fear of their adversaries … and partly from the incredulity of mankind, who do not truly believe in anything new until they have had actual experience of it.
For all of his success, Steve Jobs’ story is really about his creativity in overcoming resistance to his ideas, his ability to learn from mistakes, and his ability to organize others who did not always initially understand or agree with his vision. He overcame those barriers to guide the emergence of the products that we now admire so much. Dr. Ebert and Dr. Fernandopulle share Jobs’ ability to manage and overcome resistance. Perhaps it is just a function of persistence and their own unwavering commitment to an ideal that allows them to plow into that resistance and secure a little beachhead on the shore of a better future. I do not know what will happen to Iora in the future but I do expect that they will encounter some of the real barriers that HCHP experienced in the seventies and eighties and that I describe in this letter.
Building a Causeway to The Mainland
Last week I repeated a description that I first used in the letter two weeks ago that kicked off this series. Here it is for a third time.
...in the innovator’s world, integrating what is new with what exists inevitably produces conflicts as “creative destruction” becomes a reality. Years ago I imagined HCHP as an “island economy”. As long as we were an isolated pioneer outpost and there was a spirit of adventure, life was less stressful. We were not concerned with our work load or our compensation. We were happy exploring a better way.
One day we faced the reality that we had to be integrated with the wider world. If we were going to survive, we needed to grow. To grow we needed to attract professionals who wanted “a market compensation for market responsibilities”. It was as if we had built a causeway from our happy little island to the realities of the “mainland”. I sense that Iora is fast approaching some of the same realities that faced HCHP. The number of similarities are astounding, from the fascination with prepayment, to the redesign of the concepts of an optimal practice, and the attempt to create a more clinically useful medical record.
If you read the link above to the Wikipedia piece about Schumpeter's concept of creative destruction you can surmise that it is very similar to Clay Christensen’s “disruptive innovation”. Down in the article after all the references to Marx was the statement:
In Schumpeter's vision of capitalism, innovative entry by entrepreneurs was the disruptive force that sustained economic growth, even as it destroyed the value of established companies and laborers that enjoyed some degree of monopoly power derived from previous technological, organizational, regulatory, and economic paradigms.
Such conquests always seem to follow a period of struggle and learning for the innovators that are invading the domain of the establishment. Creation requires energy and has its costs both in money and human effort. This concept of natural resistance to creative destruction connects nicely to the statement by Machiavelli warning agents of change or innovators not to expect that their ideas will be immediately embraced, but rather resisted, especially by those who sense that their investments or their professional culture are threatened. In Christensen’s description of disruptive innovation it seems to me as if he is describing a process that initially goes unnoticed as the innovator enters the market peripherally and then gradually gains market share while the “old order” is complacent in their success and fails to recognize the potential of being displaced by the “disruptor”.
Harvard Community Health Plan was met by resistance even when it was just an idea that could not be dislodged from Bob Ebert’s mind that he kept describing to others who controlled the status quo of hospital based practice. What I have not described so far was that there was also a cry of “foul” by some practitioners in the community who were graduates of Harvard Medical School and were upset and threatened by the fact that the new practice was allowed to use “Harvard” in its name. Some wrote letters of complaint to the New England Journal of Medicine and to the Harvard Alumni publications of the day. This issue remained alive and of concern for more than twenty years and use of the name Harvard was again an issue when Harvard Vanguard was created. I always felt that the controversy over the name was a form of pushback by community based physicians who were threatened by how this new practice might affect their practices. There surliest manifestation of this resistance was a “joke” that was floating around the Boston medical community in the seventies that HCHP was an acronym for “Horrible Care for Healthy People”.
There are more granular challenges that face innovators than just gaining acceptance by the market if the innovators expect to overcome “the old order” and capture the “lukewarm” members of the status quo “who do not truly believe in anything new until they have had actual experience of it”. In the narrative below try to notice that I am using my observations of HCHP and my experience there to demonstrate some of the barriers that must be managed and are never completely overcome in any enterprise. They are often the function of members of the team struggling with the tension and personal challenge between what is best for them as an individual and what is best for the enterprise and the community it serves. I will try to use the experience of HCHP in the seventies and eighties to look at a list of challenges that include:
- Creating and managing a leadership team or guiding coalition that includes business and medical expertise.
- Promoting and managing growth in an era of limited resources.
- Managing the “make/buy” relationships: vendors, hospitals, nursing facilities, specialists, diagnostic resources.
- Maximizing relationships with collaborators who are sometimes competitors, i.e. “coopetition”.
- Understanding and promoting the “game theory” of quality, service and collaboration.
- Acquiring and managing clinical talent. The issues of parallel commitments.
- “Dyads” management and other realities of a “positive” bureaucracy.
- Acquiring competence and learning balance in the ongoing reality of the continuing debate between top down and bottom up decision making in the context of “subsidiarity” in organizational life.
- Remembering and modifying the original intent and mission in the context of oppressive externalities.
- Understanding the interplay of continuous improvement, relational contracts and a complex environment that promotes distrust.
I realize as I reflect on this list that what I may be describing is the table of contents of a medical version of Built to Last by Collins and Porras. As I write I realize that a complete discussion of the list is far beyond the scope of this letter and sadly beyond the capability of my own talent and resources. Perhaps you should just look for elements that connect to the list as I continue my tale.
From the inception of the practice in 1969, one barrier to the continuing existence of the pilot was the need to grow. On opening day in October 1969 there were 88 patients. The funding was shaky and was projected to last for only about two years. Calculations suggested that at least thirty thousand patients were needed to insure the resources necessary to continue the practice’s existence without dependence on outside resources. To attract thirty thousand patients to a new form of practice with one office in downtown Boston before the initial resources were exhausted was a huge challenge that became the primary objective of Dr. Joseph Dorsey. I am told that he was in a mode of continuous evangelism and spread the gospel of the new approach to care with daily visits to civic groups, politicians, labor leaders, state agencies, town managers, city councils, and employers by the hundreds. It is hard to imagine a local health benefits officer who had not had a personal experience with Dr Dorsey touting the advantages of prepaid, preventive healthcare delivered as much as possible in the ambulatory environment.
It worked. In less than three years they passed the 30,000 mark. Ironically the “sale” to professional corporations, academic institutions, hospital employees, and civil service employees of the cities and towns greatly exceeded the membership that came from trade unions and manufacturing. When I joined the practice I was warned by those at the Brigham who were resistant to the concepts that HCHP stressed. They said my practice would be uninteresting and a professional disaster since it would be populated by “well secretaries”. Well, that was wrong. My very first patient was a fifty five year old engineer from a well known international consulting firm based in Boston. He was an urgent “add on” to my first day’s schedule. A colleague I was yet to meet had referred him for the evaluation of episodic weakness. His problem was an idiopathic cardiomyopathy complicated by complete heart block. I was off and running to a continuous banquet of challenging clinical problems that kept me learning for over thirty five years. Suddenly, one week shy of my thirtieth birthday, I discovered that all my training at one of the world’s most respected hospitals had poorly prepared me to be the primary cardiologist for a population of about 50,000 people, which was the enrollment by July 1,1975; or as I like to remember, just about three months before “Pudge” Fisk hit that game winning homer just inside the left field foul pole in game six of the World Series.
Like a child who only gradually learns his family history and absorbs its culture, there was a lot going on internally that I was unaware of initially. I was too busy trying to do my job. Internal politics must be a reality in any start up. Dr. Ebert had leadership problems to manage from the get go that it took a while for me to appreciate. He had assembled a late sixties “dream team” of economists, experienced clinicians, rising clinical superstars, healthcare theorists, policy wonks, and systems engineers. Within the group there were creative disagreements about how to organize and deliver care. Given the support of both the Beth Israel and the Brigham, there were initially two Chief Medical Officers. Joseph Dorsey led the part of the practice that utilized the Brigham as its hospital home, and Richard Nesson led the Beth Israel practice. This shared responsibility may have been dysfunctional and within two years Nesson had left to assume leadership of the Brigham’s own outpatient clinic on his way to becoming the President of the Brigham and the founder of Partners in 1993.
There were other internal challenges that Dr. Ebert had to contend with as the founder and Chairman of the Board. There were conflicts on the business management side. Eventually stability was achieved when Robert Biblo became CEO in 1970. He would leave a few years after I joined the practice to go to New York City as the CEO of HIP (Health Insurance Plan). By the time he left to go to New York in 1977 we had grown to 80,000 patients getting care in two sites, Kenmore Square and Cambridge. He was succeeded by a dynamic young business man,Tom Pyle, who grew the organization from two sites serving 80,000 patients to over 400,000 patients with more than 14 sites. By 1988 there was a “staff model HMO” location convenient to almost everyone in the greater Boston area, including the North Shore and the South Shore. I had patients who were coming from as far south as Cape Cod, from New Hampshire in the north, and from as far west as the Berkshires. In 1985 HCHP created a second division which was a network of group practices in the surrounding suburbs. That was a strategic move that left many of us in the original practice confused.
There was nothing inherently wrong with growth, but it did undermine the original pioneer spirit that was so attractive to me. The need to hire over 500 doctors in a relatively brief time will by necessity change the hiring criteria. It was the need to grow that built the “causeway to the mainland”. Initially we were hiring physicians who were competing for the opportunity to work in an innovative environment. As we began to grow I once jokingly observed that by the end of the eighties we were willing to hire anyone who could be credentialed with the hope that they would fit. Many did not and there is nothing more disruptive or inefficient than incorporating a physician into your group only to have them leave within two years. Nevertheless, with effort, growth was accomplished and the focus shifted from creating and improving an innovative clinical methodology to managing a medical staff to achieve the primary corporate objectives of growth and revenue.
One of the most significant events in the life of the young practice occurred in 1977. Dr. Dorsey was forced out of his role as Medical Director. Some said that his enthusiasm and legendary ability to do more and ask others to do more than they could had exhausted many of the staff. Perhaps it was related to the change in CEO. Whatever the cause, it was upsetting to me. His leadership had inspired me. His response to the change was the greatest example of professional commitment to purpose that I have ever witnessed.
Some speculated that he would go to Washington to work in the Carter administration. Some reasoned that he would aid Ted Kennedy whom he knew quite well. What he did was to devote himself to practice and improving our utilization of the hospital.
Joe forged bonds with Dick Nesson and Eugene Braunwald at the Brigham which greatly enabled our specialists and surgeons to function much more efficiently and effectively. He was the creator of improved relationships across all of the medical school as he helped to establish a strong primary care residency program at the Brigham that produced many leaders to support our growth. Joe’s work and efforts were largely responsible for the completion of a major part of Dr. Ebert’s vision with the creation of a department of ambulatory and preventive care in one of the most competitive academic environments of the country. The establishment of the department ensured that every Harvard Medical student would have a primary care experience at HCHP.
During the early eighties my colleague, Dr. Mark Stockman, and I were enlisted by Joe to join him and others in an effort to improve the care given at a small community hospital on Mission Hill as a more efficient site for secondary care and ambulatory surgery. It was the greatest six years of my practice experience. We introduced many “innovations” that better leveraged the interface between the hospital and the ambulatory practice. Sadly the experience also taught me that success does not always guarantee survival in a complex and competitive world.
HCHP had continued to use both the Brigham and the BI and now Brigham and BI residents rotated through our little hospital of about fifty beds with a small ICU and very busy surgical program. By 1986 success had created the need to expand. The analysis done at that time revealed that expansion of the little hospital would be impractical and prohibitively expensive. The outcome was a decision to move all admissions, both from the community hospital and the BI, to the Brigham where its management was eager to offer “community rates in perpetuity”. Legend has it that Nesson and Pyle had the idea and closed the deal during a tennis game. I was devastated by the loss of my creative opportunity. That was when my career changed and I began to get involved with the governance of HCHP, a path that eventually would result in becoming CEO more than twenty years later.
Moving all care to the Brigham and a few distant community hospitals was difficult for me even though I had trained there and had great respect for everyone on the staff. I just did not believe that it was the right place for every patient. Things got a little better in the nineties when the Brigham acquired the Faulkner Hospital. Joe was committed to making that relationship work and again I followed his lead. The almost exclusive relationship with the Brigham persisted until 2009. By that time I was the CEO of Harvard Vanguard and Atrius Health and the data presented to me by our executive team clearly demonstrated that we could enjoy a much more efficient and effective relationship contractually with the Beth Israel Deaconess Medical Center (BIDMC) and its affiliated hospitals for our patients that lived within their service areas. We made a much resisted and much publicized move back to the BIDMC. The new hospital policy was expanded to also include better relationships with the New England Baptist Hospital, Children’s Hospital, Mount Auburn Hospital and Lahey Clinic, as well as a group of well managed community hospitals that were eager for our business. We were convinced that hospital care should be provided close to home and close to the ambulatory office where the patient’s PCP was practicing. Our performance data suggested that quality was not dependent on the exclusive use of academic medical centers.
Finance and the need to grow were obsessions in the eighties while HMOs thrived and employers were offered “sole source” relationships with insurers. HCHP became a self insured practice after Ted Kennedy pushed the passage of the HMO Act through Congress and Richard Nixon signed it into law in late 1973. Much of the change that we experienced in the late seventies and early eighties that gave rise to our great success in numbers was to be followed by the backlash to managed care as the result of how the opportunity offered by HMOs was either used or misused by other practices. By the time of Helen Hunt’s Oscar winning rant about the abusive practices of her HMO in the movie As Good as It Gets in 1997, our organization had abandoned most of our innovative efforts and transferred our focus to the effort to survive. Even if you can remember the movie you should invest the four minutes needed to listen as Harold Ramis, you may remember him as the director of Groundhog Day or as my kids do, as Egon, the nerdy and intellectual Ghostbuster, describes the quality of care that everyone wants. After Hunt's profane outburst, he described care that is centered on the patient’s and family's needs, and is safe, timely, efficient, effective and equitable.
In retrospect, I remember many events that in my mind undermined Dr. Ebert’s dream and the work done by the pioneers at HCHP in the early days. One was a marketing study that suggested that patients did not want to see nurse practitioners and physician assistants. As a result we greatly diminished their use when we should have been further driving the incorporation of them into our model. New sites were not opened with the one on one partnerships that enhanced my ability to care for my patients. I always felt that the result would have been just the opposite if the study had looked at the satisfaction of patients who were receiving care from an experienced clinical partnership between a physician and a nurse practitioner or physician assistant.
Another mistake, in my mind, was the misapplication of hospitalists and the relegation of the PCP to the office for efficiency. I have never seen a mechanism for the transfer of information or the continuity of care that exceeds the ability of a caring physician to interact with staff in the hospital, participate in the clinical decision making and discharge of the patient. I am not against the use of hospitalists. They can be wonderful. It’s just that in thirty years we have not adequately backfilled what we lost when we made it difficult for PCPs to get to the hospital.
There are many more stories and lessons learned. I am sure my memory has its deficiencies and some others who were there with me may have a different take on the same scene. I appreciate the prod to memory and reflection that my exposure to Iora Health has stimulated. If you would like to know more, you can download a PDF that was produced by Harvard Vanguard in 2009 to celebrate the fortieth anniversary of the practice. I look forward to trying to tie it all together a little more completely for you next week.
The Joy of Evening on the Lake
As the picture in today’s header testifies, there is nothing more inspiring than sunset over the water. More often than not from mid April until almost November if you you are looking for me in the evening, look out on the lake first. For too many years these were the hours when I was often transitioning from a long afternoon of practice to an evening board or management meeting. Not so anymore. I am glad to hear that “Millennials” will not put up with that sort of thing. Even if you are an aging “Baby Boomer” or a “Gen Exer” trapped in the midlife struggle to survive, you should also try to catch more sunsets.
I am amazed how slow I was to realize the wisdom tucked into Dr. Ebert’s admonition
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.
I think that Dr. Ebert’s thought includes the reality that investing more of your time in an inefficient system that resists change will never get the job done of “providing optimally for the health needs of the population” even with more money, more personnel, and more facilities. Your ability to see more sunsets may well be one of the most valid reasons to embrace Lean, innovative change or some other methodology anchored in the principles of continuous improvement. |
| 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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