19 May 2017

Dear Interested Readers,

What’s Inside This Letter and Two Books The President Should Read


On the list entitled “Most Popular” in the New York Times during this week of amazing events in Washington were opinion pieces about President Trump written by David Brooks and Ross Douthat. The Brooks column was entitled, “When the World is Led By A Child” and the title of Douthat’s piece was the tease, “The 25th Amendment Solution for Removing Trump.” Both address the question of the president’s mental and emotional fitness for office that has been precipitated by his erratic and confusingly dysfunctional behavior during his first four months in office. A third opinion piece of interest entitled “It’s Chicken or Fish” was written by Tom Friedman and asked the more direct question:

“With the Democrats lacking any real governing power, are there a few good elected men or women in the Republican party who will stand up to the president’s abuse of power as their predecessors did during Watergate?”

The thesis of the Brooks article is that the president’s behavior is indicative of someone who is both inexperienced and simultaneously impervious to the appreciation of his own limitations and unable to change because of deep seated deficiencies in self control and an insatiable need to be affirmed. Years ago I had a teacher who stressed the difference between “childlike behavior” and “childish behavior.” Brooks’ description of the president would correlate with the negative cast of “childish” behavior.” He postulates that by age 25 most of us have mastered three tasks that still elude the president.

First, we have learned to sit still and focus our attention on a subject that we need to understand. The president seems proud of his inability to do this.

Second, he suggests that most people “of drinking age” have enough self awareness to know what they know and don’t know. Brooks points to the president’s comment in a recent interview with Time magazine where in a follow up to his statement several weeks ago that he never knew healthcare was so complicated he told the interviewer, “In a short time I understood everything there was to know about healthcare.” Brooks adds evidence to his argument by reminding us that in an interview with The Economist the president also claimed to be the originator of the metaphor or cliche, “priming the pump.” I was delighted to see that Brooks concurred with a conclusion that I wrote several months ago when I suggested that the president was the archetypical example of the Dunning-Kruger effect. That is the sad state of being so incompetent that you are unable to appreciate your incompetence, and are in the dangerous position of not knowing or appreciating what you do not know. Even Donald Rumsfeld knew that his biggest source of error was from that category of “not knowing what you do not know.”

Finally Brooks reminds us that by the time we reach adulthood most of us can perceive how others are thinking. Brooks observes that Trump seems to lack a “theory of mind.” Brooks sees a man for whom other people are “black boxes” that are either with him and affirm him, or disagree with him and are targets of his disapproval.

Brooks finishes with no advice. He passes on the fear and concern of David Roberts who wrote an article in Vox entitled “We overanalyze Trump. He is what he appears to be.” Robert asks the question that is on many of our minds when he wonders:

But what if there’s nothing to understand? What if there’s no there there? What if our attempts to explain Trump have failed not because we haven’t hit on the right one, but because we are, theory-of-mind-wise, overinterpreting the text?

In short, what if Trump is exactly as he appears: a hopeless narcissist with the attention span of a fruit fly, unable to maintain consistent beliefs or commitments from moment to moment, acting on base instinct, entirely situationally, to bolster his terrifyingly fragile ego.

We’re not really prepared to deal with that.

Brooks offers no solution, but Ross Douthat reminds us that the twenty fifth amendment to the Constitution gives us a recourse. Although, he believes that it is highly unlikely that we would use it in a preventative way. He sums up the situation by discounting the possibility of impeachment while offering an alternative remedy:

...it is hard to betray an oath of office whose obligations you evince no sign of really understanding or respecting.

Which is not an argument for allowing him to occupy that office. It is an argument, instead, for using a constitutional mechanism more appropriate to this strange situation than impeachment: the 25th Amendment to the Constitution, which allows for the removal of the president if the vice president and a majority of the cabinet informs the Congress that he is “unable to discharge the powers and duties of his office” and (should the president contest his own removal) a two-thirds vote by Congress confirms the cabinet’s judgment.

In his article Friedman essentially say, “Fat chance of that!” to Douthat’s suggestion. He sees the Republicans the same way that former Bush II speechwriter David Frum does, as having sold out to the idea of using a malleable and easily led Trump as a stooge who will sign anything they can pass. There is a lot they want to undo besides healthcare, as they open the nation’s pocketbook and resources for the wholesale exploitation of us all. Ironically those who are especially vulnerable are the disgruntled Trump blue collar voters in places like Ohio, Pennsylvania, Michigan, and Wisconsin that put him in office. Friedman’s response is practical. Get off Facebook and stop wasting your time watching Melissa McCarthy, Alec Baldwin and the SNL crew making fun of Sean Spicer and the president, and start working to win the House and Senate in 2018.

Based on what I have just written and the reality that what I say or think has only the impact of one voter, my advice to the president would be to listen to your advisors, attend your briefings, read more than the executive summary or bullet points that you are given, and begin to try to imagine what you might do to maintain or enhance America’s greatness, as promised. I would remind him that great leaders strive to augment their deficiencies though a search for knowledge and respect for the people who can use their talents to mitigate their deficiencies. Great leaders think about what they say because they know things happen when they speak, and they want more than the forced momentary approval of sycophants. They want the satisfaction of knowing that during the brief time that they had the power they used it to advance the true agendas of a great nation that cared equitably for all of its citizens and for all of its neighbors on this shrinking and warming planet.

According to the Gallup polls in 2016 the most important issues to voters of both parties were the economy, jobs, terrorism and healthcare. Voters want a job if they don’t have one, and they want job security if they do. They also want a sound and growing economy, a safe world, and good healthcare. In each area over 75% of voters said these issues were important. Healthcare is not a stand alone issue because it is also a big part of concerns one and two.

Trump did figure out how to use the public’s fears and dissatisfaction with healthcare to get elected. “Repeal and replace” is an easy slogan. It is unlikely that either repeal or replace can be accomplished without presidential leadership being applied to the production of workable solutions that protect and improve the public’s worries. I have invested about forty to fifty hours reading the books of Elisabeth Rosenthal and Robert Pearl, and I would like to suggest that the president do the same thing. (I am a slow reader and assume that he is too.) Pearl spends a lot of time in his book speculating about the president’s options and making sound suggestions. A little less time watching “Fox and Friends”, and a little less time doing campaign rallies on his way to Mar-a-Lago should allow our president to knock off that task and be much better prepared to lead us to better healthcare long before the Senate is through with their version of the next step in healthcare.

I would also highly recommend both books to you. Several years ago I was so excited about the potential benefit of John Toussaint's On the Mend:Revolutionizing Healthcare to Save Lives and Transform the Industry that I offered to use part of my discretionary budget to purchase a copy of the book for anyone in our practice who would promise to read it. Fourteen hundred people took me up on the offer. I wish that I could make the same offer now to you for both Rosenthal’s An American Sickness: How Healthcare Became Big Business and How You Can Take It Back and Pearl’s Mistreated: Why We Think We're Getting Good Health Care and Why We're Usually Wrong. I have already written about both books and I have just begun to scratch the surface of their utility. You will hear more from me about both books over subsequent letters.

The books are similar but different. In her book Rosenthal does a very complete analysis of what is wrong with the healthcare industry and how things got to be so self serving for those who control how the cash flows. Both writers focus on the responsibility of caregivers to lead toward solutions. Pearl’s analysis includes attractive references to behavioral economics and how brain function, attitudes, and biases affect our opinions about healthcare. He emphasizes again and again that events and decisions must be analyzed in the context in which they occur if they are to be fully understood. He believes that context and external circumstance are important determinants of priorities. I would say that Rosenthal’s emphasis is on “what” is wrong. She does her best work examining the facts that create the problem of high healthcare costs. It is almost a legal brief or a bill of indictment. Pearl’s analysis is more clinical and delivers insight into “why” things are so wrong and how context shapes our opinions and our openness to solutions. In the end they both underline the importance of true reduction in the cost of care and agree that expensive care is the product of decades of decisions gone wrong and not the outcome of the ACA.

The main portion of the letter this week begins with a list of the work still to be done that I made two years ago about the time that Donald Trump announced his candidacy for president and everyone rolled their eyes. That was back when we naively thought that the ACA was here to stay. It continues with a discussion of the chapter in Dr. Pearl’s book that I would most like the president to read. I would also be delighted if Speaker Ryan or Majority Leader McConnell read it. That might not be a realistic expectation since their political agenda is a large part of the acute problem, and they are so far off base in their recommendations in the AHCA that they are unlikely to be the origin of a workable solution.

The letter concludes with the observation that it has been an interesting weather week. We were washed out on Saturday and woke up on Mother’s Day with three inches of heavy snow. Tuesday was gorgeous on the way to temps in the nineties on Wednesday and Thursday. The Celtics are facing an uphill grind as they try to knock King James from his throne and allow him with all of his court to return to their favorite golf courses next week. We are definitely into the transition of the seasons and despite all the variability in the weather and sports, the picture has much more certainty than the sketch we can draw of the future of this presidency and what will happen next to the ACA.

Mr. President, Please Read Chapter 6, “The Affordable Care Act in Hindsight”

In August 2015 I was asked to participate in a course being offered to young physician leaders by the Tufts Healthcare Institute. I had participated in the program before and was delighted to be asked back. The theme for the course had been updated to “Practicing in the Era of Healthcare Reform.” My assignment was to speak on “The Evolution of the U.S. Healthcare and Insurance System.” The subject appealed to me because I have always believed it helps to know where you came from, and the experiences of others, as you plot the course to where you want to go.

I had a good time. I chose to start the story with FDR, although I did tell my audience that we could have gone back further to Teddy Roosevelt or even earlier. Recently, I was asked if my Power Point presentation from the lecture could be used as an ongoing resource. I had forgotten that I had ended my talk with a look forward with a slide labeled “Persistent Problems.” In retrospect I don’t think that I spent much time working on the slide. I wrote it off the top of my head in just a few minutes as an afterthought and then forgot about it. It was a distillation of continuing issues that concerned me that have been the subject of many of these letters.

• Healthcare disparities
  

• Large number of people uninsured, still

• Cost a persistent issue as healthcare consumes a still increasing share of our collective resources, to the detriment of education, infrastructure and the income of the middle class

• Ambiguities about optimal finance mechanisms and the evolution of the health insurance industry as we continue the attempt to move from “volume to value”

• Emerging workforce challenges
  

• Still searching for the conceptual framework and operating system that will provide optimally for the health needs of the population.

• Effectively engaging physicians in practice evolution to improve quality and service
  

• Still ineffectively collaborating with patients to enable effective self management.
  

• Still largely practicing the “repair care” of individuals rather than the optimization of health for populations

• What we do not know that we don’t know
  

As I was reading Robert Pearl’s chapter on the ACA, I was reminded that President Obama had published his own ideas for improving the ACA about a year after I made my little list. His paper was published in JAMA in the late summer of 2016 during the run up to the election. Pearl lifted a quote from the President Obama’s article which captures the spirit of my continuing concerns. President Obama said:

I am proud of the policy changes in the ACA and the progress that has been made toward a more affordable, high quality, and accessible health care system...Despite this progress, too many Americans still strain to pay for their physician visits and prescriptions, cover their deductibles, or pay their monthly insurance bills; struggle to navigate a complex, sometimes bewildering system; and remain uninsured.”

Both Dr. Rosenthal and Dr. Pearl spend time discussing the objectives of the ACA, its successes and the work left to be done. I was struck by how well Pearl had explained all of the objectives of the ACA. He presented a deft analysis of the role that President Obama’s values and concerns had played in addressing the short term objective of extending healthcare to millions of citizens without access to care, and the long term objective of how to lower the cost of care within the accepted parameters of the reality of American values like:

• Private provision of care with virtually none of the system of care owned or operated by the federal government
  

Pearl points out that Obama studied the successes and failures of prior administrations and made every effort to avoid the pitfalls of his predecessors. Pearl brilliantly catalogues the “correct bets” the president made and the bets that did not score or turn out as hoped.

Pearl begins his creative discussion by reminding us of Daniel Kahneman’s “availability bias” and its reverse “unavailability bias”, or as Pearl says,

“...the events and figures that we know about but don’t often encounter get pushed down into our subconscious, rarely entering our thought process...You’ll find perhaps no better example of it than U.S. health care.”

He points out that Obama was working against the reality that with so many Americans getting good coverage from their employers, the fact that over 50 million other Americans did not have insurance was not their concern. Obama and others looked at the same reality and realized the inequity and were moved by the ultimate waste and expense of 50 million people in a country of our wealth not having access to care. Pearl emphasizes that 50 million people was a minority of less than one in six. That one in six Americans had no care did not seem to bother many of the nearly 85% of the population that might see their care affected by a solution to the problem. Pearl builds a case for the fact that it was because of Obama’s experience as a community organizer in Chicago that he was more than aware of the 50 million people without care and the pain and loss that was associated with their lack of access to care. He continues:

“So when Barack Obama stepped forward as the newly elected president in 2008, he set about a long and arduous journey to address the huge disparities he saw in access and clinical outcomes.”

Pearl describes a story in which he was a player. He was one of the people that President Obama called to Washington to provide input to the development of the ACA. He points out that Obama adopted the lessons learned the hard way by Roosevelt, Truman, and Clinton. The result of the effort was “a policy born of political reality.”

Pearl continues:

Obama concluded that it would be unproductive to send Congress a well-baked yet poorly backed plan... to the surprise of many, rather than painting the legacy players [specialty societies, hospitals, insurers, device manufacturers and big pharma] as villains or obstructionist, the president included them in the discussions…

We all know the story of what happened after the death of Ted Kennedy and the election of Scott Brown while the bill was in conference between the House version and the Senate version. The conference to resolve the differences is where Obama had hoped to improve the final bill. Once the Democrats had lost their filibuster proof 60 votes, the only possibility of passage was for the House to accept the flawed Senate bill and then do a little “clean up” through the filibuster proof “reconciliation” process. It was a move of strategic genius, but it was a bad start for a piece of legislation that few people completely understood, and many never wanted to try to understand.

Pearl is writing after the election of President Trump and in the time before the House bill to repeal and replace the ACA was passed. But he provides us with a valuable view of the ACA that could be helpful as the Senate debates its bill. He points out that Obama knew that the transformation of the American healthcare system would be a long process, even though there would be immediate criticism if it did not make an immediate difference.

The bill’s layout--front loaded with expedited, bipartisan enactments and back-ended by the most controversial provisions--was a politically sensible move for the president and one of the most important reasons the legislation passed Congress. The expedited provisions were the ones that just about everybody favored, such as extending coverage to young adults up to age 26...the most problematic parts included a new tax on medical devices, along with major penalties for the most expensive plans (dubbed the “Cadillac tax”)... But there is much more to the ACA...Beyond its layout and between the lines, you’ll find the unwritten implications of the law and the strategy President Obama thought stood the best chance of addressing the fundamental challenges of American health care today.

Pearl points out that expanding coverage was the quicker and easier part of the task. Reducing the cost of care was the harder, longer job. Pearl says that the bill contains seven “bets”, and Obama knew it would take time for several of them to play out. I will list the bets with brief comments and let you and President Trump consider them.

Big Bet 1: Cover the forgotten - The reality that 18 million people got healthcare with the ACA and that perhaps as many as 24 million or more may lose coverage if it repealed may be its most effective defense. The “forgotten” included the 18 million working poor who could not afford insurance but did not qualify for Medicaid. The ACA originally offered the states the ability to enroll every individual making less than 138% of the poverty level. That is about $15,000 for an individual and $32,000 for a family of four. Sadly, because 18 states have refused, less than half of the 18 million were ever enrolled.

Big Bet 2: Cover the Excluded - the second line of defense for the ACA and an uncertainty becoming a problem for the AHCA, is that the ACA forbids exclusion for care or higher premiums because of a preexisting condition. The insurance realities of this provision make the unpopular “mandates” necessary without huge federal subsidies or a move to “single payer” health care. So far all the “solutions” that the Republicans have presented come across as alchemy.

Big Bet 3: Creating the Insurance Exchanges - this really was a Republican idea. It was part of “RomneyCare.” Pearl points out that the first two bets were that covering preexisting conditions and giving preventative care to the “forgotten” would lower the cost of care by avoiding more devastating medical outcomes. The exchanges were developed to be beneficial for middle class consumers who were working hard but could not afford coverage. As Pearl says:

“It was about creating a whole new way to compare, understand, and buy health insurance.”

Big Bet 4: Caring for Seniors and Rewarding Excellence - this is the move by Medicare from volume based FFS toward value based reimbursement mechanisms like Medicare Advantage, ACOs, and bundled payment mechanisms.

Big Bet 5: Integrating a Fragmented System - this was actually an expectation of both the Exchanges and innovations like ACOs. If the Exchanges drove competition, then innovation, consolidation, and integration would be by products of the new methodology. As we all know. he has lost this bet so far. The insurers are abandoning the exchanges because of the poor selection and the lack of subsidies necessary to “get over the hump” of the initial coverage of the accumulated needs of years without coverage. The ACOs have also encountered difficulties “getting going.”

Big Bet 6: Finding a Meaningful Use for Technology - The HITECH act was passed the year before the ACA with bipartisan support. The adaptive changes required of practices and the IT providers have diminished the return on investment. The answer is not to throw away what we have accomplished, but solutions that produce the benefits that computers should provide require new workflows and cultural changes, as well as technical competencies that are developing much more slowly than the Obama administration had hoped.

Big Bet 7: Measuring Quality and Effectiveness - Perhaps a non physician could have never imagined the power of the combined pushback of clinicians, big pharma, and device manufacturers against this strategy. PCORI, the Patient Centered Outcomes Research Institute was a great idea, but Machiavelli advised us 500 years ago that we should expect resistance if we did anything that challenges the status quo. Pearl describes the issue:

The president expected PCORI to clarify which approaches achieve better health outcomes for patients at a lower cost. He hoped that all doctors would follow its recommendations and embrace the approaches shown to be effective. But in retrospect, President Obama and his staff underestimated the power of the legacy players to resist change.

Pearl's description lays out the strategy. He points out that President Obama expressed his concern and deep understanding of policy development to offer solutions to the problems in JAMA before Trump was elected. It is noteworthy that since the election and probably after Pearl sent his book to the publisher, Obama wrote a second article that was in a January 2017 issue of the New England Journal of Medicine to further assess how to improve the ACA. Again his thoughts are very compatible with my little list from August of 2015. In the NEJM piece President Obama is offering direct advice to President Trump and the Republican majority in Congress as they prepared to repeal and replace the ACA with poorly developed programs. His advice remains timely:

Health care policy often shifts when the country’s leadership changes. That was true when I took office, and it will likely be true with President-elect Donald Trump. I am proud that my administration’s work, through the Affordable Care Act (ACA) and other policies, helped millions more Americans know the security of health care in a system that is more effective and efficient. At the same time, there is more work to do to ensure that all Americans have access to high-quality, affordable health care. What the past 8 years have taught us is that health care reform requires an evidence-based, careful approach, driven by what is best for the American people. That is why Republicans’ plan to repeal the ACA with no plan to replace and improve it is so reckless. Rather than jeopardize financial security and access to care for tens of millions of Americans, policymakers should develop a plan to build on what works before they unravel what is in place.

Obama is offering advice that is consistent with continuous improvement science. I am convinced that he is a natural “Lean thinker.” I bolded an insightful “Box 9” reflection. Box 9 of the A3 is where we glean what we learned in our imperfect first attempts to solve the problem. What has happened is not failure. It is discovery. As he suggests, and as Pearl’s book confirms, we have made progress. We are a little closer to the goal and we must build on what we have learned.

Obama’s statement is the starting point for President Trump, Vice President Pence, Speaker Ryan and Mitch McConnell and his Republican colleagues in the Senate. So far I see little evidence of a high level of understanding of the problems and potential solutions, and even less evidence that they have learned anything over the experience of the last several years, other than that they better be careful about rescinding many of the benefits Americans now believe should be continuing policy. Obama’s strategy was not a total success but hopefully what was accomplished will be hard to repeal because the public has slowly begun to understand that the ACA was written in the context of a real effort to solve big problems that in the long run can not be ignored or solved with faux solutions that are politically attractive but are deceptions.

It’s time for the president to read the book or at least Chapter 6.

What A Wild Week

When I say wild I am not talking politics. James Comey is gone and we do have a new “Special Counselor” in Robert Mueller, although I was really hoping for a “Special Prosecutor”. I am talking about the weather. Last Friday and Saturday it rained enough to make me look for an arc, then to my surprise we woke up to three inches of wet gloppy snow on Mother’s Day. Monday was dreary, like a cold day in late fall. Tuesday was a gorgeous Spring day . Wednesday and Thursday may turn out to be as hot as any two days that we will have all summer, and the loons were crying in the night. In four days we had all four seasons!

My dilemma was whether the header for this week should be a picture of the last blast of winter snow or have the look of summer. I let my son Jesse who crops the pictures and does the lettering decide. He voted for summer. I hope you like the picture. I have taken pictures of this same view many times, in many seasons. What you see is Mount Sunapee and a sliver of Lake Sunapee taken from the top of Burpee Hill where there is some nice pasture between homes that have breathtaking views. The summit is about three quarters of a mile into one of my favorite walks. You can bet I will do the same walk sometime this weekend.

On another note, the Red Sox showed a little life in St. Louis and now they are out on the West Coast where the ninth inning comes after bedtime. I am too nervous to watch the Celtics, but I hope for the unlikely. We will see. Wherever you are and whatever you do this weekend I hope that you find a little joy despite the uncertainties of the transitional weather and this transitional world that we are all trying to figure out.

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