2 December 2016

Dear Interested Reader,

This Letter and More

Last week’s letter got a few nice responses. None was more appreciated or instructive than a quick note from John Toussaint who thought that I might like an article, “Improve the Affordable Care Act, Don’t Repeal It”, that he had published in the Harvard Business Review after the election. I liked John’s article very much and heartily recommend it to you. I also recommend it as important reading to Congressman Tom Price who the NYT Editorial Board describes a radical choice by President Elect Trump to be the Secretary of Health and Human Services. Dr. Seema Verma who Mr. Trump has named to be the administrator of CMS should also read it.

Both Dr. Price and Dr. Verma have impressive resumes and also have very disturbing professional records of introducing and promulgating policies that will challenge the intent of the ACA to expand medical care to the underserved. Dr. Price is a direct threat to the Medicare that many of Mr. Trump’s supporters take for granted. Dr. Verma is an advocate for policies extending Medicaid to the states with techniques that will surely result in increased burdens for most of the underserved while extending an inadequate coverage to many citizens in “red states” who have so far been denied the benefits of the ACA, but also voted with gusto for Mr. Trump.

I am disappointed but not surprised by the appointments. Unlike the President Elect, Dr. Price and Dr. Verma understand healthcare and are perfectly capable of setting back the search for the Triple Aim while coopting an agenda with programs that are designed to look better on paper than they will be experienced by those who are so dependent on support from public finance. They have records that raise concerns because now, after six years of Republican frustration, they have the opportunity to shape and redirect the healthcare policy of the incoming administration based on a core objective of quickly and effectively reducing the federal tax dollars going to support entitlements.

I will expand on my concerns in this letter. I will also try to continue to develop suggestions and potential strategies for preserving some of what has been accomplished by the ACA. Dr. Toussaint’s article is a very articulate defense of what the ACA has accomplished, how it can be improved, and what we should try to save. The question is how do we organize externally as we prepare internally for what will be challenging times.

I think that we are all participating in a process of gradual revelation. It is hard to know what to expect from an individual who functions from an unfamiliar set of operating principles. What does seem clear from most of the President Elect’s appointments is that his decisions so far have not been a disappointment to the angriest members of his political base. He may have said a few things right after the election that suggested he would be more moderate in his decisions about healthcare, the environment, foreign affairs, or on issues of immigration, but his appointees seem to be stalwarts intent on implementing his original proclamations. It is a challenge to imagine responsible and effective countermeasures. This letter continues to explore potential strategies and tactics to perpetuate the goal of

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

On a personal note I suddenly realized this last weekend that I was passing the fiftieth anniversary of my first “retirement”. I retired from a lackluster career in football on November 26, 1966. Football did pay for my college education and was probably an interesting flourish on my application to medical school, but by the end of the 1966 season it was time for me to hang it up. Standing on the sidelines in the midst of a continuous roar in “Death Valley” watching the Gamecocks lose to our biggest rival the Clemson Tigers, I knew that I had come to the end of one road and was ready for a new direction.

More importantly than my sudden realization that it had been been fifty years since I last donned a pair of shoulder pads was that I was seized by the thought that football was no longer a major interest for me. I am still interested in the game, but I have gradually developed some perspective. I had almost forgotten that the Clemson-Carolina game was being played. Other activities and interests have now moved way ahead of football which has become an increasing concern for anyone who cares about the longterm health of young men. Let me explain by continuing the narrative.

After suddenly remembering early last Saturday that Clemson and the University of South Carolina would be renewing their long rivalry later that day, I looked in the newspaper and discovered that the game would be played at Clemson where I left the game so many years before. After finding out that the game would be on ESPN, I realized that I was really too busy enjoying the visit of my son and daughter-in-law, who have little or no interest in football, to watch the game. Sunday I was curious enough about the outcome to look for the score in the Sunday paper. I expected to see that Clemson had won since they are the third ranked college team in the country. I was not emotionally prepared for the magnitude of their victory. The Tigers beat the Gamecocks 56-7. Ugh.

The lopsided score sent me on a second revelry back to that last Saturday in November 1966 when I took off my uniform in the locker room after sitting on the bench for most of the last game of my career. At twenty one I was both a failure of some sort and a retiree! The Gamecocks lost that day fifty years ago also, 35 to 10. We finished a dismal season with a 1-9 record, having beaten only North Carolina State in our first season under a new coach, Pepsodent Paul Dietzel, who could rival the President Elect when it came down to appreciating one’s own accomplishments. Coach Dietzel was sort of famous because earlier in his career, after his LSU team won the National Championship in 1958, he made the disastrous choice of breaking his contract at LSU to take on the impossible job of rebuilding Army. Like others who are impressed with their own accomplishments, he was sure that there was no football program he couldn’t fix. After failing at Army, he failed to make South Carolina another LSU or Alabama.

As I had expected before the game, I played on kickoffs and a few plays in “garbage time,” and then it was time to move on. Technically I could have played another year, but I think the issue of whether I had any future in football had been clearly settled. Coach Dietzel had never been a fan of my talents. He always gave me grief when I arrived late for practice after a chemistry or biology lab. It was time to move on with life. I had been accepted at Emory and Vanderbilt Medical Schools a few weeks earlier, and had an appointment in Boston the next week for an interview at Harvard.

Looking back on my ten year football experience, I feel lucky to have had only one “for sure” concussion. I lost a tooth and acquired some orthopedic liabilities that eventually matured into permanent reminders of the fun that I had. The best part of the experience is the memory of camaraderie with teammates. I also can look back and realize that I learned a lot about being part of a team, even though my most significant contributions were being on the part of the team that worked hard Monday through Thursday to get the better players ready for Saturday.

My reward was a few minutes on the field on game day, and lessons that would be slowly realized over the next twenty years. Learning early in life how to manage disappointment is a gift of some sort that I am drawing on now as I think about the next four years. Over the last fifty years I have changed and so has football. I guess you can say that we have “grown apart”, but the world has also changed. On the day of my last game there were no African American students in uniform. There were only a handful of recently enrolled black students in either university. That reality has changed much for the better, but we must always realize that there are those on the fringe who wish it was not so.

I am still interested in football, but if it is a sunny day or there is a chance to be with family and friends, I know that I am not missing much and the score will be in the paper tomorrow, or Comcast will record the game for me for later viewing, aided by the ability to fast forward through the commercials. Football also taught me to think about time in packages of four years. Four years is not that long a time. You can do a lot in one four year period to get ready for the next four years. As I look down the road at the next four years, there is comfort and challenge in that thought and in all the other things I learned before I retired from the football world of hard knocks,

If you missed last week’s letter you can read it, sort of, in its abridged form on strategyhealthcare.com. You might find it interesting to scroll back through several weeks. When I scroll back to the early summer, I feel like I am watching a disaster in slow motion.

Is This The Shape of Things To Come?

As the President Elect announced his choice for Secretary of Health and Human Services and for the Administrator of CMS earlier this week, I could not help but think back to the several times when as CEO of Atrius Health I had gone to the offices of HHS at 200 Independence Avenue SW, just a few blocks down from the Capitol dome. As I was reflecting on those heady past moments of promise for the ACA and the Triple Aim and what the new appointments might mean for those dreams, I was struck by the irony of the fact that HHS is housed in the Hubert Humphrey Building. As one walks past security the first thing that you see carved in stone on the wall to the left is a quote from Humphrey who was perhaps the most most earnest of all liberal senators of the fifties and early sixties.

"The moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; and those who are in the shadows of life, the sick, the needy and the handicapped."

I was mesmerized by the quote when I first saw it. I was moved as I realized how hard Humphrey, Lyndon Johnson and so many others had worked to give us Medicare and Medicaid. It was even sadder to realize that all the heady plans for a “Great Society” were lost in the tragedy of a needless war in Vietnam. Leading the country in complex times is hard, even for the best and most experienced public servants.

As I further reflected on the grim news of Trump’s most recent genuflection to the far right and how incompatible his choices were with the views that he had expressed just a week before about preserving what was good in the ACA, my thoughts were augmented by the words and melody of one of my songwriting son’s older songs which began to roll through my head. Ironically, he put the song up on the Internet on January 23, 2012 which will make it about five years old when President Elect Trump takes the oath of office to defend a constitution which seems somewhat of an annoyance to him. I love the title: “Is This The Shape of Things To Come.” Just in case you do not click on the link to hear the song, here are its words.

Is this the shape of things to come?
Is this the ground we walk upon?
Is this the way we live and die and carry on?
Is this the day we hoped would come?

Change what you would. What’s the use?
The unmistakable truth:
We’d do it all the same

And somebody out in America
Has found a new belief to push their heart away

And who would have thought
That the shape of things to come
Would just reveal the things that never change

Is this the shape of things to come?
I ask just because it’s an awkward one
I ask because I need to know if there’s somebody out there to love
If there’s anybody I can trust

I am the salt of the Earth
The unmistakable truth
The one that got away

And somebody out in America
Is looking back and thinking that I look the same

But who would have thought
That the shape of things to come
Would just reveal the things that never change

Change what you would. What’s the use?
The unmistakable truth:
We’d do it all the same

And somebody out in America
Has found a new belief to push their heart away

If that’s what you think
Then the shape of things to come
Will just reveal the things that never change

In the brief explanation published with the song he writes:

This week’s song was written in anticipation of an unknown future. The words are a play on the old concept that the more things change, the more they stay the same. Is the shape of things to come the same as the shape of things as they are now? Do people change? Do fortunes change? Does the country change, or are we merely playing out roles in a repeating history on a loop? Can anything or anybody ever change if we are too cynical to believe that it can?

I am trying not to be cynical. It is just that this post election period has been hard and right now it feels like both losing by a lopsided score (even though the winner did not have a plurality of the popular vote) and sitting on the bench unable to do much about what is happening other than ask questions and hope that some insight emerges to replace the angst with wisdom about how to survive disappointment, and make progress toward a goal that seems much further away than it did three weeks ago.

With each announcement this week of a new appointee by President Elect Trump my emotions took a big dip. I almost aspirated my coffee when I read on Tuesday morning in the New York Times that what had been hinted before would be true. Tom Price, Republican Congressman and Chairman of the House Budget Committee and author of the last attempt and probably the next effort to repeal the Affordable Care Act was to be the Secretary of Health and Human Services.

Congressman Price is an orthopedic surgeon, turned politician, who grew up in small town Michigan, then attended medical school at the University of Michigan. He came south for his residency training at Emory. After several years of orthopedic practice he became a state senator and then a congressman. He has now served the relatively affluent 6th District of Georgia in the northern suburbs of Atlanta for six terms. He is the congressman of some of my cousins, nieces, nephews as well as a few old acquaintances and friends. I am sure that several have voted for him as well as for President Elect Trump. Other relatives live next door to his district.

He had a successful suburban practice while also running the orthopedic clinic at Atlanta’s famous Grady Memorial Hospital, a hospital where many uninsured and the desperately underserved of Atlanta go when they “are dying in the street.” Grady is the Bellevue, the Cook County, the Jackson Memorial, the Boston Medical Center of Atlanta, and like all of those institutions it is chronically underfunded for the work that it must do. It is hard for me to imagine how a person who has had his professional experience could be one of the most focused opponents of the ACA. To add to my amazement is the reality that he is an enthusiastic coconspirator with Paul Ryan to privatize Medicare.

I had heard many stories over the years about the financial plight of Grady. It has had hundreds of millions of dollars of bad debt that have significantly improved since the passage of the ACA. Surely the taxpayers of Fulton and DeKalb counties who make up the shortfall in the budget each year have noticed the improved finances. I know that even though Georgia is one of the states that did not expand Medicaid under the ACA there are fewer uninsured in Georgia since its passage. If you clicked on the link you will learn that in 2010 the uninsured rate in Georgia was 19.7% and in 2015 it was 13.9%. That is without the Medicaid expansion. Congressman Price’s position has held a lot of Georgians hostage to an ideal that has hurt them. Now he has the opportunity to spread the pain nationally.

The case against Dr. Seema Verma for the position of Administrator of CMS is more subtle. Over the last few years she has been successful as a consultant who has helped some of the “red states”, most notably Indiana, that refused the Medicaid extension, to craft programs that achieved some coverage for new Medicaid patients through exemptions that CMS granted as a compromise. With her plan a person who gets Medicaid in Indiana is very likely to have to spend some of their meager resources to prove they have “skin in the game.” If you are struggling financially and barely making it by some combination of jobs, it seems strange to have to pay for what is given to citizens in another state just so the governor and members of the legislature can crow that they have held the line on their values. The work that Dr. Verma has done is also reflected in the ideas of Speaker Ryan’s crafty document about a “Better Way.” I am sure that many poor people would gain self esteem if they could pay some part of their health insurance. What I am not sure of is that they will have the resources to pay, and I expect that unfortunately many will opt out of coverage since part of the plan is to eliminate the mandate. The ultimate goal of such an approach is not universal coverage. The real goal of such a program is a reduction in entitlement expense.

In an article about the appointments, Kaiser Health News summarized Verma’s mindset and the work she did for Mike Pence and Indiana by saying:

Indiana’s unique Medicaid expansion was designed to appeal to conservatives. HIP 2.0 asks covered people to make a small monthly payment to access health insurance. A missed payment can result in six-month lockout from insurance coverage. Those provisions aren’t allowed under traditional Medicaid, but Indiana got special permission from CMS to implement them through a waiver.

Medicine does not have a singular point of view. The physician readers of Medical Economics probably tend to be more self employed and perhaps more focused on current and pending business problems and regulations than their employed colleagues in systems of care like Kaiser or Atrius Health. Many doctors in private practice are worried about reimbursement and feel abused by CMS and commercial payers. Medical Economics has been offering a poll with a simple question, “Does the election of Donald Trump give you hope for your practice’s future?” The answer changes as more people respond. A week ago, before the healthcare appointments, the score was 64% yes and 36% no. Yesterday, a few days after the appointments, it was 61% yes and 39% no. This has certainly been a year when we have been mislead by polls, but it will be hard to have a united front to protect the gains of the ACA for the Triple Aim if the majority of practicing physicians do favor the policies of President Elect Trump.

I have seen it written that the repeal of the ACA will differentially affect hospitals and health systems more than physicians. If 10-20 million people lose their coverage over the next year or so, it will certainly put pressure on hospital revenues. Physicians can more easily avoid bad debt than hospitals. Uninsured patients with broken bones from automobile accidents will be still taken off the streets of Atlanta to the trauma bays of Grady Hospital, Dr. Price’s hospital, where they will receive care regardless of their ability to pay. Perhaps President Elect Trump's plans include repeal of EMTALA, the federal law passed in 1986 that “requires anyone coming to an emergency department to be stabilized and treated, regardless of their insurance status or ability to pay, but since its enactment in 1986 has remained an unfunded mandate.” Perhaps repeal of this law is in Dr. Price’s legislative agenda, although Candidate Trump promised that no one would “die in the street” from their medical problems while he was president. That is a “low bar” political promise with perhaps a short half-life.

Earlier this week an online news service which many in the business of healthcare read, FierceHealthcare, published an article saying that major industry groups did applaud the appointments of Price and Verma. Obviously Democrats like Senator Chuck Schumer, who will likely be the next Senate Minority Leader, are upset about Price’s appointment and plan to defend Medicare and fight his confirmation as a first step in their political comeback. They are hoping the defense of Medicare and the ACA will be winning issues in the 2018 elections. Indeed the New York Times reports that now only one in four Americans want the ACA repealed. They like it! It is beginning to feel a little like Britain after the Brexit vote when many who voted for exit from the EU suddenly discovered that they really did like a lot of the good things, like open borders, that went with the EU membership that they had just discarded rather thoughtlessly.

So, what’s a body to do? First, do not lose heart. We have not yet seen an end of change. In Lean, when our solutions fail to yield the results that were desired in the “ideal or improved” state, we reevaluate and create “counter measures” through an exercise called an A4. In my opinion the A4 is almost as important as the A3, the original solution process. Progress is hard and first offerings almost always can be improved.

Secondly, as I suggested in last week’s letter, focus on what you can do at home. The tools of continuous improvement like Lean are agnostic to regulations and finance. They can improve the feel and function in any system. The one thing that we can all count on, no matter who is HHS Secretary or CMS Administrator, is that there will be continued downward pressure on revenue which can only be survived by process improvement. If your organization does not have Lean or some other operating system designed to lower operating costs through improvement, it is going to be like trying to cross the desert without a canteen or a compass. Remind yourself of your mission. Visualize how you will be able to continue to serve the underserved. Realize that the best way to take care of your own future is to meet the needs of your patients.

Thirdly, be vocal and join forces to resist the knee jerk repeal of the ACA and all the benefits that it has brought to all of us. Success will require a new bipartisan coalition. America has terminal gridlock that can only be moved by disastrous elections. We can use healthcare as a wedge to break up gridlock if all across America concerned clinicians and healthcare professions are frequently contacting both Democratic and Republican members of Congress to let them know how important improving healthcare is. I agree with David Brooks who envisions one benefit of this horror show (my characterization, not his) as the emergence of a new coalition of centrists across a wide spectrum of issues. That coalition should have as one of its foundational concerns the realization of

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

The Triple Aim should be “the shape of things to come”. That is a “box 3” statement in an A3 for the coalition for an America without gridlock that can demonstrate what Patty Gabow calls “the social solidarity” necessary to get things done. My biggest fear is that “the shape of things” in terms of our ability to work together will not change.

It will be very sad if the result is continued gridlock. We are at a crossroad between continuing what has been or doing remarkable things. To do remarkable things we have to remember the people who need care or need their care to be less expensive.

Change what you would. What’s the use?
The unmistakable truth:
We’d do it all the same

And somebody out in America
Has found a new belief to push their heart away

If that’s what you think
Then the shape of things to come
Will just reveal the things that never change

Somethings do not change and should never be forgotten. Hubert Humphrey’s test of government will also be the test of Donald Trump, Mike Pence, Paul Ryan, Tom Price and Seema Verma. It applies to us all of us in healthcare.

"The moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; and those who are in the shadows of life, the sick, the needy and the handicapped."

Walking at Twilight

Twilight is a favorite time for me. The fading light allows the emergence of things that are often obscured by the bright light of day. From late April until late October, more evenings than not, I am on the water watching what happens to the sky just after the sun settles behind the trees on the western end of the lake. During these colder shorter days of late fall and winter the kayaks and canoes are on the rack and I am often in the middle of my walk when the sun goes down. I walk with a reflective sash that has a blinking red light on the back. I wear it with the hope that it will prevent me from becoming road kill. Despite the device I always step off the road when a truck or car approaches.

I was about two miles from home, engrossed in the audiobook of Infinite Jest and walking past the long finger of land that almost divides the lake into two separate bodies of water when I looked up from the road and saw the scene pictured in today’s header. If you look just above the “M” you can see a faint point of light that is probably Venus (it doesn’t look red so it is probably not Mars). What the original photo showed that was lost unfortunately in the cropping that was necessary for the header format was the reflection of that small point of light on the water just in front of me and near the branch in the foreground that I tried to capture for perspective. It is amazing what you can do with an iPhone camera.

There was an interesting op ed piece this week in the NY Times that debunked the focus on being in the moment. I will leave it to you to explore the idea, but walking, running, fishing or just about any physical activity, including mowing and raking the lawn, has allowed my mind to “tread water” or find rest from a world that seems to be about to discard or crush me. In exercise there is renewal and ironically in those blessed moment of mindlessness there is a mindfulness. If you are worried about the shape of things to come and are not sure how you will bear the pain of worrying what might be undone, let me suggest that you take a walk at twilight. It is amazing what there is to see in the dark.