20 January 2017
Dear Interested Readers,
Inauguration Day and What Is In This Letter
By the time you read this letter Donald Trump will be our 45th President. There has been a flurry of uncertainty these past few weeks as appointments for high positions have led some to suggest that we will be led by a club composed of billionaires and holders of fringe views. Since the new President won the nomination of the Republican Party against the will and efforts of its leadership, he has crafted an alliance between the bits and pieces of the shattered old GOP and his own base of angry people that Hillary Clinton unfortunately called a “basket of deplorables.” Opinions that were once considered strange and unsupported by collective experience, science, rational thinking, or the lessons of history now seem poised to become the vectors of a shift in national policies that could reverse many of the accomplishments of the last twenty years.
Thoughtful commentators are struggling to make sense of what they see happening. Many had expected a change in President Trump’s rhetoric between the election and the Inauguration. Thomas Friedman used his column this week in a piece entitled “Retweeting Donald Trump” to bemoan the opportunity that our new president missed when he failed to began to “bind the wounds of division” as he promised he would do on election night.
Donald Trump is President because he convinced majorities in thirty one states to vote for him even as he lost the popular vote by almost 3 million ballots. What he uncovered was the huge rift between those who live on the coasts and in metropolitan areas and those who live in the heartland. It is staggering to realize that minus the votes in California and New York the President won by over three million votes. He demonstrated that many people were concerned with progressive social changes that violated their values. We learned that working class white men were upset as they saw their perennial advantages declining with the dramatic improvements in opportunity experienced by those traditionally on the outside of control. He drew from the anger of those who had lost jobs to globalization and mechanization of manufacturing. He capitalized on the fear of harm from terrorists. He exploited xenophobia in ways not seen since the internment of Japanese Americans during World War II.
The President’s argument during the election was that he was a very successful businessman who could use his management and negotiating skills to correct all that was wrong and prevent all that people feared would come to be. In his speech of acceptance of the Republican nomination he asserted that he and only he could make America great again. With a very unique speaking style he sold that idea to enough people in the right states to earn the opportunity to make good on his assertion.
The core of his argument that he was the one to “Make America Great Again” was his great business expertise. There has long been controversy over whether or not government should be run like a business. Six presidents in the twentieth century had business experience but all of them had also held elected office. Herbert Hoover, who was perhaps the most successful businessman turned President, had also been a cabinet member before his disastrous presidency. We will now give businessmen another chance since several key cabinet posts will be held by billionaire business people.
Our new President does have the advantage that his party controls both houses of Congress. We will not have a divided government even if we do have a very divided country, as will be demonstrated by those sitting out the Inaugural celebrations. Tomorrow the resistance that fears this inevitable national leap into an abyss of personal and national uncertainty will be lead by women as they attend huge rallies in Washington, New York, Boston and in all 50 states with supportive demonstrations planned in 30 other countries. Those protesting the new administration are deeply concerned about the reversal of progressive social changes that were once considered great advances. Some fear surprises from an administration that seems to dance toward authoritarian methodologies. Many fear that more change could occur with the confluence of President Trump’s control of the government and the continued creative application of misinformation, anger and fear that we witnessed during the campaign.
I will have watched the Inauguration by the time you read this letter. In all fairness, I want to hear what the President will ask of us and promise us. Except for a few casual glances offered with the evening news, I will pass on the parade and all the other events of celebration. Those celebrations have not interested me in the past and certainly are of little interest to me now. I will be listening to the voices of dissent and wishing them well with their efforts, but I, following the example of President Obama, am also hoping that our new President will be successful. That said, I am extremely skeptical about what he will accomplish. I, like so many others, live in fear of what might happen if the challenge does exceed his skills. As I said in last week’s letter, and as you can review on strategyhealthcare.com, I plan to be a member of the loyal opposition.
There are two sections in this letter. The first section represents my continuing effort to keep up with the debate over the future of the ACA. The discussion includes a look at an excellent article by Don Berwick written for the Huffington Post that demonstrates how very interconnected the ACA is with all of healthcare. Berwick is pretty convincing as he describes how repealing the ACA will create a lot of collateral damage. I also direct you to a Stat article that brings you up to date on the evolution of “repeal and replace” toward “repair and rebuild”.
The second section builds off the idea of focusing on what you can do locally. The reality of healthcare improvement is that it represents a back and forth process between external forces beyond our immediate control in the form of actions by government at the national and state level, and what we do at the local level. Two weeks ago I returned to an article by Shortell and others from 2011 about ten issues that drive success or failure in an ACO. In the second section I discuss three of those issues in more detail.
Information for Responsible Resistence
A few weeks ago those of us who had experienced a few moments of unfounded hope based on positive comments that President Trump had made about the ACA had our hopes dashed when he announced that Representative Dr. Tom Price of the 6th Congressional District of Georgia would be the next Secretary of Health and Human Services. It is my assumption that after the Senate Finance Committee (Senate home of the ACA) grills Representative Price on January 24, he will be confirmed. The Senate’s HELP (Health, Education, Labor and Pension) Committee gave him a tough time this week, as noted in the New York Times article about how cabinet appointees are doing in the confirmation process:
Lastly, there was Mr. Trump’s pick to lead the Department of Health and Human Services, Tom Price, a representative from Georgia. Mr. Price made the preposterous claim that repealing the Affordable Care Act really wouldn’t hurt people as long as they had bare-bones insurance policies that paid for treatment only in catastrophic circumstances. He couldn’t offer any convincing defense of his proposals to strip hundreds of billions of dollars from the budgets of Medicare and Medicaid. In response to questions by Senator Elizabeth Warren, he said that spending on the programs was the “wrong metric” to judge them by and argued that lawmakers should instead focus on the “care of the patients.” Quality of care is certainly the most important standard, but why would drastic cuts to those programs magically result in people getting better medical treatment?
Mr. Price also could not explain why he and a broker he hired traded health care stocks when he was proposing and voting for legislation that would affect those companies. He refused to see that even if he didn’t violate insider-trading laws, his investments represented a huge conflict of interest.
Despite his views and despite his financial entanglements, I assume that the Republican majority will confirm him. Then what? You have probably read a lot of conflicting articles about what might happen. The President says the result will be universal coverage that will make everyone very happy. The CBO and others who have a more granular understanding of the law and the insurance business are predicting that tens of millions will lose coverage. As the Stat article describes:
The Obamacare repeal effort is just getting underway and already the political wordplay is dizzying. On the GOP side, the rhetoric has gone from “repeal and replace” to “insurance for everybody” to “repair and rebuild.” Meanwhile, Democrats continually warn that the Republicans are trying to “rip apart our health care system.”
House Republicans seem to understand that repealing the ACA has the danger of negative political consequences. The public is beginning to understand that they should learn a little more than they were offered during the election when healthcare was hardly discussed. Perhaps you have heard about the woman who voted for Trump because she hated Obamacare, but she was very upset to hear that he was going to repeal the ACA and cost her the benefit of having her son on her insurance policy.
Greg Walden of Oregon is the Chairman of the Energy and Commerce Committee of Congress where much of the action will occur. He has long been an opponent of the ACA and is credited with the creation of the slogan “repair and rebuild” to replace “repeal and replace”. Walden has led the efforts to get more Republicans elected to congress over the last two elections and just maybe he has the political experience to give him some insight into the downside of rapid repeal. We will see.
What worries me most is the difference between “rhetoric and reality”. Tom Price says that as HHS Secretary he will make sure that no one has “the rug pulled out from under their healthcare” and President Trump promises “something better.” But nowhere is there more detail.The Washington Post seems skeptical of Trump’s assertion and suggests that the job will be harder than he realizes:
Trump declined to reveal specifics in the telephone interview late Saturday with The Washington Post, but any proposals from the incoming president would almost certainly dominate the Republican effort to overhaul federal health policy as he prepares to work with his party’s congressional majorities.
Trump’s plan is likely to face questions from the right, after years of GOP opposition to further expansion of government involvement in the health-care system, and from those on the left, who see his ideas as disruptive to changes brought by the Affordable Care Act that have extended coverage to tens of millions of Americans.
Perhaps the most important point that the Stat article makes is the ambiguity in the way Republicans use the term “universal coverage”. When I use the term I mean that everyone has coverage to high quality care that includes chronic disease and preventative health benefits across the board as recommended by the IOM in the ten determinates of a better system of care as described in Crossing the Quality Chasm. When a Republican politician uses the term it means that everyone could have coverage of some kind at least for catastrophic conditions. The New York Times points out that using the term “Universal Access” in a disingenuous way that does not take into considerations the realities of how the insurance market works could lead to big problems for consumers. It’s a wink-wink kind of thing as implied by a quote in the article: “Our goal here is to make sure that everybody can buy coverage or find coverage if they choose to,” a House leadership aide told journalists on the condition of anonymity at a health care briefing organized by Republican leaders.Don Berwick and the Stat article point out that there is more to the ACA than the insurance that it provides to those who have gained coverage through it. In a very succinct article in the Huffington Post, which you must read, Berwick describes the complexity of American healthcare better than I have ever seen it presented. He writes: To get your bearings, keep in mind the main categories of health insurance coverage in the U.S. There are five: Medicare (the federal “single payer” program that covers roughly 58 million people over 65 years of age), Medicaid (the federal-state matching-funds partnership that covers 68 million children, people of very low income, people with disabilities, and people in nursing homes who have spent down the bulk of their assets), employer-based insurance for 156 million, the non-group market (about 22 million people who have to find insurance on their own), and the Children’s Health Insurance Program (which is another federal-state matching funds program that covers about 8 million children and pregnant women in families of limited income).
Another 18 million are covered by the military or Veteran’s Administration. And 28 million people in our country still have no health insurance at all.
The ACA, and its repeal, affects every one of those segments, but differently.
He goes on to categorize how repeal of the ACA hurts Medicare because it has lowered the cost of care by its emphasis on quality and value based reimbursement in a movement away from fee for service. The facts are important:
Medicare spending per person went up 7.4 percent per year in the ten years before the ACA, and 1.4 percent per year since the ACA....The result for Medicare beneficiaries will be backsliding: higher costs and worse care.
Next up Medicaid:
Their “replace” proposal, still behind curtains, is probably going to try to change the way all of Medicaid is funded, from the matching program in place since 1965, to “block grants” to states or “per capita” limits, under which the federal government would simply give a fixed amount of money to each state. The intent is to reduce federal Medicaid funding. The caps would be set at levels below what Medicaid is expected to cost, and disparities in coverage among states would be locked in. States would end up holding the bag as, say, needs changed or a recession occurred. Over the next decade, federal Medicaid payments would fall by 1 trillion dollars, and 14.5 million people would lose coverage by 2021.
Ouch! But I am okay if I have commercial insurance through my employer, right?
Don sees it differently:
Repeal of the ACA hurts employer-based insurance. With tens of millions of people no longer insured via Medicaid expansion and subsidies, hospitals and doctors would find themselves back in the bad-old-days of uncompensated care and inadequate pools to support their free care. There will be nowhere else to turn for resources than to higher premiums for people who do have insurance. The new administration says it would keep many of the popular ACA protections for insured people, such as the abolishing of lifetime limits on coverage and forbidding insurers from denying coverage to people with preexisting conditions. But the math doesn’t work. There is no way to support a viable insurance market with those requirements absent the elements of the ACA that the Republicans want to end ― including the individual mandate. Bottom line: if you think your employer-based premiums went up too much under the ACA, just wait until it’s gone to see what the ACA was actually protecting you from.
Most people, including many in healthcare, have no idea what “the non group market” means.
Don explains: Repeal will hurt the non-group market in many ways most of all. Individuals who want insurance but are not in large groups are not attractive customers for insurers; many tend to have worse health and a lot of them are far from wealthy. That’s one reason why the ACA set up the so-called “exchanges,” marketplaces with federal subsidies for people whose incomes are too high for Medicaid eligibility but too low to afford usual insurance on their own. The exchanges did have problems; mainly, their enrollees have turned out to have higher risks than predicted and therefore some individual and small group premiums soared. That is all fixable – California did it, and so did Alaska. But, with repeal of the subsidies, there will be nothing left to fix; the exchanges will implode, leaving over 8 million individuals high and dry.Most Republicans love children and would probably swear that they would do nothing to deny needed medical services to insure the health of the next generation. Much pain is created in the world by not paying attention to details. The average Trump voter probably did not realize that the care of children would suffer with “repeal and replace”. Their concern was perhaps directed at those too lazy to take care of themselves. Don has news for them: And, finally, CHIP. This highly successful program has provided coverage for millions of children and pregnant women who have no affordable alternative. It has to be reauthorized later this year, and some Republicans propose to end it.We all have much to lose whether we realize it or not. You can do the analysis from the point of view of social justice or cold hard cash, but as Don concludes: Add it all up, and, according to the Urban Institute in Washington, ACA repeal will throw 30 million Americans off of health insurance. And it’s not just the poor who will suffer. Repeal will harm almost every category of insured population in this nation. It will unleash unprecedented increases in insurance rates and worsen benefits for most people with insurance. Repealing the ACA without a clear, cogent, politically viable, and effective alternative – a “replace” that works – is not responsible.Doing What We CanTwo weeks ago I wrote: Long before Atrius Health became a Pioneer ACO, one of our board members showed me a short article in the August 17, 2011 JAMA written by Singer and Shortell, “Implementing Accountable Care Organizations: Ten Potential Mistakes and How to Learn From Them.” ...If you do not have access to JAMA, the list is available as part of another Internet article.1. Overestimation of Ability to Manage Risk.
2. Overestimation of Ability to Use Electronic Health Records.
3. Overestimation of Ability to Report Performance Measures.
4. Overestimation of Ability to Implement Standardized Care Management Protocols. The development of care management protocols requires a high level of involvement from clinicians, as well as data collection and assessment. An ACO may misjudge the level of involvement necessary to develop appropriate care management protocols.
5. Failure to Balance the Interests of Hospitals, Primary Care Physicians, and Specialists in Creating Governance and Management Processes to Adjudicate Differences. It is imperative for ACO participants to utilize the structure of the ACO to improve on the quality of care delivered and to work together as a team to achieve collective goals.
6. Failure to Sufficiently Engage Patients in Self-care Management and Self-Determination.
7. Failure to Make Contractual Relationships with the Most Cost-Effective Specialists. ACOs will need to partner with enough specialists to cover the needs of their population, but at the same time, will need to partner with the most cost-effective specialists.
8. Failure to Navigate the New Regulatory and Legal Environment.
9. Failure to Integrate Beyond the Structural Level. While coordinated care is an important tenet of the ACO on a contractual basis, it may be harder than anticipated to implement it on the ground level.
10. Failure to Recognize the Interdependencies and Therefore the Potential Cumulative “Race to the Bottom” of the Above Mistakes.
An ACO must realize that all of the potential pitfalls are interdependent, and must be avoided holistically to succeed.
That is a long list, but every item is important. Where do you start? That was a question that John Gallagher and I were discussing this week with Lauren Goldman who was thinking with us about how Lean contributes to ACO success.
If I was to ask you to pick three of the “failures” to try to avoid, which three would you pick? It is not an easy question for me, but my answer is:
4. Overestimation of Ability to Implement Standardized Care Management Protocols. The development of care management protocols requires a high level of involvement from clinicians, as well as data collection and assessment. An ACO may misjudge the level of involvement necessary to develop appropriate care management protocols.
5. Failure to Balance the Interests of Hospitals, Primary Care Physicians, and Specialists in Creating Governance and Management Processes to Adjudicate Differences. It is imperative for ACO participants to utilize the structure of the ACO to improve on the quality of care delivered and to work together as a team to achieve collective goals.
6. Failure to Sufficiently Engage Patients in Self-care Management and Self-Determination. My answer is derived from working backwards from the success that Atrius has had as an ACO. As experienced as the Atrius practices were with Medical Home concepts, electronic medical records, capitation, the management of quality metrics, management of processes of care and the management of relationships with suppliers, specialists, hospitals and nursing facilities, we needed to kick it up several levels to begin to achieve success within the Pioneer ACO model. Without knowledge of the organizing benefits of process management and waste reducing concepts of Lean we would have never been able to overcome the unfair disadvantage of a low “budget” that was based on our prior market leading performance. It may seem odd, but the better you are, the more you need to focus to get to the next level of performance. It has been three years since I retired, but I know that continuous improvement will be more important over the next few years to the future of Atrius and every other provider of care than it has been so far. I do not believe that there will be more resources to waste. The most reliable increases in relative resources will be the ones you rescue from waste and reallocate to care delivery to compensate for the relative reductions that you can expect from public and private payers. I hear no politicians on either side of the aisle arguing that patients, taxpayers, or employers need to be paying more. In retrospect I think that we did not do nearly enough to Engage Patients in Self-care Management and Self-Determination. The organizations that succeed in engaging patients in self care and self determination will be the ones that will deliver Care better than we’ve seen, health better than we’ve ever known, cost we can afford,…for every person, every time…in settings that support caregiver wellnessI will return to this list over the next few weeks. It makes a lot more sense to put effort into what might make a difference than to continue to talk about the jeopardy we will all experience with “repeal and replace” or “repair and rebuild.” Trudging Through The Come and Go WinterI love winter. I just do not like it when the temperature goes up and down and we have snow alternating with rain. A cold rain is the worst. In New London we have had snow coverage of some sort since mid December, but last week’s warm weather and rains had created a lot of bare spots. I was delighted when we got six inches of snow on Tuesday night and early Wednesday morning. I would have liked nothing better than to have headed to the woods, but my wife and I had tickets to hear John Cleese at the Boston Symphony Speakers Series Wednesday night, so Wednesday afternoon we were headed down I 89 in the early afternoon as the snow was just about over. As you can see from the picture I took from the passenger’s seat, the road clearing expertise in New Hampshire is world class! I was struck by the beauty of the snow in the trees and thought that I would share it with you. I am hoping to be pleasantly surprised by a different President Trump than Candidate Trump or President Elect Trump. I do believe miraculous surprises can occur from time to time. Whatever happens I believe in the resilience of America. It is great and will continue to be great. I am also hoping that Tom Brady and Bill Belichick, both friends and supporters of President Trump, can continue their journey toward the Super Bowl. A win over the Steelers would make my granddaughter very happy, although if they lose I am sure my friend John Gallagher’s joy will balance my granddaughter’s disappointment. Finally, I hope that it stays cold enough to make all of our precipitation between now and April be snow. I am especially hoping for a big dump of snow during the week I will be going down to Florida for “Grandparents Day“ at my granddaughter’s school and to watch her play basketball as an eighth grader for the high school varsity! With luck we will also get to watch the Tom and Bill show at the Super Bowl during that visit. Whatever happens, I hope that you will celebrate the inauguration or manage your anxiety about the fate of the ACA by getting some exercise this weekend. I do my best thinking about problems and opportunities while I am in motion. How about you?
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