21 April 2017

Dear Interested Readers,


What’s Inside This Week’s Letter and Some Generalizations About Structural Evil

“Evil” is a term that makes most of us squirm a little. It seems sort of biblical or is perhaps a concept that has faded since before the nineteenth century when we relied on concepts of personified evil as represented by the Devil or Lucifer. Satan’s statue has slipped way below acceptance as he has been replaced by Darth Vader as the the leader of the “dark side” and is now regarded by most of us as more mythological and metaphysical than real.

Although we still like to “hold people accountable” for disappointing failures and lapses of personal integrity, we are getting better in our search for scientific or structural explanations for “bad outcomes” and many of the natural disasters we suffer. We are less accepting of the concepts that were once popular with our ancestors depicting a near almighty personification of evil as an agent in conflict with God seeking to make deals with weak people or tempt Jesus during his forty days in the wilderness.

What are our modern day equivalents of active evil and deals with the Devil? Are there any Faustian bargains in healthcare? As a kid, and as a budding baseball fan and Yankee hater in the mid fifties, I was captivated by the fantasy in George Wallop's novel The Year the Yankees Lost the Pennant which I read in the popular Reader’s Digest Condensed Books (Spring 1955 collection) to which my mother subscribed. Perhaps you remember the gist of the story from it’s Broadway and Hollywood title, Damn Yankees. It is easy to understand how the Devil was able to play on the gullibility of Joe Boyd, a middle aged realtor and Washington Senators fan who was so devoted to his team that he willingly accepted the Devil’s offer to be transformed into a young superstar, Joe Hardy, who suddenly appears on the scene as a slugger who can help the Senators defeat the hated Yankees. The story suggests that long term frustration and the desire to right perpetual inequity are as potent factors in our continuous vulnerability to offers from the Devil as are the traditional materialistic desires and jealousies.

In our modern world we are kept quite busy trying to explain why bad things happen. This year has been no exception. Returning to personified concepts of “evil” or the descriptive utility of the that quaint old word may represent a philosophical cop out to you, but they are increasingly attractive to me. Thinking about an active agent of the dark side seems easier than the continuing rationalizations and categorizations of the various ways bad things happen in our lives along with what or whom to blame.

My new acceptance of a Satan like personification with an army of helpers may be yet another form of accepting the outcome of the 2016 election. As I challenge myself to move away from myth and allegory in my attempts to rationalize and understand “evil’, I have picked up the idea that there are three kinds of evil. Some philosophers say that there are two broad types of evil. “Moral evil” represents the outcome of individual actions for which people are responsible. “Non moral evil” is the origin of the pain and suffering that is not the proximate cause of a human action for which someone is responsible. It is interesting that many of the events characterized as non moral evil may, like violent weather, be the outcome of human activity. The damage done from storms attributable to global warming may account for more and more of this “non moral evil.”

Others suggest that perhaps there are four or perhaps even seven types of evil. Discussions of “lumping and splitting” seem to apply to evil as well as to other human conditions; nevertheless, I am intrigued by the idea that there is benefit in thinking about at least three types of evil. The first evil is the moral evil. People do decide to do bad things for many reasons. The outcomes of their actions often result in loss, pain and suffering for themselves and others. We see their heinous crimes on Facebook, and stories about evil are the basis for much of our entertainment at the movies and on television. The non moral evil may be a misnomer, but I think there are at least two types, natural evil and systemic evil. Natural evil, events caused by global warming aside, are like earthquakes, droughts, tornadoes, floods, and forest fires caused by lightning. The list is long. Ironically, the insurance industry and lawyers call the items on the list “acts of God.”

When we consider all the acts of God and all the evil acts that arise from the darkened heart of man we have not explained all that seems wrong and deserves to be called evil. The sum of the moral failures of humankind and non moral acts of God still leaves room for other considerations about the origin of bad things that deserve to be called evil. What about the bad outcomes that arise from complexity? There are many situations in modern life, often in medicine, when every person involved has played by the rules and dutifully fulfilled their role, but the sum total of their collective actions is bad, sad, or regrettable. (I admit that morality and playing by the rules may not be the same thing.) Could it be that much of what is wrong with healthcare in America falls into this third category of evil? The term that is used by some to describe the phenomena of bad outcomes arising from complexity and the lawful but distasteful actions of institutions, governments and individuals involved in legally acceptable actions is “structural or situational evil.” Some may prefer to think about institutional or bureaucratic evil as a related phenomena.

I am not a philosopher or a theologian, but as I read Elisabeth Rosenthal’s new and powerful book, An American Sickness: How Healthcare Became Big Business and How You Can Take It Back, I can not help but think these thoughts about institutional evil. The letter this week is a closer exploration of some of Dr. Rosenthal’s insights and an attempt to use that understanding to realistically consider our options or clarify what we hope will happen.
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The core of last weeks letter is now posted on strategyhealthcare.com as an essay entitled “Where We Should Focus.” I hope that you will be able to see the consistency in thought between that posting and this week’s letter. The aligning thought behind all of these letters and all of the postings on strategyhealthcare.com is the Triple Aim. I love repeating the new iteration of this lofty set of goals. It gives me great joy to say that our objective should be

...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 wellness.

But making that lofty goal the reality of healthcare that is experienced by every American has been a journey of many decades, and the destination is still decades beyond the horizon. Rosenthal’s book is a breathtaking explanation for why our current state is so complicated and why fixing it seems so impossible. It is a book that everyone involved in the repeal and replace process should read.

The letter concludes with a brief piece about what I learned in Vermont this last week. Vermont offers a special presentation of many of our current societal issues in a much more beautifully concentrated package. If you look at Vermont closely there is a lot to learn about many of the big issues that face the whole country.


Perhaps an Explosion is the Best Route Forward


Earlier this month after the failure of Paul Ryan’s American Health Care Act to get passed over the internal squabbling of House Republicans despite their forty four vote majority, David Brooks wrote an interesting tongue in cheek column entitled “The Coming Incompetence Crisis.” He articulated his concern:

...I worry that at the current pace the Trump administration is going to run out of failure. So far, we’ve lived in a golden age of malfunction. Every major Trump initiative has been blocked or has collapsed, relationships with Congress are disastrous, the president’s approval ratings are at cataclysmic lows.

In the intervening month there have been many articles reiterating the brilliance of the president’s epiphany when he reported with surprise, “Nobody knew that healthcare could be so complicated.” During the last two weeks while Congress has been enjoying its two week Spring/Easter recess some of its members have been having boisterous town hall meetings where they are facing angry crowds that are still concerned about the Republican healthcare agenda.

I have been quite concerned about what would happen next since March 24 when the AHCA was withdrawn. My concerns quickly replaced the jubilation I had had enjoyed over the withdrawal of the AHCA. That joy lasted about two hours after the withdrawal of the bill, but was squelched when the president concluded his comments on the withdrawn bill by predicting that the ACA would explode. My smart aleck response was, “Sure, you know it’s going to explode because you can light the fuse!” The likely vector of how my concern will become a reality is nicely summarized in a New York Times editorial this week, “Donald Trump Threatens to Sabotage Healthcare.” Withdrawing financial support from exchanges will force insurers to exit, but there are also several other fuses that the president can light to make his prediction come true.

After reading Elisabeth Rosenthal’s book, An American Sickness: How Healthcare Became Big Business and How You Can Take It Back, I am wondering if perhaps letting Trump “blow up” the ACA is the fastest route to the Triple Aim. Perhaps I am a little depressed, but after reading her book I am mumbling that old piece of wisdom from Maine, “You can’t get there from here!”

To fully appreciate the book you need a little information about the author. Dr. Rosenthal is an internist who is currently the Editor-In-Chief of the Kaiser Health News. She graduated from Harvard Medical School and then did her residency at New York Hospital-Cornell Medical Center. She worked for five years in the emergency services of the New York Hospital. In 1994 she left practice to become a science writer for the New York Times. Her work for the Times took her to China and Europe before she moved back to New York in 2008 to be the Times global environmental correspondent. She began covering the ACA in 2012. In 2014 she published a series of articles on healthcare finance entitled “Paying Till It Hurts”. Over the last two years she has expanded her analysis of what is wrong with healthcare into a book which was just released on April 11. I became aware of the book through a heads up from an Interested Reader who put me onto a pre publication review in the Times by Jacob Hacker, a professor of political science at Yale.

Professor Hacker’s review is a helpful orientation to the book. The book can be viewed entirely as an answer to the question of why healthcare does not conform to the concepts or mechanisms of a traditional market. He points out that the difference between the expensive care Americans receive and the equally effective but much less expensive care in other countries can be largely explained by an analysis of the role of government. Rosenthal expands this idea with the flourish of a story teller. There is a story to how the insurance industry evolved to its current state of dysfunction and confusion. There is a story behind the transformation of charitable hospitals into self serving margin generating “non profit” money minting machines. There is certainly a rapidly evolving story to the excessive prices of drugs and medical devices.

Rosenthal’s story is not limited to the “how” of how we got to this dysfunctional moment in time. Her story is personalized to reveal the toll of pain and suffering that “good business” decisions extract from patients whom she has meet and presents as real people with real names and real reasons to despair from what they have endured. Her story subtly reveals that the ACA has not failed because it caused increases in healthcare expense. It has failed because it was not designed or empowered to change the culture of business that has captured healthcare over the past three or four decades.

I was impressed with the truth she presents that demonstrates a lack of transparency in pursuit of profit. It was interesting to see that although she did not introduce a single new piece of information that was new to me, she gave me new insights by the way she wove the information together to demonstrate why the status quo represents such a simultaneously dysfunctional, self serving and impenetrable reality that it borders on being beyond repair.

This moment in healthcare is the perfect example of structural evil. Every player operates within degrees of freedom that are defined by law and defended from change by effective political connections, self serving interest groups, and talented and persuasive lobbyists armed with dollars to drive their success in a system funded by the insatiable appetite of lawmakers and elected leaders for campaign dollars that are necessary for their continued presence in office.

The book tells “why” patients experience unnecessary expense and inconvenience from a system that often seems to have forgotten its core reason to exist. She presents healthcare as a business with certain profits, captive customers, and many practitioners who can rationalize their behavior in terms of good business decisions that generate a margin over the more traditional motivations that may have initially attracted them into service or practice.

The core to her analysis to which she returns again and again as she discusses each of the dysfunctional aspects of American healthcare is a list of the ten rules that describe a dysfunctional medical market. Those rules are:

1. More treatment is always better. Default to the most expensive option.
   
2. A lifetime of treatment is preferable to a cure.
   
3. Amenities and marketing matter more than good care.
   
4. As technologies age, prices can rise rather than fall.
   
5. There is no free choice. Patients are stuck. And they are stuck buying American.
   
6. More competitors vying for business doesn’t mean better prices; it can drive prices up, not down.
   
7. Economies of scale don’t translate to lower prices. With their market power, big providers can simply demand more. 
   
8. There is no such thing as a fixed price for a procedure or test. And the uninsured pay the highest prices of all. 
   
9. There are no standards for billing. There’s money to be made in billing for anything and everything. 
   
10. Prices will rise to whatever the market will bear. 
    

Against the background of these ten points, she has organized her book around a framework that mimics the process of a patient evaluation that she surely learned from “the little Red Book” at Harvard Medical School. In the introduction she gives us the chief complaint, “Unaffordable Healthcare.” Part I is “History of the Present Illness and Review of Systems.” Part II is “Diagnosis and Treatment: Prescription For Taking Back Our Healthcare.” The fix is a complete list and explanations of ideas like single payer, greater transparency, more effective use of digital healthcare, and other subjects presented to inform patients that other options are available than what they currently experience. The list includes no breakthrough ideas that are not a part of the current conversation. Her presentation underlines the reality that we are not ignorant of our woes or our opportunities. Rather, we are inept in organizing efforts to overcome the self serving control of the status quo.

It is one thing to suggest that we move to a single payer environment. It is another thing to agree on how to make the move. How do we dismantle enterprises that have enormous resources and employ hundreds of thousands of people performing tasks that may or may not be needed if there is a new form of payment? Similar questions arise when we talk about reforming the roles and deployment of medical specialists, or redefine the role of the hospital. The bad news is that at almost 20% of the economy healthcare is possibly too big to fail as an industry even as it can allow its customers to fail as individuals. Business has been and will continue to be good for the keepers of the status quo, even if fifteen percent of the population remains on the outside looking into a process from which they are economically excluded. The outlook is bleak. I was disappointed that her recommendations did not include any breakthrough ideas. I guess that was too much to hope for against the well organized forces of structural and institutional evil.

Perhaps because she knows that there is little that likelihood that we can do to overcome the organized power of structural evil in healthcare, in the Epilogue she presents a stark observation on the “fate of empires.” She reminds us of the “age of decadence into which all great societies...descend before they finally fall for good.” She continues by saying that the decadence flows from a period of wealth and power, selfishness, love of money, and a loss of a sense of duty. That list is perhaps a description of the realities that support “structural or institutional” evil. To her diagnosis I would add a collective ineptitude in managing the conflicting interests of a complex world. It is possible for all of us, all of our businesses, all of our institutions, and all of our leaders to perform within the limits of law and current concepts of ethics and still have the outcome be a dysfunctional equivalent of contemporary concepts of evil.

Dr. Rosenthal looks to consumers to demand a different outcome now that she has shown them the problems. She sees patients and those providers, ones who have not forgotten why they were drawn to the service of preserving health and reversing disease, joining their efforts to make the transition to a better state. She finishes with a charge:

They [the doctors, nurses and other healthcare professionals] want to deliver patient centered, evidence based care at a reasonable price. We, the patients, need to help, to rise up and make that possible. We have to remind everyone who has entered our healthcare system in the past quarter century for profit rather than patients that “affordable, patient centered, evidence-based care” is more than a marketing pitch or a campaign slogan.

It is our health, the future of our children and our nation. High-priced healthcare is America’s sickness and we are all paying, being robbed. When the medical industry presents us with the false choice of your money or your life, it’s time for us all to to take a stand for the latter.

It sounds like she is advocating for a coalition that makes its mission the achievement of

...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 wellness.

She is hoping that the information that her book presented will create an army of educated and engaged patients who will work with committed professionals for mutual salvation and redemption from a system of care gone wrong. She believes that the virtues of information and engagement can cancel the powers of structural and institutional evil. The alternative is to relax while the president blows up the ACA and then hope that somehow we will be able to put the pieces back together again, minus the current flaws.


Thoughts Among the Cows and the Solar Panels of Vermont


The picture in the header of this letter is the view from a dairy farm just west of Middlebury, Vermont in the heart of the beautiful Champlain Valley where my wife and I spent a few days this week with old friends. The mountains in the picture are part of the Adirondacks of New York on the other side of the lake which lies unseen between the farmland and the mountains. I have been going to this part of Vermont on a frequent basis since my first trip there in 1981. I love farm land and mountains. I get the same feeling in the Central Valley of California looking past acres of tomatoes spreading out to the horizon toward the Sierras to the east. The combination of farms, mountains and water is really hard to beat and moves the Champlain Valley high on my list of favorite places to be.

We had traveled to Vermont with one of my wife’s nursing school friends and her husband to visit another old nursing school friend who moved to the Champlain Valley fifty years ago after marrying her high school sweetheart whose family had moved their dairy business from Rhode Island to Vermont. Now five decades later her husband is still managing a large herd of cows by the rules that govern the “organic” milk industry, and she is still active in nursing education and programs of community health.

I was surprised to see how the farmer’s world in 2017 mirrors the complex interdependency of the global economy. If you look closely at the picture you will see a solar panel. There are thousands of solar panels in the valley. They cover huge swaths of land where they have displaced cows and corn as a better crop. The city of Burlington claims to be the first city in America that has a negative carbon footprint and uses only renewable sources of electricity.

To my surprise I learned that most of the silage that the cows eat is not grown locally but is shipped in from the midwest and Canada, and that most of the people milking the cows are illegal migrant workers from Mexico who are mostly almost invisible as they milk the cows and tend the herds day in and day out all year long. Just this last week there was an extended report on NPRs talk show, “On Point” that examined the problems that the dairy industry in Vermont and agriculture in general are experiencing because of the uncertain status of undocumented workers who are a necessary part of the work force. Looking across the valley at the beautiful mountains while munching on crackers and cheddar cheese, it is uncomfortable to contemplate the realities of the physical and mental health of migrant workers who are far from home, isolated and invisible, as they are involved in the economics of items that are so mundane as milk, eggs and cheese. Healthcare is not the only very complicated subject that challenges our future.

Spring is coming fast to the valley. As I walked around Middlebury and enjoyed the roar of Otter Creek as it cascaded through Frog Hollow, I saw forsythia and daffodils in many yards and the trees had hues of green and red as the buds on them were beginning to open. Out in the countryside I walked along patchworks of newly, plowed fields of brown stubble from last years corn crop and bright green fields of early alfalfa that looked like huge finely manicured lawns. But as I walked I could not rationalize the local beauty with my newly acquired knowledge of what was behind the scene. I also could not forget the rusty “double wides” and derelict properties that lined the roads going through the little towns that lie along the rocky streams between the mountains between my home and wealth of the valley. The expansive views on my walk in the valley showed me how easy it is to overlook the problems that are all around us. I really do not think the answer is to blow it all up.

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