| 21 October 2016
Dear Interested Readers,
Inside This Week’s Letter Plus a Few Extra Thoughts
I have been to Chicago this week. I did not go there to see the Cubs play. The games this week have been in LA. I came to Chicago to attend Simpler Consulting’s 11th Annual North America CEO Symposium. The name is misleading on a couple of levels. There were some CEOs in attendance but there were also plenty of CFOs, CMOs, CNOs, as well as other leaders in Lean organizations that are working with Simpler. “North American” was also inaccurate since there were attendees from the UK. The Brits may be exiting the EU but the same challenging issues of cost and quality that complicate the lives of healthcare professionals in America are just as challenging in the UK and in the EU. The difference is that the United Kingdom and most of the members of the EU consider quality healthcare to be an entitlement and as much a responsibility of the collective as education and adequate housing.
The final component in the name of the conference that merits explanation is Simpler. Simpler has been in a serial process of merger and acquisition over the last three years that mirrors the journey of many of its customers. We are living in an era of affiliation and acquisition to enable the pursuit of difficult objectives in the face of falling revenues as demand for performance increases. About three years ago Simpler acquired JWA Consulting, a very respected Lean consultancy that had followed a different path, but was built on the same principles as Simpler. Two years ago, shortly after coming together, Simpler and JWA were acquired by Truven Health Analytics, not very long after Truven had spun off of Thomson Reuters. Within the last year IBM Watson Health, a new company created by IBM over the last two years, acquired Truven, Simpler and JWA.
As is true when delivery systems consolidate, IBM Watson is working to link all of its new component organizations into an integrated whole that will enable its customers to improve their performance as they seek to respond to financial challenges, shift their organizations toward value driven performance, develop population health skills and become confident in their ability to effectively accept and manage risk. It is a huge undertaking. Over the last several months Truven, Simpler and all the “other recently acquired assets” have been working with IBM Watson’s management team as well as advisors from customers and others in the healthcare industry to create an innovative new organization through the orderly strategic assembly of these assets.
With “other recently acquired assets”, I was referring to the astonishing fact that during its brief existence IBM Watson Health has also acquired Phytel, Explorys, Merge Healthcare, and The Weather Company. They have spent over 4 billion dollars acquiring the component pieces of a company that will be foundational to healthcare transformation. You ask, “What is the Weather Company doing in the mix?” Well when you are predicting the risk that the frail elderly or patients with lung disease might have, it is good to be able to factor in the weather. The ultimate goal of this audacious exercise is aligned with the Triple Aim. The planners are confident that they can make a successful application of technology and improvement science grounded in data analytics and the evolution of cognitive analytics. They are comparing their project to the effort to put a man on the moon. IBM was a big player in that effort and sees no reason why being a facilitator of better health for everyone should not be their next big audacious objective.
The conference was an exciting opportunity for me to see how my observations of the current state and my ideas about what is possible intersect with the opportunities that the evolution of IBM Watson offers. The conference covered a lot of ground including reports of recent successes from some of Simpler’s clients. Perhaps the best way to help you imagine what might be possible with Watson linked to Lean would be to pass on to you some of the key points made by the speakers. I am not exaggerating when I say that the agenda contained enough material to keep me writing for at least a month. I do plan to “harvest” more than one letter from my time in Chicago.
There are social functions and plenty of networking around an event like the Simpler CEO Symposium. It was not a marketing event. Everyone there either worked for one of the newly connected members of the IBM family, was a customer of one of the organizations in the new affiliation, or, like me, was an adviser, familiar with the challenges and sharing a deep belief in the importance of the Triple Aim.
As you might expect, during the break time between presentations and the social functions before and during the conference, we were talking more about the election than whether the Cubs would beat the Dodgers. Just as there were both Dodger and Cubs fans in the conversation there were also attendees who politically lined up with both of the two major parties or who were still undecided about whether to vote at all or cast their vote as a protest for a third party candidate with no chance of winning.
Everyone at the meeting seemed convinced that the greatest threat to the future health of the nation was our continuing inability to reduce the cost of care. Most of us realized that many of the accomplishments since the beginning of the quality era in the late nineties would survive the uncertainty of the election. One speaker spent time emphasizing the huge bipartisan majorities that produced MACRA as evidence that it and the drive for value based objectives would survive no matter who won the election.
Equally true was the shared acceptance of the analysis that quality is a function of our patient centeredness and our ability to deliver care that is safe, efficient, effective, timely, and equitable. It’s been fifteen years since publication of Crossing the Quality Chasm. That document is now foundational to a shared belief among the attendees that the improvement of our current processes of care is necessary, but just improving what we do will ultimately be insufficient to achieve the changes in performance that must occur for us to produce:
Care better than we’ve seen, health better than we’ve ever known, cost we can afford…for every person, every time.
Everyone attending this conference realized that achieving the lofty vision of the Triple Aim demands substantial innovation. They concur in the opinion that success will also require the spread of all that has been learned, but not adopted, by so many who continue to try to get through each new day with skills that have not evolved to match the demands of their customers/patients.
The world has changed around healthcare as it persists with a “guild mentality”. Our challenges are both external and internal. Externally, consumers and purchasers of care are expecting more. At every level of financial involvement, from the individual patient to public payers and the large multinational employers like IBM, there are demands for increased value and lower expense. The cost of care is rising and patients are absorbing much of those increases in the form of higher costs for basic coverage that is even more expensive because of large deductibles and higher drug costs. They are newly armed and learning how to use the benefits of increasing transparency. There is a greater availability of information on performance and dissatisfaction with care that does not meet standards that they would accept in their own businesses. Consumer and payer dissatisfaction and anger are accelerating the demand for healthcare to change.
Internally, siloed organizations with unwarranted variation in practice, and wasteful operations are struggling to survive while fighting with employees and dissatisfied customers even as they experience even greater regulatory scrutiny. It is interesting to postulate how we got here, but it is more important to realize that just continuing to do what brought us to this moment with old tools and yesterday’s mindset will not work. At one moment near the end of the conference one speaker did state that doctors over sixty would not be able to make the transition. He then went on to say that it was unlikely that those over fifty could be reoriented to new pathways of care. He was betting on the Gen Xers and the Millennials. I hope that he is wrong about those who are “in the way”. I do believe that one of the other speakers was right when he predicted that our energy for change will be generated by fear of financial failure. Perhaps Watson can help us rise to these internal and external challenges and provide us much needed help as we seek to delivery on the justified demands of consumers and payers.
There is much to do. As I have said before, “the What”, the Triple Aim, is now a settled question and an accepted concept. “The Why” is also becoming increasingly clear. Our communities demand more and our current methods of care are unsustainable and frequently ineffective. “The How” is the challenging question that will require more than just the effective use of the assets we have. We must pursue the development of new and effective tools like Watson may offer. We must spread the acceptance of improvement science and teach its culture and tools. We must cultivate the engagement of individuals and communities in the recognition that we can never enjoy the health we desire without much work on the non medical or social determinants of health. Finally, there is the “Who”. One speaker referred to Hillary Clinton’s, It Takes A Village. I agree. I think “the Who” is everybody. Healthcare professionals of all stripes, medical organizations across the spectrum of sizes and missions, individuals, families, communities, employers, and public servants all must be joined like a village for concepts like population health, value creation and the creative use of big data and machine learning to be successful.
After a description of the Chicago Symposium and some gee whiz, Buck Rogers visioning of what might be possible, I return to a celebration of fall. I hope that you will not be disappointed that I feel that the presidential election process deserves no further discussion. I do believe now is the time to begin to think about the process of pulling the country back together beginning November 9. I hope that when the election is over both parties and their candidates will accept the outcome of the election and agree to our customary respect of the rule of law and the other fundamental principles of democracy that have carried us through some tough times over the last 240 years.
Last week’s long discussion of the nine minutes of the healthcare conversation in the second debate has been edited down to a more digestible offering that you can find on strategyhealthcare.com. Let me invite you to give it some consideration and leave a comment. I care about what you think. I am sure that more dialogue is the first step toward a bipartisan resolution of the way forward toward universal coverage that would include the other 30 million Americans who are still outside the circle of care. There are many ways to get involved in the conversation. Leaving a comment may be an easy first step for you!
An Exciting time in Chicago
Have you ever wondered what it might be like to be working to improve the care of underserved populations in one of the nineteen states that has opted not to adopt the Medicaid expansion of the ACA? The usual profile is a state with both a Republican governor and legislature. There is a remarkable match between “red states” and states that refused the Medicaid expansion. One such state is my ancestral state of North Carolina. My mother’s family’s roots go back to the mid 1700s in what is now Lincoln County, North Carolina. My father and brother are there and have personally benefited by the fact that Carolinas Healthcare has built a new hospital, improved the local availability of specialty care and has given new support to many of the PCPs who have affiliated with them. Members of my family have gotten care from the same father and son for more than fifty years. The father is now retired and the son has merged his practice into the Carolinas system. The improvement in care my family has enjoyed does not extend to many of the vulnerable citizens of Lincolnton and North Carolina.
The first speaker at the 11th Simpler CEO Symposium was Hugh Tilson, JD, MPH, the Executive VP and COO of the North Carolina Hospital Association. Hugh and his colleagues are using Lean as they seek to work with the North Carolina legislature to find ways to improve the support of North Carolina Hospitals. Healthcare finance is tough in a state where the “bad debt” of hospitals is perpetuated by the fact that almost a quarter of a million North Carolinians are without coverage because they fall through the crack between eligibility for government support purchasing care through the exchange and “unexpanded” Medicaid. Hugh and his colleagues have not only supported the Lean transformation of several North Carolina’s hospitals but they have also used Lean to improve the efficiency and effectiveness of their 51 employees. Lean may be famous for its ability to improve production and reduce waste in manufacturing and healthcare, but Hugh and his staff have used it to optimize the effective utilization of the resources of a non profit working with government. It was an inspiring presentation that demonstrates the power of both “when there is a will there is a way” and leadership coupled with a management system that focuses on process improvement.
Following the report from North Carolina we were updated on the progress at Mountain States Health Alliance by John Jeter, the CFO for the system, and Nikki Vanburen, the CNO at Johnston Memorial, one of the hospitals in the system. Mountain States is in the midst of a merger process with its largest competitor. Nikki and John gave a terrific picture of how Lean has improved multiple clinical and business processes within the hospital and throughout the system. Mountain States brings great care with the latest technologies to a service area in Eastern Tennessee, Southwestern Virginia, and contiguous parts of Western North Carolina. It serves small cities, small towns and many patients who live in rural areas. The focus of their presentation was that executive leadership coupled with an organization where everyone is dedicated to improvement will produce results.
I was excited that the next presenter was Bill Kassler, MD, MPH who is the Deputy Chief Health Officer and Lead Population Health Officer of IBM Watson Health. Dr. Kassler was recruited by IBM because he has spent his career “at the intersection of clinical care and population health”. When he joined IBM he had been working as a PCP in an FQHC while serving as CMO for the New England Region of CMS. He has great expertise in the value based reimbursement efforts of CMMI. Dr. Kassler laid out the vision of IBM Watson Health and described the power of coupling machine learning and artificial intelligence with the efforts of process improvement. It was “blue sky”, “Buck Rogers” thinking. I was captivated by the possibilities of what might happen if we could incorporate the ability of Watson to augment the skills of clinicians in practice. What if a clinician who is uncertain about the next step in the care of a complicated patient could ask Watson how the patient compared to other patients and what had worked best for patients that were matched? Watson can search a data reservoir of hundreds of millions of cases. There are so many possibilities to explore and so much waste that could be reclaimed. My head is still spinning.
In the new world of possibilities that technologies like Watson offer, clinicians will need to be trained differently. Efforts at process improvement and a focus on population health will require skills that traditional medical education does not offer. Kaiser has decided to open a new medical school that will produce physicians who are trained for the challenges of the practice in 2030. Christine Cassel, MD, the former President and CEO of the National Quality Forum, the ABIM and the ABIM Foundation and an advisor to President Obama on his Council of Advisors on Science and Technology is the Planning Dean for the new medical school which will open in 2018. It was under Dr. Cassel’s leadership that the ABIM launched the Choosing Wisely Campaign. The doctors that Kaiser will produce will be comfortable with collaboration, understand how to bring the insights of population health to the individual patient and will be ready to use the power of technologies like Watson to achieve the Triple Aim.
The first day finished with the inspiring story of the pursuit of excellence at Northeast Georgia Health System. Carol Burrell is the CEO. The system has over three hundred doctors and several thousand employees working in award winning ambulatory clinics and hospitals serving about 400,000 patients. They have recently opened a new hospital designed with Lean to serve the outer reaches of Atlanta as it expands to the Northeast. The story was a tale of persistence as NE Georgia began with Six Sigma and then tried “do it yourself Lean”. When that failed they discovered the power of making Lean their operating system by engaging the assistance of JWA to teach them Lean. Their senior management learned that to lead a transformation that included physicians they must also be transformed.
The second day’s presentations were an up to the minute review of the realities of the emergence of value based reimbursement and population health. The information reviewed in the two spectacular presentations and the discussions that followed should be enough to create an anxiety attack in the board and upper management of any organization that has not begun to acquire the skills to succeed in a new world of value based reimbursement. The opinion of the first speaker, Michael Nowicki, Professor of Health Care Administration at Texas State University is that insurance companies will go away over the next decade as employers and public payers negotiate directly with integrated delivery systems. The impact of medical costs on the growing national debt will finally force the relative reduction of resources for healthcare. Providers will be accepting more risk through mechanisms of capitation within ten years. If this is true most organizations are not ready for the challenge.
Dr. David Nash is the Founding Dean of the Jefferson College of Population Health (the first in the country) at the Thomas Jefferson University in Philadelphia. His lecture was a beautiful description of why our failure to understand and incorporate the principles of population health have lead us to waste trillions of dollars and underfund services and infrastructure that are desperately needed. He reminded us that 10-20% of “health” is attributable to healthcare care. 80% of health is a function of realities that do not occur in a hospital or a doctor’s office. Only 3% of Americans regularly do 5 things that optimize their possibilities for health.
- Exercise for 20 minutes 3 times a week.
- Don’t smoke.
- Eat fruit and veggies regularly.
- Wear seat belts regularly.
- Are at an optimal BMI.
Connecting what we do to manage populations to improve the health of individuals will require tools like registries, new collaborations in the community to improve the social determinants of health and an understanding of vulnerabilities and priorities of populations that both big data and Lean can facilitate together. Combining process improvement with the power of Watson will be hard work. Work flows must be developed. There will be challenges that will surprise us. The status quo, no matter how dysfunctional it is and how poor its results, never goes away quietly. Change is an adaptive process but I have a renewed hope that good things will eventually happen no matter who wins the election.
A Brief Encounter During a Beautiful Week! Outside
We have had more than a year of turbulent pre election politics punctuated by sudden and unexpected storms that pelt us with huge surprises or bits of misinformation that feel like golf ball sized hailstones. The best part of the last year where I live has been the weather. Today’s header reveals the glorious beauty of my world via a picture that I have lifted from a video that was shot from a drone by one of my neighbors. As you can see in the picture, I am surrounded by color. The picture nicely reveals the large peninsula that was left in the middle of our lake by the glacier that carved our environment about fifteen thousand years ago. I live on the upper shore in the picture at the far end of the lake looking across the lake toward the beautiful colors on the peninsula.
It has been an unusual year of good “outdoor weather”. Back in the winter, during the presidential primary season, there was not much snow and ice. It was a little warmer than usual, so that walking was easier than most winters. The summer was dry but not too hot and during most of the weekends the skies were blue. Outdoors was the place to be and somehow the weather helped us tolerate all of the vitriol that was tossed around at the conventions. Now even as the television plays one attack ad after another, all you need to do to clear your head is to look outside. One of the first words my two year old grandson learned was “Outside!”. When he says “Outside!” he means, “Let’s go outside!” Outside is my prescription for surviving the next eighteen days.
This last week has been a terrific week to be outside. Where I live, Monday was as nice as any day in June, plus we had the added joy, as you can see from the picture, of all of the colors of the leaves everywhere you looked. All of the trees just danced in the sunlight. It was such a nice day that the usually sad task of taking my sailboat out of the water was a joy.
We were not the only people at the boat landing. I motored the boat from its mooring over to the landing while my wife pulled the boat trailer over to meet me. As she exited our drive to head to the landing, an SUV full of older people pulled next to her and the driver asked in a heavy accent if there was a public access to the lake down our road. Her answer was, “No, but I am headed to the public landing and you can follow me.”
I had not known of that first interaction. What I saw when I arrived was two late middle aged couples with big cameras climbing out of a rented SUV. It was not a site that I expected. They began to take pictures of the lake and the foliage as they chattered back and forth between themselves in excited tones in some language that I did not recognize. All the while I was struggling with the boat. My trailer is old and I use it only to carry the boat to and from the landing in the spring and in the fall. I was surprised when the oldest appearing man in the group asked me in perfect English, but with a distinct accent, if they could help me.
The men and I quickly got the boat aligned on the trailer. That was when the spokesman asked if he could take pictures of our car. My wife has collected quite a few stickers that decorate the tailgate of our vehicle and give anyone who bothers to look a definitive statement about our political affiliations.
The bumper stickers produced a conversation. The visitors were from Haifa and had come to New England from Israel on a two week trip to see the foliage. I was relieved that they seemed much more interested in the beauty of our region than the nature of our politics and began to point out where they might see our loons, or perhaps if they were lucky, get a glimpse of the eagle which can often be seen managing his world from a tall tree on the tip of Stanley Point. It occurred to me that we were as much connected by our shared vulnerability to the outcome of the current political process as we were by our common love of the beauty around us. |
| Be well, take care of yourself, stay in touch, and don’t let anything keep you from making the choice to do the good that you can do every day,
Gene
Dr. Gene Lindsey
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