23 December 2016

Dear Interested Reader,

About This Letter and the Continuing Response to the Election

The core of last week’s letter was a consideration of what might be a constructive response to the election of Donald Trump as president. The main section of the letter was precipitated by Dan Burnes’ call to me about developing a defense to the threat that Donald Trump’s promise to repeal and replace the ACA posed for all that has been accomplished over the last quarter century of focus on quality and the more recent focus on the Triple Aim. The letter elicited a few comments from readers asking for more specifics about what a concerned person might do.

When I edited the letter for publication on the stategyhealthcare.com website on Tuesday under the heading “Where Do We Go From Here”, I included two new links. The first link was to a white paper published by a group of former congressional aides suggesting responsible ways to organize to oppose the agenda of Trump’s administration. Ironically, their paper, “Indivisible: A Practical Guide For Resisting the Trump Agenda” was based on their observations of the effective organization of the “Tea Party” opposition to President Obama.

The second link was a connection to an article from John Cassidy writing for The New Yorker suggesting nine points for action. The article, “Nine Ways To Oppose Donald Trump” produced many of the same suggestions that the longer form paper from the congressional aides had made and both were highly aligned with the thoughts that Dan and I had come up with in our conversation that had been reported to you in the Friday letter. I liked the Cassidy article so much that I posted it on Facebook. I was not prepared for the response that ensued, but I still liked the article. My Facebook friends list includes many “friends” from high school days in Texas and South Carolina. Some of those folks voted for the President Elect and thought my posting was “divisive.”

Since last week’s letter I have also discovered that the Boston Globe’s online medical journal Stat is now publishing a daily Trump in Thirty Seconds: Science and medicine in flux. You might want to sign up. Stat is informative and focuses on a range of interested readers from clinicians to administrators, to big pharma, medical scientists and investors in healthcare. All of these segments of the healthcare sphere have reasons to be apprehensive about the future under an unpredictable administration that says that it wants to take the country in a different way.

There are two essays in this letter. The first is an attempt to connect the opioid overdose epidemic to an overall discussion of the social determinants of health and the challenges to the Quadruple Aim:

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.

The second “article” is an overdue review by me of the historically negative role of the AMA. I should introduce it to you with the admission that I am not an AMA member. I have always disagreed with their positions. I have been a member of the Massachusetts Medical Society during the later part of my career when we enrolled all of the physicians of Atrius Health in the Mass Medical Society. During that period of time I may have been automatically enrolled in the AMA, but I never chose to be one of their number. I am proud of the fact that I have tried to avoid the AMA because once again the AMA is on the wrong side of history. I am pleased that there may now be an alternative organization that you should hear about.

Next week’s letter will be both a look back at a year many of us found to be very trying and an attempt to continue to be hopeful about what might be possible for the Quadruple Aim in 2017!

The Opioid Overdose Epidemic Gets Close To Home

This week’s New England Journal of Medicine has a “Perspective” article entitled “Ending the Opioid Epidemic--A Call to Action” by Dr. Vivek Murthy, our surgeon general. It occurs to me that Dr. Murthy would have made an excellent choice to be CMS administrator or Secretary of Health and Human Services had Hillary Clinton been elected.

The role of Surgeon General sounds immense, but it is likely that the average American and many healthcare professionals do not really have much of a feel for the responsibilities of the job. In essence the Surgeon General heads up the uniformed US Public Health Service which has about 6500 employees and periodically issues warnings of dangers to the public’s health as was done in 1966 for smoking and in 1980 for alcohol. The Surgeon General is appointed by the President and confirmed by the Senate.

If you read Dr. Murthy’s piece, and you should, you will get a thorough review of the problem we face. Perhaps it is the public health issue that triggers the most intense sense of dread. This last year the Zika threat got a lot of attention, as did the Ebola scare two years ago, but both those issues were avoidable for most of us and our families. The threat of opioids seems to loom for all of us, or at least for someone we know, no matter who we are or where we live. We are startled when entertainment personalities like Prince or Philip Seymour Hoffman succumb to this disease. It is easy to respond with confused comments like, “What a waste!” One of my sons, a Prince fan, said that most people did not realized that he was not as young as he once was, and was in great pain whenever he performed. He had already had a total hip replacement.

Dr. Murthy’s article notes the role of chronic disease and chronic pain in the life cycle of suffering that culminates in opioid dependency and death. It is easy for us to fall back on a concept of opioid addiction being the outcome of a “sinful” fascination with “getting high” and an attraction to dark behaviors, but that is not the story behind the epidemic and the pictures of the victims that you can see and read about in almost every edition of your daily paper if you look closely.

I read the “Remembrances” in the Globe most days before I read the sports pages. The opioid deaths are easy to pick out. Sometimes the family is straightforward and just says that he/she lost their heroic struggle with addiction, and then there is the request that a donation to an appropriate halfway house or program to be made in lieu of flowers. Most of the time you just read of a person who died unexpectedly in their twenties or thirties. One day last week there were three such notices between the last names beginning with “S” and “W”.

All of those notices were disturbing but were abstract and about members of other families until the phone rang early last Saturday morning. My second oldest son, who is a social worker in Albuquerque, was calling to say that his cousin in South Carolina, the son of his mother’s brother, a twenty eight year old father of a two year old daughter, was found dead in bed. The young man, who had been working hard to get his life in order, had overdosed on opiates given to him by a coworker to try for his severe back pain. We had long known that this young man was struggling to find his way, and recently it had seemed like progress was being made.

Over the years my son had tried to help his cousin. He had helped him come to Boston for visits and had made special trips to see him in South Carolina as attempts to try to help him. The young man had been to see therapists, and he had had some difficulties with the authorities. His life was troubled, but he had loving parents and a family that tried to help but could not overcome the threat he faced. I did not know him well given my limited connection to that part of my older two son’s family over the last thirty five years, but I was aware of the concerns about this troubled young man when I last saw him ten years ago at my son’s wedding. The obituaries of the more than 600 people who die every week of their overdoses are a constant reminder of one of the greatest failures of our society, and of the public health threat to every family that is much greater than Zika or Ebola will probably ever be.

What is most upsetting to me is that practicing physicians are the origin of the problem for many who die. I do not know if I ever contributed to the death of someone with an ill advised prescription for an opioid, but collectively we are all part of the problem. In the eighties and nineties we started writing a lot of prescriptions for those with chronic pain. We had been told that we were leaving many people in pain that they did not deserve because we were being “puritanical” in the application of our personal biases and values, or our lack of empathy. Appropriately, the pendulum has now swung again. This time the movement is toward the application of systems thinking to the use of opioids. The greatest value of Dr. Murthy’s article is in the large graphic presentation of a logical approach to proper practice when prescribing opioids for chronic pain. Maybe you already follow similar guidelines.

We rolled out a such a program when I was CEO of Atrius Health. The program stresses managing by a process grounded in data. It may not be something that a physician who cherishes “clinical autonomy” or believes in avoiding “cookbook” care will like. I would argue that clinicians who are at the peak of their artful ability to manage patients will be challenged as they try to successfully follow the program in the face of the demands that patients bring them when either seeking relief from pain or requesting prescriptions to feed their established problems.

Drew Altman, the President and CEO of the Kaiser Family Foundation, has published a terrific blog post in the Wall Street Journal this week entitled “Understanding Who Opioid Users Are Underscores Challenges.” Reading this article as a companion article to Dr. Murthy’s article is a fortuitous opportunity. The Altman post is full of information that underlines the reality that as practicing physicians we are part of the problem and must be part of the solution. Our dilemma is to manage chronic pain without fueling the supply of opiates that foster the epidemic.

There is also no doubt that there are “social determinants of health” at play in the origin of this epidemic. The “war on drugs” begun by President Nixon for political reasons has been a forty five year effort that has filled jails but has not solved the problem. It has aggravated, not relieved the social determinants of the disease of addiction. Our efforts to help the victims of drug use will also be unsuccessful unless we focus on those persistent problems in our society that contribute to frustration and waste human potential. Those social issues must be addressed if we are ever to end this nightmare of unnecessary deaths. All of the problems of poverty and untreated mental illness and addiction are vulnerable to the funding of government sponsored programs. Dr. Murthy points out that we are still waiting to see how the new administration and Congress will respond to these challenges.

I do not know what stance and programs that a Trump administration that is intent upon reducing entitlement spending and wants to “privatize” everything from education to healthcare will propose as a response to the growing concerns this problem has created. Both Dr. Murthy and Dr. Altman comment on the reality that the problem is vulnerable to political issues in “red states” and that it would be a disaster for the fight against the opioid epidemic if 20 million people were to lose their access to healthcare.

It is easy to talk about “repeal and replace.” It will also be easy to measure the impact of the efforts of those who follow Dr. Murthy and the programs that follow “Obamacare.” No matter what comes from Washington, I hope that most physicians will accept Dr. Murthy’s challenge and also be mindful of the realities that Dr. Altman stresses. This is a problem we should own. This is a problem we must solve.

The AMA: Must It Always Be On the Wrong Side of History?

I was not at all surprised to read the AMA’s strong statement of support for the appointment of Representative Tom Price to be the Secretary of Health and Human Services. I was also not surprised to read articles of outrage from more progressive physicians about the AMA’s endorsement of Representative Price. I have found that uniformly the AMA’s natural position on most political issues is usually the inverse of mine. President Obama was successful in negotiating for the AMA’s weak approval of the ACA before it was passed but have they been enthusiastic supporters of it? An article, “Why the AMA Endorses Obamacare—But Your Doctor Does Not” from 2012 outlines the diminished influence of the AMA over the last few decades. The AMA has equivocated before in its attempts to play both ends to the middle, and so it was with its endorsement of the proposal that Price be the nominee.

The reaction to the AMA’s endorsement on November 29 was swift. By December 1, just two days later, more than 4800 physicians had signed a petition expressing their anger at the endorsement. Becker’s reported on the petition:

"We believe that in issuing this statement of support for Dr. Price, the AMA has reneged on a fundamental pledge that we as physicians have taken  —  to protect and advance care for our patients," the letter reads. It is unclear from the letter if the physicians are AMA members or not. The organization has roughly 250,000 members, according to an AMA spokesman. The letter claims the organization represents about a quarter of U.S. physicians.

Whether the signatories were AMA or not, on the same day that impressive response became news, the AMA was backtracking and explaining their reasoning on their Facebook page.

We've been listening to the feedback from physicians and medical students in recent days -- and we would like to share additional context regarding our statement on Dr. Price's nomination for HHS Secretary.

First and foremost, we want to make one thing clear: regardless of administration or Cabinet, the AMA remains devoted to improving health insurance coverage so that patients receive timely, high-quality care, preventive services and other necessary medical treatments.

Our history with Dr. Price includes many instances of productive dialogue on topics where our policies and his are in sync, and also on topics where we differ fervently. Our support of Dr. Price is not support for his every policy position. But we do strongly support having a capable, knowledgeable physician in this leadership position. We must be realistic; the election is now over, and as happens in every election, one candidate won and now must choose his Cabinet. And as a non-partisan organization, the AMA has an obligation to work with the incoming administration and strive to find common ground.

That sounds terrific, but what are Dr. Tom Price’s positions that have so many of us upset? Probably one of the best and most readable discussions of what Tom Price’s stated opinions are and what he has done in the past can be understood in a well written article that appeared in the Atlantic on the same day that he was endorsed by the AMA. What is chilling in the article is the description of the influence that the HHS Secretary has over how the ACA works. How the public experiences the law can be substantially changed by the administrative powers of the the Secretary without any action by Congress or the President.

The diminished influence of the AMA and its historical lack of recognizing what is best for the country and patients in general is nothing new. As far back as a hundred years ago the AMA was fighting universal healthcare. The AMA was a huge critic of Roosevelt’s Social Security Act until universal healthcare for the elderly was removed. David Blumenthal and James Marone in their terrific book, The Heart of Power: Health and Politics in the Oval Office, tell the fascinating story of how Harvey Cushing, famous neurosurgeon and influential AMA member, convinced Franklin Roosevelt not to include healthcare. Cushing’s daughter was married to Roosevelt’s son and they shared grandchildren and many social occasions that gave Cushing access to Roosevelt.

When Harry Truman tried to introduce a single payer program the AMA was there to kill it. Twenty years later they fought the introduction of Medicare and Medicaid, and for the first time they did not get their way. I chuckle every now and then when I think where the practices of most physicians would be without Medicare. Even Medicaid has been a sustaining source of income for many and for many of the nation’s hospitals. The AMA’s attempt at self serving the interests of physicians is so upside down and backwards that a good rule of thumb could be if the AMA is against something, we should all be for it, and if the AMA is for something you better try to figure out what is wrong! I think that the last statement applies to their endorsement of Representative Price.

One encouraging outcome of this latest clumsy move by the AMA is the possibility of a new physician organization that is more aligned with the principles of the Quadruple Aim. The Clinician Action Network was the sponsor of the petition. You can still sign their petition. I first learned about the three young physicians who started it all in an article on the Doximity Website.

They may just be the origin of the movement that I was calling for last week.

...It is preposterous perhaps to imagine, but those who see value in what has been accomplished need to come together in an all out coordinated effort to preserve and improve, not repeal and replace, the ACA.

History demonstrates the path for success for unlikely processes of change can sometimes lead to surprising successes. John Kotter teaches that foundational to effective change is the formation of a guiding coalition. Actually, the first step is to have a cause, but the first action is to form a large volunteer army from up, down and across the organization (or the nation) to serve as the change engine.

Could the Clinician Action Network be the group that leads the way? They seem to be off to a good start. 5000 physicians sounds like a lot of doctors until you realize that there are over 900,000 in the country. The AMA claims to have about 250,000 or a little more than 25% of all doctors in its support. We need to learn more, but I am sure that the more we learn the more we will realize that once again, as been true so many times before in history, the AMA is on the wrong side of history when it comes to the big issues that make a difference.

Walking With My Little Buddy

It’s been a pretty good week for walking, although a few days have been mighty cold and then it was icey after the warm rain over the weekend. I love the scenes that I see around the lake in the late afternoon light. There are many places where the road is a just a few feet from the ice of the lake. The little cove in the header picture this week is a great place to catch a big bass in the summer. It looked very cold and gloomy in a way that challenged my mood, but still had an eerie beauty in the twilight of a very cold afternoon. I thought that I would share it with you.

This is a great week for grandparents. I am expecting to see both of my grandchildren this week. My oldest grandchild, Cami, aged fourteen, will show up with her parents late on Christmas night. They will arrive after spending a few days and Christmas morning in Lynchburg, Virginia with her other grandfather. I hope to take her over to the gym at Colby-Sawyer College and watch her hit a few jump shots. She is a high scoring forward on her undefeated (10-0) Ransom-Everglades Junior High basketball team when she is at home in Coconut Grove, Florida. I can hardly wait to hear the net “swish”. Thanks to the iPhone, I have seen her her hit that shot on video, but I want to see it for real.

One person who is also waiting to see her is little Harold Lindsey, age 29 months. Harold and his parents arrived from Santa Cruz, California on Tuesday. “Hawold”, as he refers to himself, is a walker and a talker. He is a perpetual motion machine. He can give a complete list of all the people that he is expecting to see over the next few days. We have already visited all the cows within a half mile radius of my house. We are still looking for pigs. He likes to walk with my one of high tech walking staffs, normally reserved for uneven terrain on woodland trails or mountain sides, shortened down to his size. He calls it his “lightsaber” and intermittently challenges me to be “Dark Vader” and cross sabers with “Luke” in short jousts. He has never seen the movies but he has the books.

Harold likes “outdoors”. “Outdoors” was one of his first words. A request to go out can be polite as in “Outdoors?” or can be emphatic as “Outdoors!”. Snow is a new experience for Harold. He likes to poke his “lightsaber” into snowbanks, but mostly Harold likes looking around on walks and commenting on what he sees and where he’s been. He is fascinated by a branch that a recent storm has left suspended from electrical wires that cross over our road. I am sort of wondering what will happen to that branch also.

Harold has told me about his airplane trip. He came on the red eye from San Jose to Boston. On Wednesday as we were walking up the road to check out a barn and see a horse and several cows he informed me that he had been a baby, but he is now a boy, and is expecting in time to be a man. Harold is right. Things do move on. It is amazing to see how much vocabulary he has acquired since I last saw him in California three months ago. Harold is not expressing any concern about the world he will inherit, but Cami’s dad has told me that she is very upset about the mess she is inheriting. She was upset for several days after the election. She plans to use her vote in 2020 to begin to plot a course toward a better world for herself and Harold. At the moment she plans to be a physician. She usually does whatever she says she is going to do. I am looking forward to her med school graduation in 2028 or 2029.

I hope that your holidays will be terrific. I know for sure that a walk with those you love will be a great way to savor a good end to a tough 2016 and get in the mood for a much better 2017.