23 March 2018

Dear Interested Readers,


Hope versus Fear and The Messages of Martin Buber and Desmond Tutu: Community versus Conventional Wisdom and Self

President Trump came to my little state this week to articulate his plans to address the opioid crisis. It was another opportunity for him to use fear to co opt a serious problem for political benefit. I cringed as I heard him snarl that we should execute drug dealers as they do in places like China, Singapore, and The Philippines. I hope that you will read the op ed written by Scott Lehigh and published on Wednesday in the Boston Globe. The piece is entitled “Transparent Trumpery.” Lehigh begins with dark humor, “Careful, more-than-once-burned-twice-shy former Trumpsters:The Great Trumpkin is trying to dog whistle you back home. Lehigh implies that like all the talk about “the wall,” like all the tirades against illegals who prey on law abiding citizens, the tough talk about the opioid crisis is a call to his base that reinforces his stance with the far right of white supremacy.

The speech suggested that poor little New Hampshire is victim to all of the illegal Hispanics and criminals from other minorities who hide out in Boston, Lawrence and other “sanctuary cities" in Massachusetts just below the border where they are protected and then run their death dealing business across the stateline into New Hampshire where it’s about time for him to start getting ready for the 2020 election. A side benefit to singing and shouting about stringing up drug dealers is that it is a distraction from other more uncomfortable topics like the ongoing investigation of Robert Mueller and the efforts of women to get the courts to set aside non disclosure agreements so that they can describe his behavior with them.

I see little benefit in trying to produce an in depth examination of how shameful the president’s New Hampshire speech was other than to use his oft repeated Twitter comment, “...SAD.” Another reason that I do not need to expend much effort analyzing the speech is that the world’s most effect purveyor of “fake news,” The New York Times, has done a much better job analyzing the speech than I could ever do with an editorial that they wrote this week, “Trump’s Bluster on the Opioid Epidemic.” I will copy and paste for you some of their pithier points.

President Trump has declared that his administration is getting serious about the opioid epidemic several times since taking office. But he has repeatedly failed to offer a substantive plan — and he has floated at least a few truly absurd ideas. He did it again this week.

Mr. Trump gave a rambling speech on opioids on Monday in which he offered few details about how he would increase access to substance abuse treatment and prevention to help the millions of Americans suffering from this disease. Some 64,000 people in the United States died of drug overdoses in 2016, including 481 in New Hampshire, one of the hardest hit states in the country, where Mr. Trump gave his speech.

That sets the stage. You should check out some of the links. They followed with a good review of the ridiculous idea of executing drug dealers and Trump’s use of the moment to sound off once again about why we need a “wall.” Their summary of the president’s ideas was succinct.

It was Mr. Trump playing his greatest “law and order” hits — as usual, full of sound and fury but signifying nothing.

They did offer some opposing arguments.

But we do have convincing evidence that ratcheting up the war on drugs, as Mr. Trump and his attorney general, Jeff Sessions, want to do, would not work. Since the early 1980s, the federal government and states have imposed increasingly harsh criminal penalties on drug dealers and users. Not only did they fail to stem drug use or the availability of illicit substances, but they may have contributed to their spread by taking resources away from treatment and prevention efforts. It is no wonder, then, that the per-gram retail price of heroin fell by about 85 percent between 1981 and 2012, according to a report published in 2016 by the White House Office of National Drug Control Policy.

They concluded their piece with an attempt to be balanced and cautiously positive.

Mr. Trump’s New Hampshire speech did contain a few good ideas — but only a few. He said that the administration would seek to reduce opioid prescriptions and expand access to medication-assisted treatment for those suffering from addiction. Experts, including a commission appointed by Mr. Trump last year, identified these and other solutions months ago, but the administration has taken little action and provided few details about how it would carry out these ideas.

There are a number of other good ideas that Mr. Trump and his team have done little to advance, like getting health insurance companies to cover mental health and substance abuse treatments as well as they cover other medical treatments, something required by federal law. He could also encourage 18 states that have not expanded Medicaid under the Affordable Care Act to do so. This would make addiction treatment available to millions of additional people. Not only has he not sought to expand that program, but Mr. Trump and Republicans in Congress have proposed deep cuts to Medicaid, which covers about 38 percent of people with an opioid addiction, according to the Kaiser Family Foundation.

In summary, given our prior experience, the serious nature of the challenge, and the multiple social and economic realities that contribute to the cause of the problem, let me offer an incomplete set of ideas:

• Forget death penalties and “lock em up, keep out” strategies.
  
• Approach the problem as a public health issue arising from many different but related problems.
  
• Attack the problem at many levels. Work to understand and improve the root causes. Use education and alternatives to opioids as therapeutic approaches to effectively manage chronic pain and anxiety to prevent “new cases” from arising from misuse of meds.
  
• Expand the resources available for research, prevention, and treatment.
  
• Make adequate and effective treatment universally available by expanding and adequately funding Medicaid and enforcing commercial coverage requirements as recommended in the New York Times editorial.
  
• Offer the country the hope that we can do better if we all engage in the problem as we have done in the past with public health issues like AIDS and polio.
  
• Offer leadership that draws us together as a community facing a common challenge that we have the collective resources to meet.
  

As I was pondering the president’s speech and trying hard to control the anger that it induced in me, I took a walk. While walking I was listening to Ezra Klein’s podcast of a recent conversation with Jaron Lanier, one of the pioneers of virtual reality and the author of several books on the interaction between humans and technology. Klein always ends his interview with the same question, “Name three books that have influenced you.” Lanier struggled with the question. His first choice was James Carse’s Finite and Infinite Games: A Vision of Life as Play and Possibility. It took Lanier several minutes of conversation to produce two more titles. I was very surprised by his second choice which really made a lot of sense in the context of what he had been saying over the last 90 minutes. His second recommendation was Martin Buber’s I and Thou.

That comment hit me as the doorway to the consideration of basics of alternative approaches to so many of our current issues, including opioids and the other social concerns behind the deep divides that test us these days. When I think about Buber and I and Thou I almost immediately think of Desmond Tutu and his focus on “Ubuntu” philosophy. In a book I have not read Tutu describes Ubuntu philosophy [the bolding is my addition]:

“Ubuntu [...] speaks of the very essence of being human. [We] say [...] "Hey, so-and-so has ubuntu." Then you are generous, you are hospitable, you are friendly and caring and compassionate. You share what you have. It is to say, "My humanity is caught up, is inextricably bound up, in yours." We belong in a bundle of life. We say, "A person is a person through other persons."

[...] A person with ubuntu is open and available to others, affirming of others, does not feel threatened that others are able and good, for he or she has a proper self-assurance that comes from knowing that he or she belongs in a greater whole and is diminished when others are humiliated or diminished, when others are tortured or oppressed, or treated as if they were less than who they are.”

The concept is briefly explained as “I am because we are.” Buber’s “I and Thou” also describes equal and reciprocal relationships that create community. Treating people as objects or problems is inconsistent with both philosophical constructs. Buber's ideas were often spiritual but he resisted being classified as a theologian. In later life he was a Professor of Sociology at Hebrew University. He was more interested in the “here and now” than the here after and was an advocate for the good that happens when people move from thinking about others as objects, threats, or “means” and see those with whom they live in community as fully franchised and equal participants in a conversation about the moment.

I heard no “Ubuntu” and no “I and Thou” in the president’s comments about the opioid epidemic despite the fact that he played with our emotions by introducing the parents of a young man who died from an overdose of fentanyl. When fear, threats of force, and references to things that are meant to scare us are at the root of strategies to solve complex problems, I fear that we will only see the problem get worse or be replaced by an even greater problem. When we start executing drug dealers rather than looking for ways to treat everyone damaged by the epidemic we are ignoring that addiction is a medical problem that is often precipitated by poor medical management of pain. Imagining the opioid epidemic as a problem rooted more in the physiology and neurochemistry of afflicted individuals is much more likely to be effective than stigmatizing it as a lack of character. Trying to solve all complex problems by eliminating the afflicted and other outsiders who can be scapegoated as the source of our annoyance and inconvenience will always satisfy some, but rarely is such action justice and rarely does it lead to effective solutions to the problems that frustrate us. All of the countries that Trump alluded to that manage their drug problems with executions are variations on “authoritarian” states. Human rights are inconvenient to public policy in those societies.

Whether you call it “Ubuntu,” or if you prefer to focus on seeing the humanity in others as “I and Thou,” in the original German of Buber, “Ich und Du” where “du” is the intimate “you” that is used for family, friends, and love interests, the core ideas are similar and represent more than a “mindset.” They are concepts that are foundational to the ideals that are necessary for any society that seeks to offer universal freedom and opportunity to all of its citizens. These ideas and ideals transcend our politics, or rather must exist if we are to practice the politics of a true democracy. The ideas subsumed by “ubuntu” and “I and Thou” are totally inconsistent with deciding “who is in” and “who is out.” They are also totally consistent with the principles and instincts that drive most healthcare professionals to offer their skills to anyone who needs them and make us collectively interested in being sure that we do everything we can to insure that those who need us can see us.

The essential parts of last week’s letter are waiting for you on the strategyhealthcare website. I hope that you will check it out and recommend it, as well as these letters to your friends and colleagues whether or not they work in healthcare. I hope that you will read both the letters and the blog postings as my attempt to be in community with you, Ich und Du. To that end, I hope that the feeling you have when you read what I have written is one of someone sharing what he thinks and feels with another person whose opinion is respected and valued. I would hate for you to think of me as some old guy “telling” you what he thinks you should think or feel. I am very interested in know what you are thinking and feeling, and I am always delighted when someone takes the time to share their point of view with me.


Why Does Healthcare Cost So Much?

About 10 days ago JAMA published an interesting study that has not gotten as much attention or debate as it perhaps deserves. It is my hope that its impact will grow and that the insight that it offers will make a difference. The article “Health care spending in the United States and other high-income countries” can only be read as an abstract unless you are a JAMA subscriber, but several trade publications and Time magazine’s health postings do give us the sense of the findings. I don’t think this is “fake news.” I have had the honor of meeting one of the authors, Dr. Ashish Jha of the Harvard T.H. Chan School of Public Health, and I trust his scholarship. As Time writes:

A group of researchers compared data from the U.S. and 10 other high-income countries: the United Kingdom, Canada, Germany, Australia, Japan, Sweden, France, the Netherlands, Switzerland and Denmark. They found that spending in the U.S. far outpaces that in other nations. Health care accounts for almost 18% of the U.S.’s GDP, compared to 9.6% to 12.4% in the other developed countries, the paper says.

These findings are not really at variance with much of the conversation in the literature for the last several years, despite the fact that at first glance the part about there being no relative underinvestment in social services to explain the difference between the experience in America versus other developed countries. I am not interested in arguing with the findings. I think the findings are disturbing, should have been obvious to us for a long time, and suggest that the path to the Triple Aim, especially the part about delivering care at a sustainable cost, is going to be even harder than we had allowed ourselves to consider.

Let us not get confused. This study does not suggest that we should not expect a return on investment when we try to improve the social determinants of health. It does not suggest that attempting to reduce “overuse” and “misuse” with the “Choosing Wisely” campaign is a bad idea. The study subtracts nothing from the need to focus on continuous improvement or the shift from “volume to value.” The point of the paper is that an examination of the total cost of care reveals that our care costs more because each unit of care costs more and not because we practice in a radically different way. Our medical professionals earn more than people doing the same work in other countries. Our pharmaceuticals are not overused compared to other countries. Although other countries may overuse meds the same way we do but they pay half of the price we pay for the drugs they use. Our administrative costs are much higher. In every component of the total cost of care we pay more and get a little less.

The problem is greater than just a problem of price. It is also a problem of value. In most markets you expect that if you pay a premium you get a better product, but if we are paying more and getting less as measured by poor outcomes we are really getting “gypped.” I hate paying more for less. Did you ever have a conversation with a person in an adjoining seat in an airplane and were surprised to discover that you were paying twice as much as they were to get to the same destination? What makes that even worse is that you are sitting in the middle set and they have the convenience of the aisle. What the authors describe is even worse. We are paying more and not arriving at the same place. The problem is further compounded by the sad fact that even though we are spending 18% of our GDP on healthcare which is twice as much compared to the other countries studied, all of their citizens get to ride, but 10% of our citizens never even got on the airplane. They have no “ticket to ride.”

The authors asked a straightforward question, “Why is health care spending in the United States so much greater than in other high-income countries? The authors suggest that the meaning of their study is no more than: Efforts targeting utilization alone are unlikely to reduce the growth in health care spending in the United States; a more concerted effort to reduce prices and administrative costs is likely needed.

For me one of the most jaw dropping moments I can remember in all the healthcare meetings I ever attended was when I listened to Don Berwick give his keynote address at the annual IHI meeting where he described “Era 3.” I was right with him step for step as he lead us “up the mountain” of progress in healthcare complete with a description of all of our wrong turns and dead end trials from which we had to backtrack. I almost fell of the mountain when he got to his ninth and final step, “Reject Greed.” I heard a collective guttural “ugh” as six thousand people suggested through their simultaneous spontaneous visceral response that he was asking too much. Why would anyone accept less or even ask for less than they can justify by pointing to “market data?”

When I was the Chairman of the Physicians’ Council at Harvard Community Health Plan I knew that I could get 400 physicians to give up an evening at home if I told them the meeting was about compensation. I am no fool. All of our meetings were advertised as “compensation” meetings even if we added other subjects of less general interest like our quality strategy to the agenda. Across the country hospitals are merging for market leverage that will protect, if not allow them to increase their price. Big Pharma keeps running their ads with smiling patients as the voice over describes all the contraindications and potential complications that they must reveal as they ask you to ask your doctor why you have not been prescribed their product that will transform your life while it empties your purse. The greed in the business of medicine knows no shame and Dr. Jha and coauthors have documented that American medicine gets the gold medal. We are “the that which there is no more than…”

I am at a loss to say what we should do in response to the findings. Perhaps we should listen again to what Don Berwick said, but I doubt that will happen. What happens in other industries that are overpriced? I had patients who were attorneys whose firms failed and their incomes plummeted. I had architects as patients whose incomes fell precipitously during economic downturns when new construction stalled. The world changes for other businesses, but I am unaware of any time that we have ever had an industry wide resetting of the pricing structure in healthcare. Pigs will fly before that will happen.

I am usually a pretty positive and hopeful individual. Nevertheless, I see no way that Big Pharma will ever reduce its price for anything short of the government nationalizing the industry, and I am not being facetious. One of the biggest failures of our government was the passage of Part D of Medicare which does precious little for many patients at a huge expense to all of us. Passage was only possible because the government gave up the possibility under pressure from Pharma’s lobbyist of using the purchasing power of over 60 million Medicare customers to negotiate lower prices with Big Pharma. From Pharma’s point of view the political contributions they made to do the job were farthings on the dollar of return for the riches they gleaned from part D. It was a great investment for them to make. Part D passed as a “welfare program” for their industry.

The JAMA article should encourage many readers to buy and read Elisabeth Rosenthal’s An American Sickness: How Healthcare Became Big Business and How You Can Take It Back which is now out in paperback. I read the book with the expectation that the last part of the title inferred that she would offer answers that would enable us to lower the cost of care. She did not. At her best she described some personal strategies for individual consumers that fall under the rubric of how to save yourself while the ship is sinking. Unfortunately Dr. Jha and colleagues also fail to offer a plausible solution to the price problem.

I rarely end a subject on a down note. The best I can do is to suggest that we strive to “red line” prices and continue our efforts to eliminate overuse and misuse of medical resources as we redouble our efforts to practice continuous improvement and improve systems engineering to eliminate waste in both practice and administration. Prices times units of service determine cost in a fee for service economy. The other option is that value based reimbursement or a straight up return to capitation offers some hope, but all of the mechanisms I have seen so far translate into very little initial reduction in revenue for individuals or institutions which really means the price stays the same as the payment mechanism changes. I am disappointed to say that I see very little will on the frontlines of the majority of healthcare providers and institutions to act on the findings of this study. I hope that I will be proven to be wrong.


At The Bleak End of Winter There Is a Chance to Make a Difference

Perhaps you have thought that I was a little daft with all my celebrations of winter in recent weeks. I do like winter. The 19th century English carol, “In the Bleak Midwinter” is hauntingly beautiful and inspires me to want to get out into the elements. What I do not like is the bleak end of winter, although I know we must pass through “mud season” to get to the joys of spring, summer, and fall. I was taunted all week by the weather reports about a fourth nor’easter that was supposed to turn Wednesday evening into a commuter’s disaster. I was scheduled to be at an afternoon board meeting of the Boston University Medical Group on the campus of the Boston Medical Center and begged off and “attended by phone” for fear of finding myself in a snowy parking lot on I 93 going north after the meeting. The minute that I requested the opportunity to attend two and a half hours of meeting on the phone I felt guilty. The guilt only got worse as the brunt of the storm came late in Boston and never arrived up where I live.

The picture in the header for today’s letter shows plenty of snow. I took the picture to show what is left of the huge woodpile that a group of us created last summer and fall as a resource for the poorer members of our community who are dependent on firewood to get through the “bleak midwinter.” When a call comes in volunteers are recruited by my friend Steve to help him “make a delivery.” I learn something about my community and the people who live here every time I go on a delivery. It is also good exercise. There is no paperwork and no charge, although Steve keeps a list of clients. Firewood sells for $275 to $350 a cord in our market. An amazing number of people heat with wood plus or minus space heaters. The story is often that they once used propane or oil but the furnace is now not working and they can’t afford to repair it or replace it. The downside of leaving wood out in the open on a farm is that after it snows we must plow out the road to get to it and then dig the wood out of the snow before we can load it into a truck for delivery.

Despite the fact that our woodpiles have shrunk a lot since they were neat stacks last fall, Steve estimates that there is still enough wood left under the snow to allow us to continue deliveries as long as winter lasts and our clients call. I hope that he is right. Because the piles are getting smaller it’s time for me to stop praying for more snow and start praying for the strength to get through mud season.

Another reason that I am happy that the storm went out to sea is that I know that tomorrow, Saturday March 24, young people all over the country will be leading as many of us follow them and support them as they express their feelings about guns in our society, and as they demand that their schools become free of gun violence. My wife and I will be joining the students from our town as we travel to Concord where concerned citizens are gathering from around our state to have their voices heard. We will be showing solidarity with the “March for Our Lives” rally in Washington organized by the students from Marjory Stoneman Douglas High School in Parkland, Florida who have been so articulate about the tragedy at their school. Wherever you are and whatever you are doing this weekend I hope that you will be in community with others practicing ubuntu.