25 August 2017

Dear Interested Readers,

What’s Inside Plus This Week in Washington and Some Comments About Poverty and Homelessness

Last week’s letter asked a question, “Are Consolidation, Competition, and Innovation the Answer?” As I began to write, I quickly recognized that the answer to the question about the “answer” would require at least five separate letters. I elected to begin by taking a look back fifty two years to a time that seems very similar to this moment and the pronouncement by Robert Ebert that:

“The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.”

That statement is still true. It is a good news/ bad news dichotomy. The good news is that we do not need to spend more to realize the Triple Aim. The bad news is that we have not yet overcome the barriers that have flummoxed us and prevented our success for over 52 years. Given what I hope will be an attempt to begin a bipartisan search for answers, I felt that it was appropriate to start the answer to the my question by going back to our earliest efforts to expand care to everyone. So Part 1 of what will probably be a five part series was a look back. If you missed the letter or would like to remind yourself of the high points via a revised version, checkout Tuesday’s “Strategy Healthcare” posting.


This week in “Are Consolidation, Competition, and Innovation the Answer? Part 2: A Closer Look at Innovation,” I will share some of my thoughts about the power of innovation to be the explanation for how we will get a little closer to better care for less money. Improving every individual’s care and the nation’s health at a lower cost through innovation would certainly validate Dr. Ebert’s assertion that our objective is not going to be realized by supplying more personnel, more facilities and more money. Is innovation the whole solution to Ebert’s riddle? Last week I got ahead of myself when I said it was necessary but insufficient. I also said,

I believe in innovation. I believe that organizations without continuous improvement, cultures of learning, and effective programs of innovation will eventually fail.

I hope that this week’s letter will add substance to that assertion, but I will correct myself by modifying the statement to read:

I believe in innovation. I believe that organizations without continuous improvement, cultures of learning, and effective programs of incorporating innovations into their workflows will eventually fail.

Last week’s letter contained a list of barriers to innovation. The barriers range from the obvious to the usually undiscussed, and also include the subtle and unseen. I hope that by the end of the discussion you will be looking for the barriers to innovation in your professional environment and have a bit more courage to address them.

We had a different week in Washington this week. Congress is still on vacation. Events and issues regarding the healthcare of the nation have moved from the tense battle between those who want to repeal and replace the ACA into preparation for a more intermediate discussion about how to shore up the exchanges. The president seems not to have heard the pronouncement of the CBO, which he does not trust, that failing to fund the CSR (Cost Sharing Reductions for insurers in the exchanges) will add to the national debt. Senators Alexander and Murray, the chair and ranking (Democratic) member of the Senate Health, Education, Labor and Pensions committee are planning sessions of testimony. They do seem to understand and trust the CBO and give the appearance of ramping up a bipartisan process beginning with taking testimony from some state insurance commissioners and governors in early September. Senator Alexander is hoping to create legislation that will pay the CSR in the short term and encourage insurers in ways that will stabilize the exchanges for 2018.

Those testimonies would be a good starting point for an attempt at a bipartisan approach to a better healthcare bill that would build on the foundational principles established by the ACA. Through it all I hope that we do not forget the tens of millions of people (11.3 % of the population reported in April 2017) who were never covered by the ACA at any cost. It is clear that many progressive politicians are beginning to consider advocacy for a single payer system as part of their next attempt at higher office.

The real news items in Washington this week do not focus directly on healthcare, but probably will indirectly impact the positive possibilities of what might eventually be done. The president has always had a testy relationship with the majority of Congressional Republicans. McConnell seems to suggest that the hope for Trump’s effectiveness may be doomed. The two, along with Paul Ryan, appear to be headed into open conflict over the debt ceiling with the outcome and its impact on everything including healthcare more uncertain than ever before. The president made a lot of threats at his campaign style event in Arizona this week after trying hard to look presidential in his address to the nation about his policy reversals on Afghanistan.

Many presidents have endured defeats of their healthcare policy offerings. Truman came up short. Nixon got half a loaf. Healthcare was the biggest defeat the Clintons endured, and Obama never got exactly what he wanted. The president is not looking into a mirror and asking the fundamental question required to find solutions to complex problems, “What part of the problem am I?” Blaming John McCain and Mitch McConnell for the failure to repeal and replace Obamacare will not help him keep the government funded, pass tax reform, or enact legislation to improve infrastructure and create jobs. The threat to shut down the government if funding for the border wall that Mexico won’t build is not passed should get the attention of those of us who care about healthcare. It is an irresponsible taunt from a president who doesn’t demonstrate that he understands how to govern, and who is afraid of losing the affection of a base that loves him because he is willing to pander to their darkest ideas, fears, and prejudices.

President Trump was elected by a coalition of people who enthusiastically embraced him as the dark answer to their complaints, fears, and prejudices, joined by many who voted for him because he was “not Hillary.” The opportunities for bipartisan progress on healthcare could be lost as his frenzy increases under stress he may feel as the “not Hillary” vote abandons him. Things could become more out of control if/as Republican members of Congress realize that they may be held accountable for the damage he has done. I shudder as I imagine his descent into further chaos that could occur as he becomes more and more desperate to act on the unrealistic and ill advised promises he made to his base, or if Robert Mueller comes up with something that raises more doubts about his relationship with Putin and Russia.

On a brighter note, let me tell you about a great book! In April I heard on NPR that Harvard sociologist Matthew Desmond had won the 2017 Pulitzer Prize for general nonfiction for his book, Evicted: Poverty and Profit In the American City. I like facts, history, and true stories so over recent years I have observed that I am reading more “narrative nonfiction” and a little less fiction. John McPhee may be the “father” of this genre, and one of the first authors to grab my attention twenty years ago. Malcolm Gladwell, Peter Hessler and Robert Wright have informed and entertained me over the last decade or so with their own variations of the style.

I have long accepted that the dominant reality in the set of social determinants of health was poverty. Coupled with that sad fact, I have long considered the most destructive and misused statement of Jesus to have been:

For ye have the poor with you always, and whensoever ye will ye may do them good: but me ye have not always.
Mark 14:7 King James Version (KJV)

I think some people hear the “poor with you always” part and shrug their shoulders.

I much prefer Matthew 25:40 (KJV)

And the King shall answer and say unto them, Verily I say unto you, Inasmuch as ye have done it unto one of the least of these my brethren, ye have done it unto me.

I fear that Jesus’ suggestion that poverty was an eternal reality, reported in three of the four Gospels, that we will “always having the poor with us,” has often been either a subtle justification for delaying the search for the solutions to poverty, or worse yet has suggested to some that we should not even try. The sense of the interpretation of some seems to be that the poor are a hopeless mess. The derivative thought is that their plight is their own fault. Their suffering is discounted under the formulation that they suffer as they do as the outcome of bad behaviors and poor judgment. I find the concept of seeing that everyone is deserving of our love, respect, and support to be more uplifting and closer to what I see so often in the best moments of care that are offered by the medical professionals that I admire. The beauty of the Triple Aim is in the universality of its goals. The Triple Aim sets its sights beyond the barriers of poverty. It accepts the challenges of the social determinants of health.

There are several great reviews of Desmond’s book that I could offer you but I will give you one paragraph from Jennifer Senior’s New York Times review from February 2016.

The result is an exhaustively researched, vividly realized and, above all, unignorable book — after “Evicted,” it will no longer be possible to have a serious discussion about poverty without having a serious discussion about housing. Like Jonathan Kozol’s “Savage Inequalities,” or Barbara Ehrenreich’s “Nickel and Dimed,” or Michelle Alexander’s “The New Jim Crow,” this sweeping, yearslong project makes us consider inequality and economic justice in ways we previously had not. It’s sure to capture the attention of politicians. (Hillary, what are you reading this summer?) Through data and analysis and storytelling, it issues a call to arms without ever once raising its voice.

To that I will add that I am always amazed by what I really do not understand or how superficially I understand many of the areas where I think I have expertise. This book showed me in very powerful ways just how poverty and homelessness begats many of the seemingly impossible to overcome problems that challenge us on the road to our lofty Triple Aim. An ACA alone or a single payer invitation to all, even enhanced to our most magnificent dreams of universality, will never get us to the goal of better health for all without addressing the tough issues that create and sustain homelessness. It is hard to even discuss, let alone start solving problems that we do not fully understand or lack the courage to address. Desmond’s book is surely not the whole story, but reading it will open your eyes. If we all listened to his story, he could move us just a little closer to the society that border walls and the round up of illegals will never achieve.

The next to last chapter, “Epilogue: Home and Hope” is a magnificent challenge to us all to do better. He presents solutions that work in other countries and could work here. He also asks some disturbing questions, like why do we spent over $170 billion a year on tax credits for those who are affluent enough to own a home as we did in 2008, the year of the study, and about $40 billion to do a poor job providing housing for a fraction of the poor that same year. Many of those dollars spent on the poor actually ended up as a subsidies to landlords who maintained substandard rental units. How can we ever dream of the Triple Aim when the inequities go far beyond access to care? He advocates that adequate housing should be an entitlement for every member of our society. Like healthcare such a change in policy would probably save money from our current costs for programs that do not work. If reading Hillbilly Elegy opened your eyes, Evicted will bring tears to those opened eyes. In the last chapter, “About This Project” we get a clear picture of why Desmond cares so much.

What will be much easier to achieve than a victory over the injustices that support poverty will be a Red Sox return to the World Series. The letter closes with an acceptance of the coming of fall and expectations for the Sox, Patriots and Celtics, as well as my recurrent suggestion that the road ahead will most likely have a gentler slope downward if you do get out and about in the final days of summer.

Are Consolidation, Competition, and Innovation the Answer? Part 2: A Closer Look at Innovation

“The answer to what?”, you might ask. Keeping it simple, I mean the high cost of care. To keep it short I could just say, “Consolidation, competition and innovation will help, but even maximized to the nth degree will never in and of themselves be enough to lower the cost of care to levels enjoyed by the other equally developed nations of the world. They lower their healthcare costs by leveraging a more effective combination of universal coverage and focused investments in social issues like education, housing, and social services. My argument is directed at those politicians and others who would offer simpler solutions and tout innovation and competition as the goals their bills will achieve, and the healthcare executives who claim that they would be more innovative and competitive if they could just expand their reach by mergers that create larger and more effectively consolidated enterprises. I do believe there is a role for consolidation, competition and innovation. All three are necessary but none alone or even all three together is sufficient.

As noted last week, there are many barriers to consider when we think about optimizing innovation within a single enterprise. I am sure that you can add others to this incomplete list which I have already begun to try to revise.

• Satisfaction with the status quo 
  
• Complex systems where one unit can exist comfortably for a while as others suffer
  
• Apprehensions of middle and upper management
  
• Today’s work
  
• Effort versus [immediate] benefit
  
• Matching what can be done with what needs to be done
  
• Funding in an era of external pressures on finance
  
• Incorporating potentially effective innovations into work flows
  
• Aging professionals and emerging workforce shortages
  
• Red ink and the need to cut the budget
  

The major emphasis of this discussion is innovation within organizations, but before going further I should insert the idea that innovation between enterprises may offer us as much or more benefit. I will come back to that idea next week when I discuss what I call “consolidation.” The most beneficial “innovations” may lie at the level of public policy or collective action in local markets, at the state level, or at the level of the federal government. We desperately need new ideas at the federal level that go beyond mechanisms to support value based reimbursement. Under the Obama administration innovation was a high priority that was embodied in the creation of the Center for Medicare and Medicaid Innovation (CMMI). The future of CMMI in the Trump era remains uncertain. Recently CMS announced major changes in the pilots examining bundled payments for orthopedic surgery and cardiac disorders. Gone for a while at least is the sense of possibility that thrilled me when Atrius Health accepted the challenge to be a part of the Pioneer ACO project. ACOs remain a growing potential for innovative cost reduction in an era of potential value based reimbursement that is increasingly embraced by insurers, but do ACOs live under a cloud of uncertainty?

My final introductory comment is an attempt to clarify what I mean by innovation. I learned from colleagues at Simpler who are expert engineers with a vast understanding of the difference between innovation, invention and improvement that an innovation is a totally new presentation that may combine elements of many inventions and improvements, but most characteristically delights customers. We all immediately think of Steve Jobs and the iPhone. Jobs was not an inventor. He led a team that brought other people’s technologies and inventions together in a way that delighted customers who never imagined that their phone could be a personal computer, a health promoter, a way to see people in real time on the other side of the world, a movie camera, a musical instrument, and much much more. Ironically, it seems like most millennials rarely use it as a telephone and will not answer if you try to call them. Finally, as it has been widely copied by others, it is on a trajectory of increasing utility. More about that when we discuss competition. All that said, I am lumping innovations with improvements and inventions for this discussion even though I know that there will be purists who might object. I am also extending the concept of “innovator” to include the early adopters and mimics of innovators. I hope that is not too upsetting. If you review the partial list of barriers once again you will see why I take these freedoms.

For your reading ease here is the list again:

• Satisfaction with the status quo 
  
• Complex systems where one unit can exist comfortably for a while as others suffer
  
• Apprehensions of middle and upper management
  
• Today’s work
  
• Effort versus [immediate] benefit
  
• Matching what can be done with what needs to be done
  
• Funding in an era of external pressures on finance
  
• Incorporating potentially effective innovations into work flows
  
• Aging professionals and emerging workforce shortages
  
• Red ink and the need to cut the budget
  

To use innovation to improve and lower the cost of care within an organization all these barriers and more must be addressed. Even if we remove the intensely expensive process of creating innovations which is far beyond the financial capabilities or expertise of most health systems and practices and opt just to incorporate other people’s innovations, we are still looking at most of the barriers.

When I think of an organization that has distinguished itself as an innovator I usually see a senior leader in my mind’s eye. I see a Glenn Steele, a Rick Gilfillan, a Gary Kaplan, a Patty Gabow or a John Toussaint. Without leadership things may be created, but the future adoption of innovations, no matter how brilliant they might be, is at risk from the start because of the powerful realities of the external pressure of finance and the internal rigidity of the status quo reinforced by the immediate resistance of the need to do today’s work. It is similar to the paralyzing reality that Desmond describes that reinforces poverty. If all your resources are required to pay the rent and nothing is left over for food, self improvement, or offering opportunities for growth and development of your children then you are trapped in a self reinforcing cycle of poverty and despair. With the burden of failing organizational finance and the inefficiencies of the workflows of the status quo, is it a surprise that a frightening number of medical professionals are experiencing burnout and have a blank stare to meet the announcement of yet another “innovation” that they must master?

When I think of innovative organizations I am often aware of the fact that these organizations have cultures that clarify why they exist, and also clarify balanced expectations between their management and professionals. These organizations usually have effective programs of quality improvement and have widespread knowledge of, and acceptance of, some process of continuous improvement. These assets can only be acquired through time and resources invested in staff education and the exercise of “distributed leadership” that understands how to live by “relational contracts” and the principles of “subsidiarity” and “federalism.” On such a foundation middle management is empowered and more inclined to seek the opportunity to incorporate innovations into the workflows that they facilitate rather than undermine what’s new motivated by the fear that what is new will cost them control and security.

Healthcare professionals often have years of experience that are challenged by innovation. An innovation, if adopted by your hospital or practice, may turn what you previously envisioned as a glide path to retirement into something that feels like climbing El Capitan. When you are a master of the past and have a financial or personal stake that change may undermine, you may show up to the meeting that discusses a proposed innovation with questions and concerns that are a polite way of saying, “Over my dead body!”

Most of us own “bells and whistles” on electronic gadgets, or we own tools that we can’t operate, and we are content never to realize the full value of the money we have spent. Why is that? Speaking for myself I can say that what seemed like a good idea when I laid my money down was not discounted by the frustration I would realize when I tried to get my gizmo to connect to the Internet. Ownership is not usership. Innovations, like tools and electronic devices, yield a return on investment only when used. What percentage of the capabilities of your EMR do you use? What percentage of its “tools for practice management” have you incorporated into your daily work routine? Most clinicians use their EMR in ways that track more similarly to their use of a paper record than the practice management/population management/ financial management tool that it is. Is it a surprise that Meaningful Use was far from a popular pay for performance opportunity? When the effort required today to learn and incorporate the innovation is balanced against today’s schedule and a steep learning curve that must be climbed at the expense of precious moments of respite, it is little wonder that what Machiavelli told his Prince about innovation 500 years ago is still operative today.

“There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things.”

In other industries leaders seem better equipped to make the “pain of not changing [innovating] greater than the pain of change.” The worry of us all should be that resistance to innovation will be successful while our enterprise is still successful and still has the resources to invest in creating innovations or adopting the ones others develop. Innovation is best when it is “anticipatory” of the opportunities it will enable. Sadly, we often see enterprises that have the ability to resist innovation and delay the pain of change until it is too late to avoid the pain of collapse and failure. Most of us were inspired by the ideas in Jim Collins’ classic book Good to Great, or at least heard about it even if we did not read it. I have found that few people know about or paid much attention to his important sequel, How the Mighty Fall. I have never seen a hospital or practice that got to the place of deep cuts in personnel and services in its last agonizing efforts to stay afloat, or maintain its cherished independence, recover by “innovating” or launching a successful program of continuous improvement. I guess that would be as likely as an ICU patient getting off a respirator by joining a health club. Every moment has its opportunities and possibilities as well as plenty of good reasons to put off innovation and improvement until later or when “things are better.” Red ink is not consistent with improvement. The recognition that innovation and improvement are ways to avoid darker days requires courageous leadership and supportive governance.

I have not come close to exhausting the subject but I may have exhausted you, but read on for one last concern. I am afraid that too often when we talk about or think about innovation we are thinking about a software product, some app or some new medical device or technological game changer like augmented intelligence. Those things are great and I am all for them, but I just want to emphasize that ideas and actions can constitute innovations also. I am very hopeful about the potential to lower the total cost of care through more effective patient engagement, especially in the self management of health and chronic disease. It should be possible to envision a day when a hospital admission for an ambulatory sensitive diagnosis is a “never event.” Programs that are labeled “hosptial in the home” and applied carefully as we gain experience may be transitional toward that audacious goal. I do not think that current processes of ambulatory care will ever get us there.

To put it bluntly, for most people getting care from their doctor is a frustrating experience and disaster can occur at any moment from initial contact until it all ends hours later in a line at a pharmacy or after multiple failed attempts to draw your blood in the lab. I know that your practice or hospital is not like this. But remember, you are part of a small numerator with a national denominator that is up near a million, just counting doctors. The ambulatory practice financed by fee for service revenue is usually an impossible environment in which to attempt to promote patient engagement or pass on the tools of self management. Often the clinician has neither the time, intent or ability to try to diminish the patient’s need to return frequently. All of the drivers are for a short visit billed at the highest possible level with the earliest possible return. The principles and possibilities of the “experience economy”described almost twenty years ago by Pine and Gilmore have not penetrated this reality, despite all the attempts by enlightened organizations to act like the Ritz-Carlton or despite all the Press Ganey surveys.

I have the hope that someday all of our innovations will come together to yield

...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…

I hope that that day arrives sometime before there is moss on my tombstone. I know that Dr. Ebert went to his reward secure in the idea that innovation was good. He had the personal scars and disappointments to know that it was hard. He surely must have had the personal satisfaction of knowing that he had moved us along a bit toward the distant goal.


Transitional Days and Growing Sox Excitement

In last week’s letter I mentioned that I was beginning to see a little color along the shore line of my lake. What I was describing has persisted and become more beautiful this week as you can see in this week’s header. The building in front of the birch with the flaming crown is an antique boathouse that is probably about 125 years old. It’s presence gives testimony to the fact that this lovely little lake has been a nice place to watch the seasons come and go for a very long time. Earlier this year I caught a huge largemouth bass on a “green wooly bugger” just a few yards off shore from the boathouse.

The red leaves are a warning that summer will soon be over. Sundown is an hour earlier than it was in early July. The water temperature is falling just as fast. We had an evening last week that demanded a fire to clear the chill.

The Red Sox have been giving me a different kind of chill. They are make slow progress taking two steps forward followed by one to the rear. The Yankee series was great, and I think their performance in Cleveland has been acceptable, but could have been better. I am not optimistic, just hopeful. I know that in baseball impressive winners can become sudden losers. We have been burned before. My hope tells me that this year may be World Series year!

Whether you care about the Sox, can’t wait for Tom Brady to lead the Patriots to another Super Bowl, or are filled with anticipation of the Celtics season because of their big trade for Kyrie Irving, or couldn’t care less about sports, I hope that you will get some exercise this weekend. An interesting article in the New York Times this week reports on a research study that shows lots of exercise in our younger years sets us up nicely for an active retirement. There is a pretty good return on investment with exercise.

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