26 January 2018

Dear Interested Readers,


Reading to Gain Perspective on the Larger Picture That Determines the Future of Everything

This time last week we did not know what would happen in the standoff between the Democrats in the Senate and the President over the demand by the Democrats that we solve the problem of what to do about the specific issues of the “Dreamers,” an important part of the larger set of questions about immigration, as a precondition to the approval of a budget for the remainder of fiscal 2018. As it turned out, the bilateral willingness to allow a shutdown of the government rather than making concessions to the other side had at least one positive outcome, the six year renewal of CHIP, the program that insures children whose families fall into the crack between eligibility for Medicaid and the financial ability to obtain their own coverage. Assured access to care for over nine million children has been at risk since CHIP expired last fall. Securing their coverage by any means must be considered a great victory for common sense, some kind of bipartisanship, and a vote for a better future for America.

I was not surprised by the argument between Democrats and Republicans over which party was to blame for the shut down. What did surprise me was the debate within the Democratic Party after the Democrats quickly agreed to a three week extension, until February 8, about the time the Winter Olympics start, of the finance of the government for “just a promise” to bring some bill solving the “Dreamer” problem to a vote in the next three weeks with the CHIP agreement thrown in for good measure. Some Democrats feel that their leadership “caved.” Others believe that much was gained, and little was lost. I agree with David Leonhardt of the New York Times who thinks that Senator Schumer did the right thing, and the outcome was a strategic positive. I agree that if no progress is made in the next three weeks, all the issues and opportunities come up again, and will be strategically and morally supported by the reality that the Republicans failed to deliver. But who is asking me?

Despite the fact that no one asks, I do have a sense that I should have an opinion, and I hope that you do too. It is hard to look past the current moment and be positive about the future. We have some big problems that go beyond the fact that we have “hit the pause button” on the road to the Triple Aim. Being information avid, and believing that the best way to be a participant in the resolution of a problem is to inform oneself, I am attracted to any book that offers an insight into how we got to where we are, and how we might begin the slow journey back toward more efficient and universally beneficial ways of conducting the business of governing ourselves. If we don’t know how we got here, how will we ever know which way to go when we finally try to move forward? That attitude makes me a sucker for people who sell books that offer insights into the chaos of the moment. You might have noticed that I pass the titles of these books on to you. My hope is that even if you do not read them, you might give some thought to the big ideas that they try to sell, and that I report via my interpretation of them, and the links to reviews that I offer.

I am usually reading three or four books at the same time. At the suggestion of Patty Gabow, I have recently read a page turner, Killers of the Flower Moon: The Osage Murders and the Birth of the FBI by David Grann. The book is a reminder that white Americans have historically applied the same sense of superiority to native Americans that they have to Black Americans, and that injustice and terror have long been operating principles in our society.

I have almost finished reading Michael Wolff’s Fire and Fury: Inside the Trump White House, which I have found to be less controversial and more believably written than some of its reviewers have suggested. True, Wolff isn’t the world’s greatest writer, and perhaps at times one must suspend belief as if reading fiction, but the story he tells seems fundamentally true, even if at times a bit over the top. There is an element of a “tabloid” or trash fiction style, but the narrative tracks the story as I have followed it, and offers comments on the reported events from the inside perspective of those involved. Overall, I find the story as presented, and the conclusions he suggests, to be mostly plausible.

A more important book which that I have recently read, is The Broken Ladder: How Inequality Affects the Way We Think, Live, and Die by Keith Payne. The author is highlighted in a recent New Yorker article that you might have read that was written by the very talented Pulitzer Prize winner, Elizabeth Kolbert. It is a terrific look at inequality from the perspective of an academic psychologist who employs concepts of behavioral economics and neuroscience in his research on the outcomes related to inequality. Professor Payne began life as a poor boy in a small town in Western Kentucky and is now a professor at the University of North Carolina. His book feels very important as it draws almost as heavily on his personal experience with poverty and inequity as it does on his knowledge of recent research in psychology, behavioral economics, and neuroscience. The most important chapters for me have been the ones on how inequality is viewed differently by the right and left, how inequality contributes to poor outcomes for both ends of the economic spectrum, and how racism functions as a multiplier for the problems of inequity and poverty. Kolbert’s article gives you an introduction to the idea of the universally negative impact of inequality on health outcomes, and how we all see ourselves, as does a recent interview with Payne that I found online from The Daily Tar Heel, the student newspaper of the University of North Carolina.

I am just beginning to read How Democracies Die by Steven Levitsky and Daniel Ziblatt, two political scientists from Harvard. To get a quick flavor of their book I would suggest that you look at the transcript of an interview with the authors this week on NPR’s “Fresh Air.” The interview quickly paints a picture of the answer to how democracies die by looking at the failure of democracy in other countries over the last century and comparing them to this moment in time in America. As you may guess, the authors’ opinion is that we stand in harm’s way, and I think events of the last few weeks, and of the last year should make us even more apprehensive than many of us are. Now is not a time to be complacent. I have been surprised that when I express my apprehensions the most common response I get is, “Well what do you think about the stock market? It is up 30% in the last year. That must mean something good is going on.” I would say to that response, “True, but probably related only by the fact that it obscures the real concern and enhances the possibility of real disaster.” Levitsky and Ziblatt are like good physicians who use prior experience to anticipate impending changes in clinical status to which the patient is vulnerable. Dave Davies, who is the interviewer, begins the conversation with what is a statement rather than a question:

You note that we have a Constitution, which is widely praised and revered. It's a set of rules, and it's actually pretty short. But you note that a set of rules, however well-crafted, aren't enough to ensure that democratic institutions prevail. You say there are norms of democracy that are just as important.

Steven Levitsky responds, the bolding is my attempt at emphasis:

The rules themselves, particularly in a very simple, short Constitution like that of the United States, can never get a - can never fully guide behavior. And so our behavior needs to be guided by informal rules, by norms. And we focus on two of them in particular - what we call mutual toleration, which is really, really fundamental in any democracy, which is simply that among the major parties, there's an acceptance that their rivals are legitimate, that we may disagree with the other side. We may really dislike the other side. But at the end of the day, we recognize publicly - and we tell this to our followers - that the other side is equally patriotic, and that it can govern legitimately. That's one.

The other one is what we call forbearance, which is restraint in the exercise of power. And that's a little bit counterintuitive. We don't usually think about forbearance in politics, but it's absolutely central. Think about what the president can do under the Constitution. The president can pardon anybody he wants at any time. The president can pack the Supreme Court. If the president has a majority in Congress - which many presidents do - and the president doesn't like the makeup of the Supreme Court, he could pass a law expanding the court to 11 or 13 and fill with allies - again, he needs a legislative majority - but can do it. FDR tried.

At this point Professor Ziblatt jumps in to make the point that over the last few decades both sides have played fast and loose with norms and forbearance.

ZIBLATT: Yeah. Well, so, you know, there's certainly this notion of an American creed where Americans have a long-standing commitment to principles of freedom and equality... this is - should be a source of some solace to us, that democracy's a - the older a democracy is, lots of political science research shows, the less likely it is to break down. And one of the reasons is a commitment of citizens to democratic norms. One thing, though, that kind of gives us kind of pause, and I think that, you know, there is a sub-current - and Steve mentioned this earlier - there is a sub-current in American political culture, and just even in the 20th century, you know, beginning with Henry Ford, you know, as we mentioned, Huey Long, Joe McCarthy, you know, all the way - George Wallace - all the way through Trump, there's a sub-current around 30 - you know, Gallup polls going back to the 1930s - around 30 percent of the electorate supporting candidates who often seem to have a questionable commitment to democratic norms.

Levitsky attempt clarification:

The creed to which Daniel refers and the initial establishment of strong democratic norms in this country was founded in a homogeneous society, a racially and culturally homogeneous society. It was founded in an era of racial exclusion. And the challenge is that we have now become a much more ethnically, culturally diverse society, taken major steps towards racial equality, and the challenge is making those norms stick in this new context.

All four books that I have recommended show different angles on the issues of norms and forbearance, but there is a concurrence in the concept that emphasizes that whether what divides us in our politics is the cause or the effect of inequality, it will be hard to engineer a return to even an illusion that America can be great without improvements in how we work together. In the future things will only get worse unless we can make a course correction that includes both a return to an exercise of the norms and forbearance that seem to be foundational, and an effective migration into the appropriate attitudes for success as a diverse nation that cares about the whole planet and justice for all humankind.

Perhaps we are doomed to recurrent experiences like the series of governmental confrontations and brinkmanship politics that seem to have become the way our business is done. Perhaps the idea of returning to an informal operating system that interprets the Constitution by looking through a lense that relies on tolerance, the exercise of restraint, and a genuine civility and goodwill for all, with a shared goal by both the right and the left of a democracy that is fair to everyone, is an unrealistic dream that like the Triple Aim, is just an idea that is attractive but beyond our reach.

Kolbert seems to get Payne’s major point in The Broken Ladder. It seems to be as she say:

Inequity is, apparently, asymmetrical. For all the distress it causes those on the bottom, it brings relatively little joy to those at the top.

In an attempt at an interest based negotiation it is always an important first step to agree on some shared objective. I guess the fact that we not blow what we have and risk further universal loses is as good a place to start as any. Deval Patrick was part of an interview published this week by Frank Bruni in the New York Times. As he was trying to describe the most effective way forward for Democrats to push the causes that seem important, he said some important things:

On “left” versus “right,” “liberal” versus “conservative” — the labels are stale. The real dynamic in our politics today is insider versus outsider. That’s what needs to be fixed.

I’m a Democrat because the Democratic Party is closely aligned with American values of freedom, opportunity and fair play. We believe in an open, market-based economy bound by those values, an education system that supports and sustains those values, a robust foreign policy that promotes those values. Consistency with those values is the only litmus test that ought to matter to us.

Further on in the conversation which was really a long discussion about how to deal with the threats of “Trumpism,” he used healthcare as an example of how to make progress toward a better future:

What matters most is that we agree on and fight for the ends, not so much the means. For example, we want every man, woman and child to have access to quality, affordable health care. There’s more than one way to skin that cat, and we should be open to debating all those ways. But let’s be careful that while the other party tries to divide us over the differences in means, they are preventing progress toward our ends.

I hope that before the next conversation about shutting down the government gets going, the Democratic leadership will take his ultimate strategic suggestion to heart:

The more we caste our approach in those terms — unifying, humble, enabling, responsive, about a better common future — the more we win, and deserve to win.


How Healthcare Finance, Innovation, Burnout, Poor Patient Experience, Healthcare Inequities and Physician Shortages Are All Connected

It has been almost ten years since I took on the challenge of trying to lead Atrius Health. The challenges then were very similar to the ones we face now. I was impressed then as I am now with the body of thought and knowledge that had been expressed in Crossing the Quality Chasm and further refined and articulated in the Triple Aim. These ideas resonated with my experience as a clinician. What felt acutely real at the time for me was that whenever we deferred action on our attempts to incorporate the six principles of quality as articulated in Crossing the Quality Chasm into operations because they seemed to interfere with the easiest route to short term gains, or we lacked the energy to do the work, we drifted further away from both the security we desired for ourselves and the collective goal of the Triple Aim. 

Last week I lifted a quote from Derek Feeley’s introduction to the IHI’s white paper on addressing equity in healthcare. It deserves repeating:


In 2001, the Institute of Medicine described “Six Aims for Improvement” in its influential report, Crossing the Quality Chasm: A New Health System for the 21st Century . The “Six Aims” called for health care to be safe, effective, patient-centered, timely, efficient, and equitable. In the 15 years since the Chasm report, health care has made meaningful progress on five of the six aims (though there is much more work to be done on all). But progress on the sixth — equity — has lagged behind.

As I look back on what I was think in early 2008 and as I was beginning to work with my team to articulate a strategic plan that we could present to our board and our practice for their thoughts and input, a few key ideas emerged that I still find relevant. They were then, and remain now, interconnected realities that like the six domains of quality must be kept in mind as we try to think about a better future.

First, universal coverage will someday be a reality in America, and we are not prepared for it. In 2005 I had heard a strategy consultancy predict that by 2020 there would be one practicing PCP for every 10,000 American adults. The discussion was depressing because given rates of retirement, the relatively sparse number of slots in medical schools, tendencies for new grads to choose more lucrative specialties, the time it takes to produce doctors, the inadequacy of PA and NP training programs, and the model of care that was driven by office based fee for service practice, the outcome seemed impossible to avoid. The American Association of Medical Colleges has been tracking the issue now for a few years. The picture is not pretty, but you can see it for yourself. What worried me in 2005 and 2008 is a persistent problem getting worse today.

Second, the only solution that seemed plausible was a redesign of the care model toward methods of better leveraging the professional skills that were available. That would require a shift in experience and responsibility for both clinicians and patients. Care model innovation was the answer. The metaphoric “factory” of healthcare needed an upgrade and redesign. In most industries you can shut down a factory and “retool” or just build a new factory. The idea of shifting care models is certainly still alive and we have made progress. I would suggest that you look at the “Perspective” article by Duffy and Lee in the January 11 edition of The New England Journal entitled “In-Person Health Care as Option B.”

Third, fee for service payment was an impediment to progress. We needed to find capital to invest or at least be paid differently so that we could invest in our practice. When we were “totally capitated” as a self insured entity, we had more flexibility to be innovative and develop more efficient programs of care. Being paid for value rather than volume is not quit the same as the capitation that I cut my professional teeth on, but risk based contracts were something we understood in our organizational history even though in 2008 only 39% of our patients came to us on HMO like contracts. It seemed prudent to try to shift to a more risked based portfolio of contracts.

Fourth, eliminating waste and promoting operational efficiency, and working with like minded business partners in our “supply chain” would yield more resources for innovation. That idea was the core concept behind my favorite financial expression, “Rescue and Reallocate.” Any money saved (rescued) by more efficiency was “found money” and could be invested in improvements (relocated from waste to investment). Those saved dollars were just as good a source of resources as getting a better payment from a contract. I seriously doubted, and think time has shown me to be correct, that we would ever return to the era of large year over year increases in payment that were multiples of the GDP. File that thought under “If something can’t go on forever, it won’t.” Embracing Lean and making continuous improvement our most significant corporate competency seemed to me to be foundational to our mission, and the best way to unlock the money in the vault of waste.

Fifth, workforce shortages, difficulties with developing workflows and incorporating computers into the care model, as well as a dependence on fee for service revenue constituted a perfect storm for professional burnout. I had read Robert Cole’s 1993 book, The Call of Service: A Witness to Idealism and was impressed by the risk of burnout in any “helping” profession or idealistic endeavor. The book appeared about the time my own professional life was thrown into chaos by the introduction of RVUs, more contracts that were fee for service, and the introduction of Epic. It was a perfect storm that almost sunk my ship since I had zero “keyboard” skills. I had done just fine for twenty years in a system that valued my ability to solve problems over my ability to generate a document that the finance department could use to justify the bill they were submitting. Again, fee for service, and its demand for justifying with no value added lists of negatives seemed to me to be an impediment, and not a support to practice. Being an effective advocate for better practice had put me into a leadership position. In 2008 the only way I could see to make things better was to change the finance and improve the workflows and supports to the practice.

Recently, my Simpler colleague, Paul DeChant, has done a wonderful job advocating for recognizing the threat of burnout and offering Lean as one of the effective tools we have to improve it. The book that he wrote with Diane Shannon, Preventing Physician Burnout: Curing the Chaos and Returning Joy to the Practice of Medicine should be required reading for every healthcare professional. Perhaps more available to you, if you have ready access to The New England Journal of Medicine, are two articles on burnout in the January 25th edition. I recommend them all, although none of them are “the answer,” what is most important is the conversation. Like the issue with opioids, the acute recognition of a chronic problem, is a moment when progress might be made.

All of the above is encapsulated in my favorite quote from Dr. Robert Ebert, Dean of Harvard Medical School when I was a student, and the founder of the organization where I spent the entirety of my career. As you have read from me before, and will see again until we incorporate its wisdom into everything we do:

“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.”

What is not obviously included in that statement, but rest assured the reason he said it, was the concern that we were failing in our moral obligation to provide patients with care that was centered in their needs and concerns. That thought was the sixth concern in my cascade of concerns in 2008.

Sixth, we are failing in our responsibility to make our efforts patient centric. Even as we pursue safety, efficiency, effectiveness, timeliness, and even equity, if we forget the necessity of putting the patient first it is all for naught.

In a way the problem reminds me of the wisdom of St. Paul in his first letter to the Corinthians where in the 13th chapter he seems to state that the only thing that matters in the end is charity (love). You probably know the poetry of the King James translation even if the scripture is not part of your personal experience. It’s all about purpose and the outcome.

Though I speak with the tongues of men and of angels, and have not charity, I am become as sounding brass, or a tinkling cymbal. And though I have the gift of prophecy, and understand all mysteries, and all knowledge; and though I have all faith, so that I could remove mountains, and have not charity, I am nothing. And though I bestow all my goods to feed the poor, and though I give my body to be burned, and have not charity, it profiteth me nothing.

In healthcare the only thing that really matters in the end is the outcome that the patient experiences. Everything else is an end to that means. We should not worship or feel bound to what is not working if that slavishness to the status quo is impeding our efforts to offer care that meets the needs of everyone in a personal way. It’s why I like the more recent iteration of the Triple Aim. It’s less wonkish and comes closer to the patient while remembering the stress that the call to service places on those who provide the care:

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.

As I look back at 2008, I see that things have not changed much. We have tried to avoid, or at least delay, some of the work that needed to be done. Lately we have been sidetracked by efforts to prevent the erosion of a few of our accomplishments. The real question that we face together is how do we get back on the road to the objective and take advantage of what we have learned from our successes and failures. We must simultaneously be working to achieve a sustainable resources, our “means,” and simultaneously improve our methods of delivering care, if we are ever going to achieve the desired end. I have had my time at bat, and now I am mostly a patient. If you are still in the game, I hope that I have said something that might be helpful to your efforts to hit the pitch that is coming to you.


Ice: A Visual Delight and a Physical Disaster

I just came back from a visit to South Florida. It was great to feel warm for a few days, although people there were complaining about night time temps in the high 40’s and daytime temps in the 60s. I did not go down for the weather. I went down to watch my granddaughter play basketball for her high school team and volleyball for her club team. The high school volleyball season is over, but between volleyball for the high school and the club, beach volleyball, and summertime volleyball camps, volleyball is a year round activity for her. If it weren’t for her, you would never find me in Florida. In the summer it’s a sauna and in the winter I am missing one of my favorite times in New Hampshire. I am always afraid that while I am away we will have a thrilling nor’easter with blowing winds and tons of snow that I will miss. I know that I am weird, and my love of winter is just another manifestation of that reality.

The only season that I do not enjoy in New Hampshire is “mud season.” The only benefit that I have identified with global warming is that mud season, the mess between winter and spring, seems shorter. I am a member of a rare breed because it seems most people do not find joy in winter, the most maligned of all seasons. My perspective has changed a bit in retirement. When I was working, it was a drag to have my commute lengthened by weather related hazards like ice and snow. Now, as a retiree, I just get up at 9, sit by the fire, read, and drink coffee while I have sympathy for all those poor souls who are still trying to get through the mess to an early meeting. I really enjoy watching the weathermen/women on the local television stations who have tried to turn every snowstorm since the blizzard of ‘78 into an Emmy worthy event.

My favorite time is just after the storm passes. Whenever that first site of the new fallen snow occurs, be it midday or on arising the next morning, my spirit rises in response to what must be the release of a flood of dopamine in my brain. I love an unblemished blanket of snow that obliterates roads and driveways like wrapping paper on a birthday present. What is even better than seeing fresh snow in the trees is seeing ice coating all the limbs of trees. Birches bend the most, and are gorgeous arches in the sunlight. Other trees look like chandeliers. Today’s header was taken late in the afternoon at the end of Tuesday’s ice storm. The gleam in the trees is not as obvious in the photo as it was in person, but the sky and the fading sun are more obvious. The trade off seems reasonable, and the picture in its entirety supports my conclusion that “after the storm” is an exhilarating moment. The only downside to a storm that is ice rather than snow is that walking is so much more treacherous, or should I say challenging, on an icy road. Snow is like walking in sand. Ice is like, well, walking on ice. I wear studs and stay off the areas that look smooth. The key is to stay in the gritty areas.

This weather in New England this weekend looks like it will be warmer on Saturday and warmer with rain on Sunday, and that is a bummer. I wish it was going to snow, or at least be cold enough for the rain to be ice. I believe in global warming. I sure hope that in my lifetime global warming never gives New Hampshire Florida weather in January. Wherever you are, and whether you love winter, or can’t wait to get to Florida, I hope that you get outside this weekend for some sort of adventure.