26 June 2015
Dear Interested Readers,
Inside this Week's Letter
When I began to write this letter I realized that there would probably be nothing more boring to write about or for you to read than a detailed description of my experience at the 6th National ACO Summit in Washington. I so bored myself with the idea that I started writing about my son’s insights into personal transformation and then I got a great note from Tanya Chermak about the Pope. As I was trying to weave all that together into something you might find readable, I was delighted to discover that both Justices Roberts and Kennedy were admirably thoughtful jurists.
In the end, the theme of the newsletter became the possibility of a continuing transformation at every level of our society. I cling to this belief despite the recent tragedy in South Carolina. Change can be slow in South Carolina where my relatives have lived, fought, worked hard and often suffered for more than 250 years, but they had it better than almost all African American families. The painfully slow pace of change in some parts of the South is demonstrated by the inappropriate flag that still flies where laws are made that should never leave anyone questioning whose life matters or to whom respect is granted.
Whew! ANOTHER HURDLE CLEARED
At 10:21 AM yesterday, as I was writing this week’s letter a banner appeared on my screen:
NPR:Breaking News
Supreme Court Rules Obamacare Subsidies Are Legal
Just seven words but a powerful message. Later I enjoyed looking at all the YouTube commentary on CNN. In particular I enjoyed the President’s words and the brief analysis of Jeffrey Toobin.
http://www.cnn.com/2015/06/25/politics/supreme-court-ruling-obamacare/
I do not know about you but I was apprehensive to the end. Despite my rationalizations that an adverse decision would not be the end of healthcare reform, I knew that a decision for King in King v. Burwell would do more than damage the access to care of 7 million people. A decision against the ACA would have undermined much of the emerging economics of the transformation of our industry. The big surprise for me was that Justice Roberts joined the majority and wrote the opinion supporting the ACA. It makes little difference to me that he commented that the ACA is not a well written act. The ACA remains a miracle and a monument to persistence. It is a wonder that it exists, even in its flawed form.
Roberts has now written both of the majority opinions that have sustained the controversial healthcare act. I know that he was appointed by the second President Bush to move the Court to a more conservative stance, but it is beginning to feel like “deja vu all over again” in comparison to the appointments of two previous justices, Earl Warren and David Souter. Both of them arrived at the court with conservative credentials and departed as progressive icons.
It is now time to begin to make the ACA better. Would it not be wonderful if the comments by Speaker Boehner and Senate Majority leader McConnell suggesting that they will not be deterred in their efforts to “ repeal and replace” the ACA could somehow morph into a concept of “expand and improve” through a bipartisanship effort that supports the achievement of the Triple Aim? Five years of resistance that includes two Supreme Court decisions and a Presidential election should suggest that it is time for a change of direction that improves the law, rather than the beginning of yet another round of expensive and detracting efforts to abolish it.
Washington: Associations with Transformation
Last week I was in Washington to attend the Sixth National ACO Summit presented by The Dartmouth Institute for Health Policy and Clinical Practice and The Brookings Institution. I have attended several of the previous summits as a speaker/panel member and usually was preoccupied with the tension associated with the task. I had been looking forward to this year’s summit for several months because for the first time I would be in attendance as a listener. I had become even more excited as I read the agenda and began to appreciate what an All Star roster Mark McClellan and Elliott Fisher, the co-leaders of the conference and inventors of the term ACO, had assembled for my entertainment and edification.
Before going further I want to give you a thesis to ponder as I wander through my thoughts about the this year’s summit. I hope that by the time you get to the bottom of this letter you will be giving this thesis deep reflection. The thesis is that the strategic objective of healthcare transformation is the Triple Aim Plus One and that ACOs are our most powerful tactic in pursuit of that strategic objective.
Before I report on the summit I want to share a few thoughts from my experience connecting Washington with personal and social transformation. Washington has always been a Mecca for me. My first trip to Washington was on a family vacation in 1956 when I was eleven. I was in heaven as I experienced so many sites that I had heard about. In 1961 on another family trip that included my first visit to Boston, we went to the capitol building and visited Congress with the aid of our freshly elected Senator from Texas, John Tower, whom my father knew. Tower, a Republican, had just won a special election to fill Lyndon Johnson’s seat in the Senate since, in the 1960 election, Johnson ran for both Vice President and Senator. Tower’s election as a conservative Republican was notable as an event that would presage the break up of the “Solid South” block of the Democratic Party that would follow Johnson’s signing of the Civil Rights Act of 1964 and the Voting Rights Act of 1965.
Perhaps what makes Washington so symbolic for me is that it feels like an important “portal” to my adult life. Driving north for an interview for medical school or later to go to medical school, or going back and forth to medical school from South Carolina, Washington is the midpoint in the journey. I would often spend the night in or around the DC area. Perhaps one of my most moving trips north via Washington occurred in 1968 when I passed through town during the Resurrection City encampment on the Mall. During this same time I was discovering that racism was not a feature unique to my home region. In Boston the issues related to busing would reveal to me that the racism and poverty that differentially disadvantaged African Americans existed across the country. The racism in the North was a little less obvious but none the less just as hurtful and wrong there as compared to the blatantly obvious examples in my native South.
During my tenure as the CEO of Atrius Health, both before and after the passage of the ACA, I made many trips to Washington, usually accompanied by Marci Sindell, the creative and very knowledgeable Atrius Health Chief of External Affairs. In my mind she was also our Chief Strategy Officer although she did not have that title. [Marci was also the able editor of these letters.] Those trips to the Capitol Hill, HHS, the Social Security and the Medicare facilities in Maryland, and even to conferences held in Washington like previous ACO Summits, stand out in my mind because it always felt that Marci and I were visiting the “gemba” of change. Another major connection for me to Washington are the pleasant memories of visiting my oldest son there while he was a student at American University’s Washington College of Law.
In 2010 my youngest son began what would be an impressive exercise in creativity and persistence. Since the fall of 2010, following his recovery from vocal cord surgery to remove a large polyp generated by the trauma of being the principal singer in an indie rock band, he has put a new song on the Internet every Monday for 240 consecutive weeks. Sometimes he recruits collaborators from his talented friends, but most of the time it is a solo effort. He writes the music and produces it, playing all the instruments and usually singing all the parts. He lays down tracks that he blends and mixes and then he wraps up the package with a drawing or photograph and a short essay. His lyrics often have a social or developmental message and at times he gets into political parody. He will frequently use a song to make a statement in music and verse in response to events like the shootings at Fort Hood, the shooting of Gabby Giffords and others at the shopping center rally in Arizona, or as a comment following the tragedy of the Marathon bombing. During his time in grad school over the last two years, the compositions were not always quite so layered and for time’s sake were often simple acoustic arrangements and not the electronic tapestries that he loves to weave.
One of his earliest productions, week 15 of the project, has become my metaphor for Washington and transformation. When I am in Washington I can not get the words or tune out of my head. I hope that you will listen to it and read the essay at:
For those of you in a hurry, here are the words. I have bolded the lines that always run through my head when I go to Washington. Inspection of the second block of words that are bolded and the section from the essay reveals that the song is mostly about transformation but then it is still a unified concept because Washington is our national stage for many transformational efforts, demonstrations, and commemorations. When he went to Washington to see the monuments and to participate in an event, the message from “the giants” was that the work of transformation was a process of discovery in your head and heart. The key is what you feel because unless you feel the need to know and discover [yourself and others] nothing transformative ever happens.
A Soul Anatomy Game
It’s just a little bit of heart
It’s just a little bit of shame
It’s just a little bit of innocence
It’s just a little bit untamed
And it’s a good amount of restlessness
And on the road the inches on the map get called the game
I took a drive to see the capitol
I wondered what it would say to me
I thought of all the ways I could lose control
Like the pillars of history
And the giants all around me told me
Son you gotta learn your soul anatomy
Your head, your heart
Your hands, your feet
Your mind, your thoughts
The rest is everybody else
The rest is yours
To know, to love
To grow, to feel
To discover that the less you feel the less you’ll know
The less you know, the worse you’re gonna feel
Just think of your worst memories
And all the days that left you scarred
And then endeavor to believe
The most important days are hard
That all your darkest days are beacons of the light that’s in your heart
And make you love the life you’ve got
Your head, your heart
Your hands, your feet
Your mind, your thoughts
The rest is everybody else
The rest is yours
To know, to love
To grow, to feel
To discover that the less you feel the less you’ll know
The less you know, the worse you’re gonna feel
And it’s better to learn to feel
Here is a little bit of the associated essay:
…A soul anatomy game? I was thinking about all the games that I used to play in my head as a kid in the back seat on long car rides. Maybe I was trying to find out-of-state plates, or looking for pictures in clouds. I still play games to keep my mind occupied when I’m driving alone on a long trip, but long trips get so introspective that I sometimes lose track of the game and find myself someplace else. In particular I was thinking about one trip that I took last fall to Washington, DC for Jon Stewart’s Rally to Restore Sanity. It was the morning after I came up with the idea for this blog, and I had been so excited about it the entire night that I hadn’t slept a wink. I was recklessly exhausted, but desperate to make the rally. As I drove I thought about all the possibility inherent in making myself write a song every week, and I realized that I was about to have to become infinitely more honest and familiar with myself. Week after week I would learn my soul inside and out.
But this song isn’t all about driving down to see Jon Stewart, giddy about a website. It’s about feeling your hardest feelings in order to better know your own soul. If there is a thesis statement in this song, it is some combination between the second verse and the end of the last chorus: “Endeavor to believe the most important days are hard, and all your darkest days are beacons of the light that’s in your heart… The less you feel, the less you’ll know, the less you know the worse you’re gonna feel. And it’s better to learn to feel.” In other words, if you avoid the things that are hard about your life, and try not to feel them, you will not truly know yourself and you’ll only make it worse. We sometimes try to bury our hard feelings, but I suggest we embrace them in order to find a more complete understanding of ourselves. This song is supposed to be optimistic!
The Sixth National ACO Summit
The brochure for the conference set the tone and described the agenda:
ACOs in both the public and private sector have continued to grow over the past
several years, ushering in more experience and evidence on what is working
and ways to continue evolving accountable care models. The Sixth National
Accountable Care Organization Summit (www.ACOSummit.com) will provide
an unprecedented opportunity to discuss remaining barriers to widespread ACO
implementation, strategies to overcome them, and policies to encourage the
continued growth and sustainability of the accountable care movement. The
Summit brings together leading policymakers, experts, and ACO implementers to
provide unique and in-depth insights on ACO implementation and ongoing health
care reform. The Summit will cover a variety of topics including innovative contract and payment arrangements, performance measurement, patient engagement, state innovations in accountable care, clinical leadership and engagement, opportunities for specialty care integration, strategies to advance primary care, employer-led accountable care arrangements, and innovations in health IT and data use. The Summit will also be a great opportunity to explore the future of accountable care contracting, practice, and policies.
Few conferences deliver as well on their objective as this conference did. I particularly enjoyed the Keynote Speakers and the panels that were presented for everyone. There were also informative smaller sessions called “tracks” that took up more specific topics.
The first Keynote was given by Patrick H. Conway, MD, MSc. who is the Deputy Administrator for Innovation and Quality and the Chief Medical Officer and Director of CMMI, and is also Director, Office of Clinical Standards and Quality of CMMI. He summarized a lot by saying, “Delivery system reform requires focusing on the way we pay providers, deliver care and distribute information.” He underlined the success of the ACO movement by pointing out that there were now more than 8 million beneficiaries in 400 ACOs participating in the Medicare Shared Savings Program. He also celebrated the results of the Pioneer ACO program as he described the new “rules” for ACOs and talked about the next generation ACO model that would use a prospectively-set benchmark that would reward quality and attainment of efficiency without the volatility of the current models. The new AC models will offer enhancements that better support coordinated care, maintain choice, improve cash flow and investment for capabilities as they focus on quality indicators. His emphasis was on what has been learned and how that information will enable ACO evolution and improvement.
Next up was a panel with the objective of discussing alignment of payment reform goals.This was an important conversation because of the recent announcement by CMI of the goal of tying 30% of FFS Medicare payments to quality and value by the end of 2016 and 50% by the end of 2018. The panel emphasized that commercial payers were following CMI’s lead so that we are rapidly approaching a tipping point in the way we pay for care.
The next panel included Andrew Dreyfus from Massachusetts Blue Cross. The subject was a discussion of the future directions of ACOs now that there are over 700 ACOs in all parts of the country. The evolution of the Alternative Quality Contract of the Mass Blues was used as an example of how progress is made and evolution occurs.
Michael Leavitt, Founder and Chairman, Leavitt Partners; Former Governor of Utah; Former Secretary, US Department of Health and Human Services was the next keynote speaker whose presentation was delivered by Skype from Scotland. He described a forty year, four phase evolutionary process that explained the era of managed care and ACOs as a continuum. He said that 1990 to 2000 was about controlling costs. He called the period 2000 to 2010 the period of defining quality. 2010 to 2020 was described as an era of “emerging value”. The future between 2020 and 2030 will be an era of “how to and scale”. The major focus of his presentation was to announce a new partnership between Leavitt Partners and Brookings to create an ACO learning collaborative.
During the afternoon of day one there were smaller group discussions. First, I attended a discussion of Commercial ACOs. The discussion emphasized that 40% of all ACO contracts are now commercial. They cover 12-16 million lives and involve 132 payers. [Massachusetts is not a good place to look to see this dramatic change, probably because the commercial market is dominated by Blue Cross which is focused on the AQC.] In other parts of the country where the nation’s top five for-profit payers dominate the commercial market, the move to ACOs is a strategic objective and is driving a more vigourous process of commercial ACO evolution.
My second “break out” session was “Strategies for Managing Vulnerable Populations”. This is a subject of great importance to primary care and I was delighted to find that Eliza “Pipa” Shulman the Senior Chief Innovation Engineer from Atrius Health was on the panel. Her panel emphasized what has been the core ACO strategy of Atrius Health, “...implementing broader person-centered service integration across the range of acute, post acute, palliative, and long term service and supports…” creates value and quality for patients and lowers the total cost of care.
The second day began with a keynote “conversation” with Dr. Glenn Steele, the recently retired CEO of Geisinger Health. Dr. Steele described a competitive future where there will be winners and losers. He discussed the compensation link for individual physicians at Geisinger that supported quality achievement of specific important goals. He also emphasized a pragmatic approach by saying that 20-25% “of the stuff we tried did not work”. His opinion was that you could have a productive working relationship with a commercial payer and “not so much” with a bureaucracy “like CMS”. He also emphasized that CMS will continue to move away from FFS and that the commercial payers will follow CMS. He anticipates that more and more physicians will move to being “employees”. Other tidbits included, “We have made a big bet on Medicaid MCO” and “I hope that private exchanges are successful and allow more employers to move to defined contribution coverage from defined benefit coverage”.
During the second morning there was an opportunity to attend two breakouts. I first attended the conference on “Specialty Care Challenges and Approaches”. The emphasis was on the challenge. I was struck by the difference in tone between this panel and the rest of the Summit. It was hard to see the Triple Aim in the presentations of the specialist despite the fact that one of them was assigned to discuss the Triple Aim. The presentations focused on concerns that arose from the experiences of the panel. I concluded that they all seemed to prefer the simpler world that existed before ACOs. There was no doubt in my mind that they all saw substantial challenges to integrating specialties into new payment alternatives. Bundled payments were definitely more interesting to them than “global” payment. The contrast between this panel and the panel on “Strategies for Managing Vulnerable Populations” which was populated by internists, administrators and PCPs, was remarkable.
The last breakout I attended was “Clinical Leadership and Engagement”. This panel included Christina Severin from BIDCO (the ACO at the BIDMC) and David Morales from Steward Health. It was a good discussion of the empowerment of clinicians to improve care. There was a surprise extension of the discussion from engaging medical professionals into the newly recognized importance of educating and engaging patients if ACOs are to gain acceptance.
The last two keynotes were remarkable. Dr.Toby Cosgrove, the cardiac surgeon who is the CEO of The Cleveland Clinic and has done over 20,000 CABGs and valve replacements and repairs, gave a rapid fire presentation of the world according to the Cleveland Clinic where innovation reigns and the expectation is a future of value based reimbursement. I was exhausted from trying to keep up with him by the end of his presentation.
I had been looking forward throughout the conference to the last Keynote from Stephen Shortell from UCSF. I had found his two page paper, “Implementing Accountable Care Organizations: Ten Potential Mistakes and How to Learn From Them” in JAMA in August 2011 and recommended to me by Rob Mechanic, to be the single most useful document I ever read about ACOs. I was not disappointed. His subject was “Are ACOs Really Engaging Patients”. His research underlines that to be successful ACOs must engage patients more effectively. Ironically the problem with patient engagement is the poorly designed workflows and the lack of interdisciplinary clinical teams. The solution seems to be more effective use of nursing and care coordinators and new “standard work” for doctors. Dr. Shortell did not get past “the what” to “how”, but then we know the “how”. The “how” to engage patients will involve innovation, cultural change and an operating system like Lean.
My take away from the conference is that things are moving very fast. Improvement and growth from ACO Summit to ACO Summit is remarkable but there is still much to be learned. We are learning by taking risks and collaborating. CMS is driving the process but the momentum is coming from the commercial payers and employers who want better value. My thesis that “the strategic objective of healthcare transformation is the Triple Aim Plus One and that ACOs are our most powerful tactic in pursuit of that strategic objective” seemed confirmed by all that I had heard.
The perfect methods for the transition ahead of us, especially for the implementation of new financial models and rules that will surely come, are still to be discovered. Clinician and patient engagement are the keys to the future. One thing is clear, organizations that are willing to accept the challenges of a self-prescribed clinical transformation will have a successful future, but it is good to remember what Glenn Steele said, “There will be winners and losers”. Whether your organization will be a winner or loser may be a function of your ability to lead a transformational process.
“Only people of the spirit change things. The rest of us just rearrange them.”
That quote from Napoleon, of all people, is the title of an article written by Sally Helgessen about Pope Francis and published in the strategy-business.com blog. Tanya Chermak sent me the article this week. In a letter with an emphasis on transformation it is a very appropriate final piece. I would encourage you to read it whether you are a fan or not of the new Pope. This Pope does understand some principles that have cross over value to healthcare.
Early in the article when Helgessen is still talking about Napoleon, she transitions to a contemporary conversation by saying:
The conqueror of Europe, whose dominion did indeed prove short-lived, was sufficiently clear-eyed to recognize the transitory nature of his military and political triumphs. But leaders today are often less astute. Although transformation has become a kind of holy grail in many organizations, it’s often viewed as an engineering or structural challenge that can be executed from the top: Get all the design elements right, and transformation is sure to follow.
The reality is that meaningful, lasting change occurs only when a critical mass of people throughout an enterprise — not all of them, but a sufficient number — begin to approach their work and commitments in a whole new way. Sustained transformation requires transformed people… In the real world, people don’t change because the CEO tells them they must do so overnight.
First, a leader needs to create opportunities to build and connect with alternate constituencies in meaningful yet powerful symbolic ways in order to counterbalance vested interests nearer to hand. Second, rather than telling others that they need to change their ways, a leader seeking transformation must instead personally model a radically open style of leadership that sets the tone for what he or she wants to see happen...transformed people transform people. This is a truth leaders miss when they imagine their positional power alone can compel lasting change. Organizations can only be transformed when the people who comprise them are transformed, and people are changed by individuals who engage them at the level of spirit....From Day One, the Pope demonstrated his understanding of a simple insight: transformed people transform people.
Coming full circle:
The most important days are hard
That all your darkest days are beacons of the light that’s in your heart
And make you love the life you’ve got
Your head, your heart
Your hands, your feet
Your mind, your thoughts
The rest is everybody else
The rest is yours
To know, to love
To grow, to feel
To discover that the less you feel the less you’ll know
The less you know, the worse you’re gonna feel
And it’s better to learn to feel
The Eleventh Monday Is Labor Day
That is right! “The days dwindle down to a precious few”. Do not waste one minute of a summer weekend afternoon sitting in front of a television set watching baseball or golf. Night games are OK to watch. Best yet are night games in the Cape League. A great alternative to baseball is going to an outdoor concert on an old farm (as pictured in this week’s header) where you can enjoy great home cooked music, talk with neighbors and enjoy food that you should eat no more often than once a week. Such an event as the one pictured at the top of this letter is a very positive way to spend a Saturday afternoon in the summer. I suggest that you look around to see what is going on outside near you this weekend. Just don’t forget the sunscreen. I know because I am keeping my dermatologist pretty busy cleaning me up after years of ignoring UV radiation.
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