26 May 2017
Dear Interested Readers,
What These Letters are About and What’s Inside This Week
I am delighted that this letter has recently picked up a few new readers. Every now and then I feel the need to remind myself and the readers of the letter of the evolution of the intent behind these weekly “Musings.” When I began this weekly exercise almost a decade ago my intent was to have a conversation with the people who did the work in the organization that I led. At the time I felt that many of them were so focused on “today’s work” that they did not have the time to see the how their personal efforts fit into the larger context of our collective efforts. There was a crisis of trust within the practice that needed to be addressed. At the same time our external world was rapidly changing and the future of group practice in Massachusetts was uncertain in the wake of the passage of “
Romneycare” and the pressure from Blue Cross to assume more risk through their innovative
Alternative Quality Contract, the AQC. The only plausible path to a secure future would demand substantial internal change that would require intense efforts at communication.
By 2008 I had spent a third of a century in the same organization. I had followed its growth and development from a start up to near failure and then rebirth. I had become aware of the reality that our course had been, and would continue to be, determined by how we responded to external challenges. The three most common pieces of advice that I got from those who were earnestly trying to support my attempts at leadership were to communicate, communicate and communicate. I had seen success occur when our leadership could effectively communicate a compelling vision that was trusted, and I had seen the organization come within a hair of bankruptcy when we lost site of our values.
Our organization was populated by several thousand employees spread over more than twenty clinical and administrative sites covering a geography of about a thousand square miles of Eastern Massachusetts. I was committed to visiting every site many times each year, but felt that I could never really effectively transmit the need for change through periodic visits alone. I reasoned that a possible solution to the communications dilemma would be to have a weekly conversation with all of the employees through a letter. I knew that for the letter to be effective it needed to feel like a personal letter. It also had to be a trustworthy presentation of the realities and opportunities ahead that addressed issues of concern. I also knew that the letter had to welcome comments and alternative opinions. The goal was to connect the extra efforts that we were requesting of everyone to an understanding of our mission in a way that would add to their satisfaction and create new connections. Sometimes those connections were with people who were in the office next door, but with whom they had lost contact.
The letter became an effective way to announce and explain each new opportunity or challenge. It offered a way to replace rumor and misinformation with an analysis in the context of our mission and the commitments that we had previously made to one another and to our patients and the community. At its best the letter did more than just communicate by telling people who we were, what we were doing, and where the opportunities and challenges were. It allowed the use of stories and metaphors to enhance understanding and commitment that was not the usual outcome of a typical institutional memo.
The letters had a purpose but they also had a personal origin. I had followed an unusual pathway to my leadership role. I had never been a medical manager. Early in my career I had been considered dangerous by some in leadership. I was a respected clinician who was often outspoken when I thought that management was losing its direction or veering away from our foundational principles. I would not have been a good player on the management team, and my efforts to become a manager were rebuffed. I was advised to stick with practice and leave leadership to others. Rebuffed by management, I became an organizational politician, and as part of the voice of the practice made my way into leadership through governance.
My progress in governance was a slow process of many years that required patience, but the various committee responsibilities did serve as a great classroom experience in the business of healthcare. By the time I did become CEO I had spent much of my time trying to be heard, and I assumed that there were probably others that shared my desire to be heard. I was empathetic and understood their frustrations. My own past history informed me that it was hard for management to have a meaningful conversation with those who did the work. I had always eschewed the organizational memo or letter from leadership as did most of my colleagues. Most of those memos were announcements of things that we did not want to know. Many of those carefully wordsmithed documents announcing bad news went directly into my circular file, back when they came on paper. Once they began to appear electronically it was easier to not open them and just guide them with the mouse toward “trash.” After the tables turned and I was the author of memos, I realized that what turned me off was that when I read a memo I was often left wondering what had not been said. Experience had taught me not to always trust what I read.
Several years into the letter I came across the work of
Professor Rebecca Henderson of the Harvard Business School that explained in part why I did not trust management, and why I intuitively felt that it was important to try something like the weekly letter to build trust through effective communication. She presented “
relational contracts” as a major part of the success of companies that practiced continuous improvement so successfully that they could lead their markets for extended periods of time.
Trust is an essential component of relational contracts and effective truthful communication is foundational to the growth of trust. There really is not much that a CEO can do on any given day to promote success other than support those who are doing the work. Providing the right support requires communication that flows up as well as down the organizational hierarchy. My major responsibility was to create a conversation that informed as many people as possible with the information and understanding necessary to be part of effective problem solving and innovation. They needed to understand what had come before, what we believed, and what challenged us in the moment if they were to participate in a conversation about what our opportunities might be and I needed to hear what was on their minds and how I could help them do their work.
I am not sure why when the leadership responsibility shifted to me that I thought a regular weekly attempt to inform and engage everyone would build trust. Somehow it seemed likely everyone might benefit from a weekly missive written in a personal voice that was a mixture of celebrations and concerns and that discussed issues of importance in real time and invited response. The letter did achieve much of what was intended with many who received it. In retrospect it seems to have been most popular with those who had traditionally been furthest from the centers of decision making. Accidents often inform us. One Friday a technical glitch prevented it from going out around noon which was then its usual publication time. By three o’clock my inbox was full of notes asking what was wrong. It seems that many people had developed the habit of reading the letter at their desk as they ate lunch.
A further explanation for the benefit of the letter came to me years into the life of the letter from a consultant who had become a friend and Interested Reader. He introduced me to the work of
Albert Hirschman, an economist with a fascinating personal history, who is probably best known for a little book that he wrote in 1970 entitled
Exit, Voice, and Loyalty. In the book Hirschman observed that in organizations when things are not going well an individual has three choices. You may choose to leave or “exit.” You may choose to stay and “voice” your concerns. Many just hunker down and remain “loyal” and hope for the best. We often combine voice and loyalty. In a short
Harvard Business Review posting shortly after HIrschman’s death at age 97 in
2012, Justin Fox did a nice job of laying out Hirschman’s ideas in a brief presentation. I like one example of the concept that he presents:
You’re a Republican intellectual — David Frum, say — dismayed by the direction your party has taken over past few years. Do you a) switch over to the Democrats, b) raise hell in the media, or c) try to stay welcome in the party’s corridors of power in order to quietly exercise your influence? In each example above, you’re choosing among the options of exit, voice, and loyalty — or some combination of two of the three (it’s difficult to combine all three, although a parent who yanks her kid out of public school but still shows up at school board meetings and gives a little money to the PTA would presumably count). The terminology comes from Albert O. Hirschman’s 1970 classic Exit, Voice, and Loyalty: Responses to Decline in Firms, Organizations, and States. As Hirschman’s death... made clear, the book has a substantial fan club among social scientists. After reading about Hirschman’s ideas it occurred to me that intuitively my letters had offered to others what I had also wanted for many years which was voice. Having the opportunity to use voice should promote loyalty, whether the option to speak is exercised or not. In retrospect, I did consider exit, but opted for voice and loyalty. The letter was an expression of that choice.
Since retiring three years ago I have applied the concept of voice and loyalty to my role as a citizen who is concerned that everyone should have access to effective care that is continuously improving in quality as it remains economically sustainable. I see the same issues of mistrust, confusion, and fear in the nation that once concerned me in our multispecialty group practice. Exit is not a possibility, although many do fail to participate. These continuing letters are an attempt at voice and an expression of loyalty.
One advantage of retirement is that since I am speaking as an individual and not as a representative of an organization. I can be less restrained in my political comments. The title of the letter in its current form, “Healthcare Musings,” is meant to infer that the letter is a window into what is rumbling around in my head. I would love for the reader to imagine that if we took a walk together or enjoyed breaking bread in some pleasant place we would get lost in a conversation about something we both cared very much about. We would open up the conversation to more personal concerns and allow our relationship to be more intimate and trusting. The blog posting each Tuesday on
Strategyhealthcare.com attempts to be more reason and less “musing.” I hope that you will enjoy both.
This last week I was listening to Terry Gross talk with Tom Rick, former Washington Post reporter on defense issues, about his book,
Churchill And Orwell: The Fight For Freedom. The conversation was an attempt to explore how to resist the totalitarian state. They discussed our current issues including the performance of the president and Rick’s experience with General Michael Flynn. At the end of the conversation Gross summed things up with the last line from the book.
The fundamental driver of Western civilization is the agreement that objective reality exists, that people of goodwill can perceive it, and that other people will change their views when presented with the facts of the matter. What do we do when that “fundamental driver of Western Civilization” seems to no longer exist? This week’s letter begins with that concern and then looks at some of the political events of this last week, like the president’s budget proposal and the CBO report published Wednesday on the House’s bill that is now being considered by the Senate. It will also discuss the range of options available, from the unacceptable withdrawal of government support to the poor to the unlikely option of a single payer solution.
Respecting What Justin Has To Say While walking I often listen to
podcasts from Tom Ashbrook’s weekday morning shows on NPR. The first hour on most Friday mornings is usually the “week in review.” The headliner for May 19, 2017 was:
Week In The News: Special Counsel, Trump Under Fire, Remembering Roger AilesBombshell week in Washington. Classified information shared with Russia. Special Counsel appointed. Roger Ailes. The president heads abroad on his first foreign trip. Our weekly news round table goes behind the headlines.
Tom Gjelton, veteran NPR reporter and husband of reporter Martha Raddatz, was sitting in for Ashbrook who has been out after surgery. I have transcribed what I heard at about 25 minutes into the conversation.
Tom Gjelton: Let’s go now to Justin who is on the line from Texas. Justin, I assume you have been following the discussion on the program so far, what are your thoughts?
Justin: Well I just had a couple of comments. Uh, I just a, I’m 43 years old. You know I have been through a few presidents, uh, that I can remember, and uh, I don’t think you guys any have criticized, scrutinized, or have been so biased against any one man in my memory. Obama could have run over and killed somebody and you all wouldn’t even cover it. Uh, you all have just flipped as soon as this man was elected president. I think that he’s doing a great job. He’s not perfect. He’s had some screw-ups here and there, but jeez Louise, nobody has even given him a chance. You all has just cut him off at the knees every chance you all get. It is, it’s unreal. It’s unfathomable how you’ll have just shredded him. You all didn’t give Clinton this much deal when he had his little fling in the White House. It’s just unreal.
Tom Gjelton: Ok Justin, Let me just ask you a couple of questions, just to clarify. First of all what is, what was your reaction to the news that the president had shared classified intelligence with the Russians? And second, what did you think of the news that Jim Comey, the FBI director, wrote a memo in which he said that President Trump had urged him to back off of his investigation of General Flynn?
Justin: Well, the deal with the Comey memo, uh, you know it, it’s, uh, what’s the problem with one man asking another man, hey do something? That is not obstruction, uh and uh...
Tom Gjelton: It is the President of the United States.
Justin: Correct, he can do whatever the hell he wants, just about. But you all, uh, but as far as the sharing classified info, you all have got, you all, the press has gotten so comfortable with being, you know Obama just letting them in everywhere. And who knows what the truth is on some of you all’s reporting. Um, if he shared a little info, big deal to my knowledge, and to what McMaster said nothing was inappropriate.
Tom Gjelton: OK Justin, thanks very much. What’s the big deal? I have listened to the tape several times and it is unclear to whom Gjelton was speaking when he asked, “What’s the big deal?” I think Gjelton was asking a rhetorical question to all of us, not just to Justin who was no longer on the the line after the “..thanks very much.”
I am sure that Patty Gabow, the retired CEO of Denver Health could answer Gjelton. I think that she would begin by referring to our national crisis of division and our lack of “social solidarity.” Gjelton is an archetypical example of the urbane, highly educated and connected individual who would immediately accept the pronouncement of
Tom Ricks that:
The fundamental driver of Western civilization is the agreement that objective reality exists, that people of goodwill can perceive it and that other people will change their views when presented with the facts of the matter. I feel like I have met Justin. He could be one of my relatives down South, or a neighbor here in New Hampshire. Perhaps he goes to my church, or I met him at a local meeting of “Rotary.” He may own the fishing shop where I buy my flies, or he could be the fellow who put some new gutters on my house. Perhaps he is the fellow that we love because he so reliably plows our snow, grooms our lawn, and is cheerfully available for every little task that we need someone to do for us now, and will need even more in the future. I do not really know who Justin is, but I will assume that he represents many middle aged and intelligent white men from both red states and blue states who can look at the same facts and from the context of their own experience come up with a completely opposite set of “facts” while looking “objectively” at exactly the same events that generate a different set of “facts” from a guy like Tom Gjelton or me. I assume that Justin’s parents, his spouse, his children who may already be voters, and many of his neighbors see the world through the same frame that he does. I can sense that he was as emotionally stressed by President Obama, Nancy Pelosi, and Harry Reid as I am by President Trump, Paul Ryan and Mitch McConnell.
The sad reality is that the moment was lost. Justin had the courage to call, and Tom treated him with respect, but the conversation ended without even the agreement to disagree or consider seriously the point of view of the other man. Later in the week while I was engrossed with articles about the CBO’s scoring of the latest version of the House’s American Health Care Act, I noticed that my wife was listening to a Facebook feed on her computer. The clip was a series of interviews with white men and women in midlife who were grading President Trump on his overall performance. The grades ranged from B to A plus. All of the graders were supportive of the president, as was a
panel of students at Texas A&M which was presented by CBS news. I knew that neither presentation had statistical validity, they were “numerator” observations at best, but I also recognize that the recorded expressions are an accurate picture of a serious reality for which we seem to have no currently feasible resolution.
I had hoped that during the week when the president was abroad there would be some respite from the daily bombardment of controversial decrees and Tweets, but it was not to be. As he flew off to Saudi Arabia the president’s budget recommendations were sent to Capitol Hill. The document was entitled “
The New Foundation for American Greatness”. The link allows you to review the staggering list of 66 programs that will be cut. The list includes business development, public education, healthcare training programs, housing programs, food stamps, and support for community clinics. It is important to conceptualize that just as the “repeal and replace” legislative agenda threatens individual access to care, a budget like this will undermine attempts to address the social determinants of health.
We are reassured by the fact that it is unlikely that these budget proposals will ever be passed as recommended, but many of the cuts could survive the bargaining in Congress that will be necessary to pass a budget. This budget is the financial expression of the philosophy of the administration, and an attempt to stay aligned with campaign promises. The fact that these cuts could be presented as suggestions for consideration is very discouraging as it engenders fear and undermines the confidence of many who are critically dependent on the programs that this administration’s budget recommendations would abolish. Many of those who should be concerned did vote for the president.
The budget is also intellectually dishonest as noted by many economist. It contains tax cuts that are justified as the creators of economic growth that will pay for the cuts and abolish deficit spending during the next decade.
None of us were really surprised by the Congressional Budget Office’s scoring of the personal and fiscal impact on the American Health Care Act recently passed by the House. I doubt that there is much that I can add to your understanding.
I would recommend reading the analysis published by the Commonwealth Fund. The authors, David Blumenthal and Sara Collins are trustworthy and knowledgeable healthcare policy experts. The authors sum up their take on the sad reality as they conclude their discussion under the heading of “What’s Next.”
The bill now moves to the Senate, where Republicans are reportedly drafting their own ACA repeal and replace plan. The reconciliation rules under which the bill is being moved through Congress (so that it can pass without the support of Democrats who uniformly oppose repeal) will require that the Senate bill affect federal spending no more than the House bill, which the CBO scores as saving $119 billion over 2017–2026. The House achieved this result through cuts of $1.1 trillion in spending on Americans’ health insurance and tax cuts of $992 billion that accrue disproportionately to wealthy people.
The CBO’s score demonstrates in black and white the consequence of such a trade-off: a steep price for millions of American families in coverage losses and a heavy toll on many people’s personal budgets. I understand the significance of focusing on the finance, but I am focused on the devastation that will result from 23 million people losing their coverage, meaning that there will be more than 50 million Americans without healthcare in 2026, and the president has the gall to say that he is on track to “make America great again.”
In a creative piece in the
New York Times Jeanne Lambrew, who was an advisor to President Obama for healthcare, imagines some headlines that might create trouble for the Republican majority as we work our way toward the 2018 midterm elections if Mitch McConnell is able to figure out a way to pass something that resembles the AHCA as scored by the CBO.
- “Trumpcare Premiums to Soar by 26 Percent.” The C.B.O. estimated that the new health care bill would add an average of about 20 percent to individual market premiums next year, on top of the projected 6.5 percent annual increase under the current law.
- “60-Year-Olds to Pay Over 50 Percent More Under Trumpcare.” The new bill would let insurers charge older Americans five times more than they charge young adults (up from the three times more allowed under Obamacare) and decrease their tax credits starting in 2018.
- “Insurers Fleeing Trumpcare.” Over the last three and a half years, people in all areas of the country had marketplace insurance plans to choose from. But in part because of questions about the future of the marketplaces, some insurance companies are reportedly planning to cut their offerings in 2018.
- “Biggest Rise in Uninsured in History.” The C.B.O. projects that 14 million people will lose coverage in 2018 as a result of cuts to Medicaid, subsidies and rising premiums.
- “Untreated Opioid Addiction Surges.” Hundreds of thousands of people who are addicted to opioids got addiction and mental health treatment through Obamacare, preventing many overdose deaths. Trumpcare would end the nationwide requirement that plans cover these services...
- “Trumpcare Is a Windfall for Millionaires.” Warren Buffett recently said that the House bill “is a huge tax cut for guys like me.”
It may be entertaining to imagine how the attempts to repeal and replace the ACA could lead to uncomfortable moments for Republican politicians, but that does little to help us maintain the progress that has been made toward the Triple Aim through the ACA. It would be a much better use of time to try to conceptualize how to either block the effort to repeal and replace the ACA or engage in a productive conversation across the aisle to find ways to produce something better. Any positive outcome would require that more than three Republican senators to “see the light.”
Paul Kane offers us an analysis in the Washington Post that gives us a starting point toward either outcome of saving the ACA or creating a coalition that might produce a bill that builds on the benefits and experience gained over the last seven years with the ACA. He sees the Republican leadership losing votes from both moderates and conservatives. The conservatives who will argue that the bill doesn’t go far enough are Rand Paul of Kentucky, Ted Cruz of Texas, and Mike Lee of Utah. The moderates who may be predisposed to work for something better may include Senator Shelley Moore Capito (R-W.Va.), who has 180,000 constituents relying on the Medicaid expansion for insurance coverage. After Wednesday’s updated estimates, those Senate Republicans, predominantly from states with large populations of people who benefited from Medicaid expansion, may dig in even further against the House bill because millions of their constituents would be left in the lurch by the GOP proposal. There are actually twenty Republican senators from states that did implement the Medicaid expansion in the ACA. Kane reports that Capito believes that the updated CBO estimate “puts steel in the spines of those Republicans.” Other potential leaders include Senators Rob Portman (Ohio), John McCain (Ariz.) and Lisa Murkowski (Alaska). We should also not forget Susan Collins from Maine and Senator (Dr.) Bill Cassidy from Louisiana.
My advice is to dream of something better like a single payer solution, but to work hard to preserve what we have, and hang on for 2018. Imagining our patients suffering under the AHCA is too painful to contemplate. The thought of the possibility should mobilize us all to express ourselves to our senators and especially to the ones who seem likely to understand the pain that the AHCA might create for those unfortunate souls among us who would lose their care.
I am frequently asked what I think about a single payer option. I do believe that in time we will have a single payer. Just as Massachusett enacted “Romneycare” to be followed four years later by the ACA, I believe that some state or states will try a single payer payment mechanism and that in time momentum will grow as other states follow the lead. That is what has happened with same sex marriage, and is now happening with laws governing the use of marijuana. Single payer will be harder. With marriage and weed all that must go away are barriers like emmotion, religious objection, and fears of how society might be damaged. For single payer to be accepted a huge industry associated with thousands of jobs must go away, not to mention fears about “socialized medicine.”
An interim pathway, a “public option” where the government would offer a plan on the exchanges in competition with commercial insurers was considered and killed in the Senate finance committee during the runup to the passage of the ACA by Senator Joe Lieberman from Connecticut, the home of many insurance companies. Perhaps the road to
...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. will pass through a public option on the way to a single payer system sometime before there is moss on all of our tombstones.
I Am Hoping That The “First Weekend of Summer” Is Not a Washout I wish that we could always count on the Memorial Day weekend being the start of summer with the same confidence that we know that summer will end with Labor Day. The reports from the weatherman are iffy and I am sitting in front of a blazing fireplace listening to the cold rain fall in the darkness outside my door.
This time of year summer is an off and on thing. Earlier this week I enjoyed walking in warm sunshine. The picture in today’s header is proof that we had a great day. The rest of the week has not been so good. I took the picture because of the wall that is crowned by tall white pines. For several years I have wondered if this wall was built sometime in the last two hundred years and then the trees grew on top of it. I am not so sure. It is possible that when the hill was cut to make the road less steep, what appeared to be a wall emerged. My neighborhood is really a pile of rocks crowned by trees. There is uncertain weather, walls in the woods, and walls along the roads I walk. It adds up to an interesting trip. I think the same is true for healthcare. We are in a strange moment of social uncertainty with wall like barriers between us and the Triple Aim. We must stay the course and look for the opportunities that will surely develop. While you are thinking about what is to come I hope that you have a great weekend.
