| 29 April 2016
Dear Interested Readers,
What is Inside This Week’s Letter
The letter this week is a follow up of sorts. I think that more than many of my recent letters it qualifies as a “musing”. In last week’s letter I semi-showcased a presentation at GPIN by Jeff Goldsmith, the healthcare futurist. I also mentioned in the letter my experience with “scenario planning”. This week’s letter reviews both of those items and is an expansion of the discussion of “the future”. With my observations I attempt to examine the ways in which we vary in our expectations and plans for the future that we will share. The letter ends with an attempt at a few chuckles about the way winter can surprise us well into baseball season. Oh, and lest I forget, there are comments about the continuing issues that the primary election process presents us and a mention of the mesmerizing fascination the media has with Tom Brady and “deflategate”.
I really like my posting this week on strategyhealthcare.com. I have tweaked my comments from the letter of April 15 about the JAMA article on income and life expectancy. I hope that you will check it out. Once again, I request that you will tell your friends that they can get this letter sent to them by signing up on the same site. I realize that free is not cheap enough for some folks but my intentions are pure. The motivation is not for income but rather to add just a little to the understanding of the importance of our attempts to work together for the Triple Aim. I love the new expression of the Triple Aim:
Care better than we have ever seen, health better than we have ever known, cost we can all afford, …for every person, every time…
Looking Into the Future For a Sense of Security
I have been thinking a lot about the future lately. That is not new. I always think a lot about the future; so much so that at times I am reminded by others to “be in the moment”. My response, usually kept to myself, is that it is too late to do much about the present. That hand is dealt and it is just a matter of playing it out. The past is in the books and useful mostly for the lessons that it makes available, if we can just be honest with ourselves about what really happened and why. The future contains all of the excitement, all the possibilities, and all the pitfalls. The future teases us with the possibilities of fulfilled dreams but it is also the home of nightmares that perhaps can be contained if imagined and avoided. The future offers us the opportunity to move beyond simple fate, if we can just sort through the complexity, and uncertainty of the moment and find a vision that will guide our resolution of all the ambiguities that loom before us.
Years ago I concocted a quote that works for me by leaving out a few unnecessary words from Charles Handy, the British business guru and part time futurist.
The future we predict today is not inevitable. We can influence it, if we know what we want it to be…We can and should be in charge of our own destinies in a time of change.
Charles Handy, The Age of Unreason
Quotes like Handy’s underline the importance of thinking about the future. For a long time we have imagined that our species alone thinks and plans for the future, but scientists have begun to construct some arguments that suggest as homo sapiens we may not be as unique as we would like to think. Some animals seem to hide “tools” and food for the future. Who knows whether they can contemplate the joy of success or suffer the anxieties and fears of failure in their futures, though their behavior suggests that they must be hoping not to be lunch for someone up the food chain from them. What I am sure of is that they do not discuss policy or use forecasts and budgets, nor share written strategic plans with others of their ilk.
Our biggest problem is not our inability to imagine a better future. Atul Gawande has famously said that our problem is not our collective ignorance but rather lies in our collective ineptitude. Our greatest problem is our inability to collectively execute a strategy for the future. The biggest barrier to that exercise seems to be self interests that trap us in the problems of the status quo. To imagine and accomplish a better future requires that together we manage our fears, self interests and variations in opinion to achieve the future and the outcomes that we say we jointly embrace.
The future is the proving ground for the outcomes of all our apprehensions and all of our hopes. I was recently reminded just how vulnerable future plans are by a line from one of my new favorite authors, Richard Ford. Ford’s writing is one of my most pleasant discoveries in retirement. In his excellent novel, Canada (2012) he has one of his troubled characters, Arthur Remlinger, advise the fifteen year old protagonist and narrator of the story, Del Parsons. Arthur suggests to Del that he should seek to gain wisdom by reading biography, especially the lives of generals. He says,
“They [generals] know plans work out very, very, rarely and failure’s the rule.”
Plans always have their payouts and problems in the future. I guess that I relate to Ford because we are the same age and in some of his writing there is the suggestion that the two of us are dealing with the unknowns of our personal future in many of the same ways. I almost always assume that narrators and protagonists share some traits with the authors who invent them, so being 15 in 1960 is a fact that Ford, the author, Dell, the protagonist and narrator, and I, the reader share.
A little further along in the book the narrator makes a comment that is grounded in years of reflection, and assigns much of the responsibility for the future to fate:
“...no matter the evidence of your life, or who you believe you are, or what you’re willing to take credit for or draw your vital strength and pride from---anything at all can follow anything at all.”
At the end of the book we learn that Dell is sixty six when he tells his story and that quote comes as a reflection nearer the end of his life than the advice he got at fifteen. That works, since the book was published in 2012 when Ford, Dell and I were all 67. That is an important fact since this quote comes from the narrator as a lesson learned since he was fifteen.
The first of those two quotes reminds us that it is easy to plan and hard to execute the future that we want. The second adds weight to that opinion and suggests to me that even though we may be experienced, gifted, strong, rational and committed, there is an uncertainty about the future that can trump all of those assets, positive character traits, and competencies. What we often forget as we reassure ourselves about our internal capabilities is that those skills must be aligned against the challenges of a future where there are potent forces that may be moving in a way that will create unforeseen conflict or problematic circumstances.
Those outside forces are a combination of externalities that arise from the will of others as well as from chance. The future that we ultimately experience will follow the resulting vector of all of these forces and realities. Some force arises from us and our will and insight, and some from those factors that may be beyond our control. Sometimes by fate or design, our skills, chance and externalities align and delight us, but as the first quote implies, the denominator of the frequency of our efforts is much greater than the numerator of our successes.
Pessimism accepted and put aside, let no one ever accuse me of failing to make plans for a better future. I am and have always been a willing conspirator for a better world grounded in the greatest good. The issue has always been how the greatest good is determined. My response to the knowledge that there are external forces and flows that may sweep me toward a future that I want to avoid is to try harder to understand and counter those facts and forces with effective strategies and seek alliances with like minded souls. Experience and others advise me that we must do more than wish or hope for a better future. How do we follow Handy’s advice and begin to “influence the future”? How do we attempt to make the future what we want it to be?
Having set the objective of preparing for a better future, how do we prepare to achieve that objective? Said simply the question is, “What might I do to change the outcome from what will happen if I do nothing?”. A key strategic consideration is, “ How do we build a coalition for the better future that we desire?” This question must be balanced by age old advice from the Hippocratic Oath, primum non nocere. I prefer to translate this concept of “first do no harm” into something more personal---“If you can’t make it better, please don’t make it worse”.
Lean has taught me a lot about the search for a better future, which is usually, but not always, the search for solutions to current and future problems. In box one of an A3 we have a “reason for action”, an opportunity, concern or problem that needs improvement. We use a process to search for solutions in the future that will lead to an improved state. That search requires creating a catalog of all the issues in the “current state” that contribute to the “reason for action”. That list is composed of barriers, needed changes, or new assets that are needed if the target or ideal state is to be found in the future. In those searches it is very easy to consider all those factors outside yourself when the only factors over which you theoretically have total control are those that are the answers to the questions, “What part of the problem am I?” and “What can I do to improve the future?”
My thoughts about the future have been heightened by the fact that yesterday and today I have been in the Washington area participating in an exercise with about thirty other people who are interested in the future. We have been playing out various scenarios that may be part of plausible futures in healthcare. The exercise has been described as “healthcare war games”, and I am not surprised to see many of the “Interested Readers” of this letter in the room. These exercises have some similarity to the work described in The Art of the Long View by Peter Schwartz. The exercise has been much like the one that I described in last week’s letter that Atrius leadership put itself through in early 2009. The idea is to use simulations of what might happen to look for common threads that might generally apply as good strategy or good policy. The elusive goal of the “war games” is the Triple Aim. Exercises of this sort may underline the complexity of negotiating a better future. The hope of the exercise is that by “role playing” the potential concerns and objectives of the players in specific markets, the exercise might surface potential concerns that need further consideration and help us avoid failure by anticipating and preparing for hidden contingencies.
As I mentioned last week, the scenario planning exercise at Atrius Health convinced us all that we could not “cut our way to success”. We saw that the common thread in the scenarios was the need to reduce the total cost of care. That insight led to moving patients to more “cost friendly environments” and introducing and investing in Lean to reduce waste and improve “flow”. We also realized that we needed to anticipate the move to value based reimbursement and actively embrace risk. Finally, we convinced ourselves that investing in staff in ways that would lead to higher quality, more safety, improved patients service and a better work environment for staff were a set of actions that would counter many of our threats from all of the potential scenarios and were aligned with the best outcomes we could imagine.
Another upcoming event puts my head into the future. I am speaking in Chicago next week on the topic of Living in Mixed Financial Worlds – How do Organizations Manage When there are Competing Financial Incentives? That topic may sound more like “this moment” to you than the future, but I would argue that for most healthcare enterprises accepting a mixed financial world where income is potentially the sum of declining fee for service revenue and perhaps expanding “value” based or population based revenue is a moment that is still in the future. All healthcare organizations are faced with a potentially unstable financial environment. To paraphrase the healthcare economist Michael Chernow,
“They feel like they are standing with one foot on a sinking dock and the other foot in a tippy canoe”.
There are a host of future considerations and fears that quickly come to mind as we anticipate traveling the road from “volume to value”. To use a worn out cliche, many of us are like deer in the headlights, not knowing what to do first or which way to run to even begin our transition to what has been called “the second curve”. |
| | I believe that the majority of healthcare organizations are like timid swimmers who keep putting their toe in the water and pulling it out. Actual efforts that include measurable change are hard to find in many organizations even though MACRA is a year old and this week CMS published its first request for comments on its “rule”.
When I first heard the proposed title of the talk that was being assigned to me my response was so future oriented that I turned their question into a question that I wanted to discuss and heard the question as, “How Will Organizations Successfully Live in a Mixed Financial World and Survive As They Move From FFS to Value Based Payment?”. My bias was and is that for the majority of organizations the idea of the transition is and will continue to be frightening. The fear of failing has delayed the start of their journey. I see active resistance to doing anything within some systems of care manifested as more strategic thought being applied to how to resist the movement for as long as possible than to starting to the move to prepare for more risk and value based payment. Indeed, as with the ACA, ICD 10 and Meaningful Use, there is widespread hope that the “second curve” future will never happen or that at the worst it can be delayed until it is someone else’s problem.
I think that Jeff Goldsmith was tapping into this undercurrent of resistance when he asked the question, “What if the crowd [healthcare policy wonks and self styled experts] are wrong? Based on where his talk at GPIN ended up, I do not think that he was trying to advocate that physicians resist the future, but I do think that he is suggesting that in the short term we need to discount our expectations. I am convinced that there will be continuing efforts to resist healthcare reform as it moves from volume to value and that resistance will mean that it will take a long time to accomplish less than we hoped.
Let’s look at the six ways Jeff suggests that the experts may be wrong. I think that he is channelling the thoughts of many. His answer to each of the statements below is, “Not”.
- Costs are Rising Uncontrollably and to Control Them We need to Change How Health Providers are Paid---he disagrees and offers data.
- Population-based Payment Is the End State of US Healthcare Payment--he is not so sure.
- Providers Will Have to Shift from Treatment to Prevention to Manage Population Health Risk--again he is skeptical.
- “Disruptive Technologies” Will Undermine the Traditional Business of Healthcare, Forcing Transformative Change--he looks at history to support an argument that this is an allusion.
- Consumer Empowerment Will Strengthen the Role of Consumer Choice in the Health System--we hope, but it really has not happened yet.
- Systems will integrate and create new value--historically system integration seems more often than not lead to “market power” and increased costs.
He is clever and put up convincing arguments based on current trends that on first glance seem to undermine the urgent necessity of changing what we do. I am sure that there were many in the audience who were asking themselves, “If what he is saying is true, why do we need to contemplate change? Things are not so bad for me or my patients. My biggest hassles come from the government and the payers with all their rules and regs. I just want to take care of my patients”.
It was a little like the Trumpian assertion that the workers of America have been devastated by bad policy in pursuit of things they care little about. He seemed to say that the experts do not get it. It would not surprise me if some in the audience were saying to themselves, “If we just got back to the business of being great in the ways we have always succeeded in taking care of our patients our problems will go away.”
What I heard was that the future is not so simple. It is easy to say reduce the cost of care; pay doctors for value not volume; population based payment is the future; change the focus of care from repair to prevention; try out some apps to manage your patients; realize that as informed consumers your patients will focus more on the cost of their care; and get into something bigger to be secure. Doing any of those things is hard while you are simultaneously taking care of today’s business. The future will be a function of both what we should do, what we can do, what we are forced to do, and the success of those who are not so sure and attempt to cling to the status quo. Every healthcare organization has a full spectrum of opinions running from advocates of the world according to Don Berwick to those like Jerome Groopman who writes that we are losing our way and need to focus on the traditional values of office and hospital practice.
I was not surprised by Jeff’s suggestion that in the future we should return to our roots and focus on what it means to practice. That suggestion is not in conflict with change for the future but it is simplistic because practicing as we have always practiced will not achieve the Triple Aim. We do not have the professional personnel or the funding to provide everyone who has resources the care they want, much less provide equitable care to everyone. A rational review of bodies and dollars available through employers, taxpayers, and the pockets of patients processed through current practice methodology shows that the answers will not be easy to find without deep change that hits everyone, the doctor, the patient and the payer.
Short term, there is validity to his suggestions and the set of current actions that he advises would be a good place for everyone to start their journey from volume to value.
- Learn to Run on Regular Gas (I assume this means reduce waste and make value based decisions)
- Develop a Fault-Intolerant Clinical Culture Built on Continuous Care Improvement (I agree that a focus on the nuts and bolts of care that is founded on systems thinking will improve safety and outcomes.)
- Teach Your Young Clinicians Elegant Diagnosis and Resource Sensitive Clinical Care (Critical thinking and choosing wisely what is necessary and avoiding what adds no value are subjects that need more than lip service)
- Smooth and Light the Patient’s Pathway through the Care Episode (Amen!)
- Become the Health System of Choice in Your Communities and Regions (This is the core of success in a value based system that accepts risk.)
That is a pretty good outline for the strategy that was the product of the Atrius scenario planning process. There is an even deeper insight that emerges from this list if it is the product of a strategic scenario process, and that is these suggestions are agnostic to the source of revenue. I often point out that Virginia Mason, ThedaCare, and even Denver Health improved quality, safety, and patient service as they reduced the cost of care in fee for service systems. The success of the Bellin-ThedaCare Pioneer ACO suggests that their approach to care improvement in a FFS world translated to even more remarkable success in the ACO. They were number one in the nation in cost and quality.
One thing that I know for sure about the future is that debates about what should be done and its urgency will continue. Self interest will remain a consideration, if not a barrier. We will not achieve exactly what we dreamed of with each new initiative. I also know that each time we try and fail or succeed but not as spectacularly as we had dreamed, we are still getting closer. What Dr. Ebert said over fifty years ago remains true:
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.
Winter’s Surprise Return
I have frequently said that winter is inconsiderate. If winter were an acquaintance of yours, you would probably consider it to be a real prankster, if not obnoxious. Winter starts and finishes more than once and loves to surprise us with previews and encores when we least expect them. I can remember snow storms before Halloween and after May Day. Winter is inconsistent and fickle. It can decide to come on strong as it did last year or lay back and take it easy as it did this year, but then hang around for weeks long after its “time” is supposed to be over and drop snow on a day when we should be playing baseball or taking a walk in the park. Winter can be like a bad cold that will not go away.
Winter can proceed an Indian Summer, basically that is the definition of Indian Summer. On this end of the calendar winter often decides to make an encore bow after a fine run of spring weather as it did this last Tuesday. In the middle of the winter’s storm in Spring, I could not resist taking the picture of daffodils in a bed of new snow on Main Street in New London that is the header for today’s letter. When I took the picture the snow was falling pretty briskly and I was excited about one more walk in a winter wonderland. I did feel short changed by winter this year since there was so little snow to enjoy, but alas by the time I got on the road late in the afternoon, the snow and the show were over.
Tuesday was Primary Day in five states and when it was over Donald Trump and Hillary Clinton were yet a little closer to what many fear, a choice between unacceptable alternatives. Ted Cruz and John Kasich have had tried to counter the inevitable by their “compact” to cooperate in pursuit of an open convention and then Cruz added Carly Fiorina as insurance? Trump’s amazing rise continued never-the-less with wins in five states. Everything about the media in this election cycle seems changed in response to Trump. I was amazed to notice that in last week’s New Yorker every cartoon was about Donald Trump, including the last sketch by the fabulous William Hamilton, who died recently in an automobile accident. I am looking forward to the end of it all, but November is a long way down the road and then winter will be back.
The saga of Tom Brady continues to work its way through the federal court system and enthrall the media. It is interesting to contemplate the reality that if Tom can get some sort of delay by winning yet another appeal, Donald Trump may be his savior. Success would only require an appeal to the next level of the court and the simultaneous election of Donald Trump who would surely pardon him if the decision went against him once again. I would just suggest to Tom that he try to bargain down the penalty in association with face saving statements from both sides.
Without the snowfall my walk on late Tuesday was just a walk in cold wet weather but I did log my miles and remained on track for my goals. It always amazes me what you can accomplish if you can just stay on track toward your objective. Some days are better than others but whether in snow, wind, rain or shine, a good walk is hard to beat. A good walk alone is a great time to think through some scenarios about the future. The only thing better is to walk with somebody and get their thoughts about the future.
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| Be well, keep planning and working for a better future and let me hear what is happening where you are,
Gene
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