| 29 January 2016
Dear Interested Readers,
Inside This Week’s Letter
A very regular “Interested Reader” has suggested to me on more than one occasion that I am a better “memoirist” than “prophet of doom”. He points out that one advantage of being a memoirist is that memory can be legitimately inaccurate! This letter begins a multi week exploration of the wisdom of the Triple Aim with reflections that go back to the mid nineties. I can say that I have made every attempt to be accurate but must admit that I have a septuagenarian’s memory. The letter describes my interpretation of how the Triple Aim became my road map for how to lead a practice.
In the next few letters I hope to continue the use of memoir to demonstrate how the Triple Aim continues to offer us the the orienting benefit of a shared objective. I hope to reveal many layers of meaning within this simple statement. I have come to believe that just as you can suddenly see deeper meaning in an old song or a favorite scripture, thinking together about the Triple Aim can open new paths as sudden insights emerge from familiar words. It will be my contention that the Triple Aim subsumes all of the traditional values of medicine and more. It can be a guide for solving the new problems that arise every day. Before we are finished with the review it is my hope that I have convinced you that having a deeper understanding of the wisdom of the Triple Aim is essential to the outcomes patients individually desire and collective must have if we are to enjoy:
Care better than we have ever seen, health better than we have ever known, cost we can all afford, …for every person, every time.
If you got lost in my rant last week about the article in the NEJM by Doctors Groopman and Hartzband there is now a revised, shorter and much tamer version on strategyhealthcare.com that I hope that you will check out. As I always say, strategyhealthcare.com is where your colleagues and friends can sign up to get these letters. I also want to recommend the writing of Dr. Paul DeChant and hope that you go to his blog and read his thoughts on the same subject in “Taylorism vs. Toyota: Managers with Stopwatches vs. Respect for People”.
Let me offer a huge welcome and thank you to the new readers this week.
Taking a Deep Dive Into the Origin of Triple Aim By Way of Memoir
This Tuesday I was the Keynote speaker at the meeting of the New Hampshire-Vermont Chapter of the Healthcare Financial Management Association. The conference was focused on the transition to value based reimbursement and the request to me was that I tell them about how Atrius Health had prepared itself to become a Pioneer ACO. I was eager to hear what the other speakers had to say because my story was about history and philosophy and theirs were about current events.
I knew that members of Vermont’s Green Mountain Care Board and OneCare Vermont, the largest Vermont ACO would be also be speaking. There were also going to be speakers from the ACOs in New Hampshire. There would be reports of some of the new insurance company delivery system integration activities in New Hampshire. I planned to be there the whole day, even though it would mean that my walk would be in the dark. I knew this would be a great opportunity to learn a lot about my new community and region. I had also agreed to facilitate a question and answer session between the speakers and the audience at the end of the day.
My presentations always include a reference to the Triple Aim as well as a few words about the contributions fifty years ago of Dr. Robert Ebert to our efforts to find a better operating system in healthcare. What I did not expect to hear or see was that all speakers referred to the Triple Aim and they all had a slide demonstrating its importance to their work as they sought to prepare for value based reimbursement. Most of the speakers also referred to the concerns about burnout and future clinician shortages in their practices and expanded the concept of the Triple Aim to the Triple Aim Plus One.
I was amazed. In contrast, I remembered a few years ago giving a presentation to a medical group and realizing that they seemed confused when I mentioned the Triple Aim. I had paused and asked for a show of hands of those who were familiar with the concept. In the back of the room I saw one hand slowly go up. I was afraid of what I might hear as I asked that individual for the definition and was relieved to discover when I got the right answer that there was one person in the room who could verify that the Triple Aim was not a fabrication.
As the day went on I kept thinking about the transformation of practice in Vermont. The state is bravely moving toward a statewide single ACO with every practice functioning as a Medical Home in an “All Payer System” reporting to one statewide board. That bold plan was their interpretation of the best path to the objectives of the Triple Aim. It is strange to realize that there are more lives in Atrius Health than in Vermont. That fact alone makes me think that what they want to do is possible.
Across the Connecticut River in New Hampshire the thinking is also driven by the Triple Aim. As I chatted with people at the breaks and went back and forth between my internal conversation with myself and the presentations unfolding in front of me, I found myself on a journey down memory lane and realized that by looking backward we might gain some insights from the experiences we have had wrestling with this brave idea.
I will begin my story looking back to 2008, a year after the formal declaration of the Triple Aim, when in mid February I suddenly and quite unexpectedly found myself pushed into the interim role of CEO of my practice, Harvard Vanguard Medical Associates and the larger organization of which it was a founding member, Atrius Health. At the time I was the Chair of the separate boards of both organizations and had been talking for a few years about the fact that I was contemplating retirement. I reasoned that there were two possible pathways forward. Option one was the traditional option of holding the fort until a “real” CEO could be found. Option two was for the organization to spend a little time resolving some internal questions and then go looking for a new CEO for a more aligned Atrius Health that had a clearer concept of the way to the future.
We had a structural problem. When Atrius was created, the original documents specified the CEO of Harvard Vanguard as the CEO of Atrius until 2007 without clarity about what would happen after that moment. We “kicked the can” forward to overcome a barrier to the formation of the confederation and also to help clarify o the regulators that there was a consistency between the non profit objectives Harvard Vanguard and Atrius.
To hire a new CEO in such an uncertain situation we had changed the bylaws in 2006 to say that the two positions would continue to be joined until 2010. It was reasonable to expect in early 2008 that it would be hard to find someone who would take a job when there was such ambiguity about the future scope of the position the moment the job was offered. I was willing to accept the ambiguity with the idea that one major responsibility would be to lead the resolution of this structural issue.
Harvard Vanguard had been in existence as a self governing practice for ten years and during that time had not had a good track record with CEOs. Including the four and a half year tenure of Ken Paulus from early 2000 until mid 2005 we had been the host of five CEOs in the 10 years of our history since January 1, 1998 when we had “spun off” from Harvard Pilgrim Healthcare where we had been their wholly owned staff model practice. Indeed, we had made a “back to the future move” because when I had joined the practice of Harvard Community Health Plan in 1975 we were just a medical group practice in the earliest discussion about trying to decide if we would become a self insured staff model HMO. The creation of Harvard Vanguard represented the end of an almost twenty year experiment as a fully capitated, self insured practice of employed physicians who individually bore little or no risk. By becoming Harvard Vanguard in 1998 we had completed an intense three year discussion about collectively accepting the performance risk for a large population of patients.
My opinion as a member of the Harvard Pilgrim board in the mid nineties was that the organization had lost its focus on quality and safety and was willing to take risks in its attempts to buy “market share” that were inconsistent with prudent management and represented a disregard for the realities of an actuarially sound appreciation of the determinants of the medical loss ratio. I was a member of the board because I was the Chairman of the Physicians’ Council of the staff model practice. As a member of the finance committee of Harvard Pilgrim and as a board member I did not keep my concerns to myself, and along with a few other board members expressed my worries. I was invited to leave the finance committee and join another committee that was more appropriate to my status as a physician.
For several reasons I was an enthusiastic member of the small core group of concerned physicians and managers that beginning in 1995 tried to create the separation of the staff model practice from the insurance company. There were several reasons that I thought that the staff model physicians and their colleagues in the practice should become an independent practice. First in importance for me was that I was disturbed by the number of patients my practice was losing because it was exclusive to only one insurer. I was seeing many patients whom I had known for ten or even twenty years leave my practice because their employer had made the decision to buy healthcare from a “sole source” that was not Harvard Pilgrim Health Care. Also of importance was my concern that Harvard Pilgrim was not financially stable because of the aggressive expansion strategy and the risky underwriting process to support that strategy. The truth was that there was no process. There were no actuaries on the payroll!
I felt that the new management team that was in place after the merger of Harvard Community Health Plan with Pilgrim Health Care in 1995 was taking chances that would eventually put the organization in jeopardy. Others in the practice shared my concerns and after we had finally negotiated the process that would begin the migration toward total separation in January 1998, I had a mental image of our practice being like hopeful survivors in a lifeboat rowing as fast and as hard as we could row to get far enough away from a sinking ship to avoid being sucked under with it.
The ship did begin to sink as predicted and Harvard Pilgrim was taken into receivership by the Attorney General in December 1999. I hated to say, “I told you so!”, but it was true. More realistically it is a breathtaking experience to see how fast you can lose 400 million dollars if you consistently sell a dollar’s worth of healthcare for ninety five cents to a million people while not managing where and how that care is delivered.
When the ship began to sink it was still true that more than 90% of our Vanguard patients were coming to us through contracts with Harvard Pilgrim. The process of expanding our contractual relationships with other payers was not complete. The public did not understand that Harvard Vanguard was not Harvard Pilgrim and their loss of confidence in Harvard “anything” led many of them to chose a new doctor as well as a new insurance provider. Our patient population fell from almost 500,000 to significantly less than 300,000.
Those were dark and frightening days. In the end both organizations survived because of great management by our “new” CEO, Ken Paulus, who replaced our “old” CEO, Charlie Baker (now Governor of Massachusetts) who was “moved up” from his position as CEO of Harvard Vanguard to be the Harvard Pilgrim CEO during a palace coup that removed the management team that was held accountable for the financial collapse. The reasoning in Vanguard was that Charlie Baker, our CEO had the skill that might allow Harvard Pilgrim to recover, and he did. If they survived it would be easier for us to survive. It was a painful separation but the bold action the board took did begin the process that ultimately saved both Harvard Pilgrim and Harvard Vanguard.
By 2004 both organizations were in much better shape. The recovery of Harvard Pilgrim can be quickly summarized by saying that it occurred beginning with the acquisition of great leadership and then talented management that returned it to sound actuarial principles, a laser-like focus on their core business, a renewal of its commitment to quality and the prudence to outsource many of the functions that could be better done by other business partners. They were not too big to fail but had they failed it would have been a huge loss to the community.
Like Harvard Pilgrim’s emergence from receivership the recovery of Harvard Vanguard was facilitated by the leadership of a charismatic and talented CEO. Ken Paulus engendered a willingness and created an enthusiasm across the full spectrum of the committed healthcare professionals of Harvard Vanguard to make the sacrifices necessary to save the mission of the organization. That determination not to fail enabled us to “burn the furniture” to get through the metaphorically “coldest moments” of our financial winter. We sacrificed real estate we loved, programs we were piloting but were of uncertain efficacy, and most painfully endured a restructuring of the practice and management that cost us some of our colleagues whose duties could be eliminated in the aftermath of our loss of a third of our practice. Those were dark days.
I have never believed that you can “cut your way” to success but even before I understood the principles of Lean I knew that tolerating and perpetuating waste and poorly performing systems does not provide quality care either. A major part of the recovery was the recognition that we had a practice that was too small to support our high tech infrastructure. That realization was the motivation to reach out to other independent medical practices that we admired and that did not have an EMR or the other assets like a data warehouse required for success and invited them to join us to share our infrastructure by creating the confederation that would eventually become Atrius Health.
With the creation of Atrius the years between 2004 and 2007 were a return to impressive success by any measure of finance or quality of care. Patients and providers who had no access to the benefits of an EMR or the guidance of a high performing data warehouse and the Vanguard processes of quality management, now suddenly had state of the art tools. Those were heady days but problems were developing on the horizon even as we were celebrating our success.
When things are going great guns there is a reluctance to pause and tie up loose ends. Having emerged from the cold and darkness of our financial winter many people wanted to enjoy the sunshine and warmth with no more talk of change and without any further sacrifice of individual group autonomy. It is hard to know for sure but it is reasonable to believe that year over year increases of contractual revenue that Harvard Vanguard and its partners in Atrius Health were able to request from the payers between 2000 and 2008, as well as the very favorable way we were treated by all of our suppliers and partners in the delivery of care, had as much to do with our recovery as any other thing we did.
Following the passage of Chapter 58 (Romneycare) in 2006 many of us began to be concerned again that the future might hold some negative externalities for us including a downward pressure on revenue coupled with new expenses and market shifts associated with changes in the regulatory environment. There was increasing concern that the total cost of care in our state would result in a new financial crisis that would have an impact equal to, if not greater than, the nightmare that Harvard Pilgrim’s poor judgement had created at the end of nineties. It was reasonable to ask, “What would happen if next year our contracts yielded only a 5% increase in revenue when for the past several years we have been accustomed to increases of 8 to 10% ?”. The answer is easy to calculate on the back of an envelop and was expressed in tens of millions of dollars of financial loss and a return to the horrors of 1999 and 2000.
If you have ever heard your auditors say, as I did when I was board chair, “Dr. Lindsey this organization may not be a going concern”, having heard it once, you never want to hear it again. Their “diagnosis” or opinion had surprised me and it took a moment for it to sink in. When I asked for clarification they surprised me again. They used a medical metaphor to explain it to me. They said, “Let’s put it this way. If HVMA were a patient, it would be in an ICU and intubated with no recent evidence of urine production despite pressors running wide open to get the BP up to 70. We would be standing at the bedside coming to the conclusion that it was time for the family to come in to say their goodbyes.”
As described, the auditors did not count on the leadership of Ken Paulus or the internal strength and resilience of medical professionals who were committed to the mission of the organization. They were also not expecting the level of support that we would get from the hospitals where our patients were admitted and from the payers with whom we had new contracts. We got support from our community, and between the support that we got and the work that we did we survived; but it was a traumatic moment for some of us that we never wanted to repeat.
Those memories of past trauma and the echos of those moments triggered by the realization that there was once again great ambiguity in a rapidly changing future were real concerns for our board in 2008. We were successful but fearful that our success was temporary, and we imagined that we might be further vulnerable to sudden unanticipated changes in the external environment. Our resources to survive sudden and unexpected changes in revenue or expense were still thin. We were still grieving and had still not gotten over the loss of a great leader, Ken Paulus, who had moved on to a new and exciting opportunity in Minnesota.
There were conflicting views about what we should do. In my mind the question was, “Do we sit tight and wait for the ambiguity of the moment to resolve or should we follow the advice of the British business philosopher of the ‘80s and ‘90s, Charles Handy?”. Charles Handy’s work on Federalism had been fundamental to our thinking when we became “Vanguard”. In his book The Age of Unreason I had read Handy’s advice:
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.
That was good advice and a subtle call for action and a warning not to “wait and see” if you are to have any chance to shape the future that is your dream.
It was in this moment, less than a full year after the Triple Aim had been first published by Don Berwick and others that the wisdom of the Triple Aim seemed like a drink of water for a thirsty practice. Now we know and recognize the triangle that is the image of the Triple Aim. In my presentation this week I went so far as to say the Triple Aim has become the objective of “value based reimbursement”.
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| | One pleasant reality and responsibility that confronted me as I became CEO in 2008 was that it was the tenth anniversary of the creation of Harvard Vanguard. We had planned a big “party” for our birthday. As part of the celebration we began to create documents to chronicle the history of our practice. We engaged a creative writer and as her project continued I got interested in learning more about how Dr. Robert Ebert had accomplished the creation of our practice back in late 1969. In my mind it was our tenth anniversary as Vanguard but our 40th anniversary as a practice.
I knew that Dr. Ebert had supported the creation of Vanguard because we had talked about it and although he was near death in 1996 he had agreed to make a video for us to use at a physician meeting where there was an active debate about the risks and benefits of separating from the insurance function. He had been excited about the prospect and gave his blessing in a video because he was to weak to attend the meeting. I looked everywhere for a copy of the old VHS tape. Finally in frustration we contacted his widow, Barbara Ebert, who went on a search and found the tape. She also asked us if we would like to have access to some of his papers which she had given to the Harvard Medical School and were in the archives of the Countway Library.
I was thrilled with the opportunity. There was a lot to read and the papers could not be copied or removed, so for several hours we sat there mesmerized by the letters back and forth between the Dean and his supporters and others on the faculty who did not like the idea. The Dean of Harvard Medical School has never had control over the Harvard teaching hospitals. It is a job that can only be done well by a person with persistence, vision, and the negotiating and diplomacy skills of our best Secretaries of State. Within the boxes of papers one letter stood out for me. There was a line on the second page that seemed to me to be a prototypical description of the wisdom of the Triple Aim. You have seen it before. It appears in almost every presentation I make and at least once a month in these letters. |
| | I was fascinated by the fact that these sentences were the core of his pitch in the letter written to the President of the Commonwealth Fund looking for financial support to develop the business plan to launch Harvard Community Health Plan. He must have made his point because they eventually gave him at least a million dollars and a million dollars was real money in 1965.
As I thought about what I read it scored with me in two ways. First, he was right, we do need to continue to look for that operating system that will efficiently contribute to the health needs of the population. Sadly, we have been looking for fifty years and we are still looking. The Triple Aim is the vision that must guide us if we are ever going to find the operating system that will allow us to escape from the pressure that the potential of falling revenues puts on our mission.
The second insight was that I knew that Dr. Ebert realized that the population was a collection of individuals, and in that context, his statement was the equivalent of the Triple Aim and was stated almost 50 years before it became the mantra of the IHI. The connection made sense to me. Don Berwick knew Dr Ebert much better than I did and had worked in our practice for many years. He had absorbed the strategy and the ideals of Dr. Ebert and had expressed them in the terms of a vision rather than as a statement of considered judgement or as an argument for a transformational pilot like HCHP.
It is ironic that on many occasions over the last five years I have heard Don say, “The time for pilots is over!” He believes it is time to engage everyone in the work of making the Triple Aim a reality. Armed with Dr. Ebert’s insights and the vision of the Triple Aim it became relatively easy for the management team that I had inherited to write a strategic plan that substantially decreased waste, enabled the survival of the organization when year over year increases in revenue fell below inflation and simultaneously created the resources to invest in strengthening the infrastructure of the organization and become a Pioneer ACO.
I must admit that the structural problems of Atrius Health did not get solved during my tenure as interim CEO or during the subsequent five years before my retirement. Change is hard but I am delighted that those issues have finally been resolved and that Atrius Health is now well positioned to continue its journey toward the Triple Aim using the culture and tools of continuous improvement.
This exploration of the Triple Aim will continue next week. If you have a point to make about how the Triple Aim has provided strategic direction where you are, please share it with me.
Last Sunday Was Not A Total Waste
As the picture in the header suggests, Sunday was too beautiful to waste inside watching retired football players talk about how great the game between the Patriots and the Broncos would be. My wife and I took a great walk on the ice of our lake. We visited three little groups of ice fishermen who were not catching many fish but were having a great time with all of their outdoor toys. After walking with my wife, I joined a couple of new friends for a longer walk starting out from the little college in the center of town.
After it was dark and the walks were over, I did watch the recording of the game. It was a sad series of failures punctuated by occasional moments of joy and hope. Despite the fact that the Patriots were still in the game until the last seconds, it is my opinion that the coach lost the game several weeks before it was played by the employment of a crazy strategy to establish a running game that was not going to happen and losing home field advantage by throwing away a game to the Dolphins. There I said it. Bill Belichick is not always right.
I hope that you will take advantage of whatever opportunities arise this weekend to be outside with friends or family. It is great fun and good for you whether you are walking briskly or standing around holes in the ice and looking for fish while you talk politics with friends. |
| Be well, and talk to me about the Triple Aim,
Gene
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