3 February 2017

Dear Interested Readers,

What’s Inside: Giving Up My Obsession With Trumpism

There is no way that I can keep up writing about all of the wrong turns, reversals, and misdirections associated with the many facets of the transition to Trumpism. Before I give up perhaps we should define what Trumpism is by what it is not and what it might be while imagining what it has the potential to become. We should also consider what it could create, what it might destroy, and what it could never do.

Trumpism is not a traditional conservative or libertarian philosophy, although it has attracted and captured many from those movements who are willing to risk the integrity of their philosophies for the false hope that Trumpism might advance their point of view and agenda. Despite the fact that some would equate it to twentieth century fascism, it is not that either. It is not accurate to imply that Trump is the second coming of Hitler or Mussolini. There are strong elements of “nativism” and “nationalism” in Trumpism that degenerate into xenophobia. There are elements of Trumpism that appear to be similar to “alt right” philosophy. Trump himself appears to share much similarity of thought with the alt right, as evidenced by the emergence of Steve Bannon as perhaps his most important advisor, but the “alt right” is also a new phenomena that most of us do not fully understand, making it hard to say that it is synonymous with Trumpism. There is an element of the cult of personality or celebrity in Trumpism. Those attracted to Trumpism may be willing to accept some elements of authoritarian leadership to advance their agendas, but just how likely that outcome is remains uncertain given the intense alignment of conservative and libertarian thought with individual freedom.

Trumpism seems broad enough to allow a home for the religious right, fervent members of the pro life movement, those who do not want to extend a full set of human rights to those who are not strictly heterosexual, and those who doubt the reality of climate change and other inconvenient warnings from science. Trumpism seems broad enough to accommodate white supremacist and could never have come as far as it has without capturing the majority of male and female white voters, but so did Mitt Romney and he lost. Trumpism is cheered by many who feel left behind in a world of mechanization and globalization of manufacturing who simultaneously want things “fixed”, but without programs of social welfare. Perhaps Trumpism is a longing for a world that never existed and probably never will be created, but the pursuit of the ideals of Trumpism could block further progressive efforts to improve the world. Trumpism sees the world as being on the edge or already in the midst of a dystopian decline. Trumpism argues for progress toward “greatness” through actions that seem most consistent with the dualistic politics of a dystopian world.

Obama called for everyone to participate in a movement driven by the “audacity of hope” and famously said, “Our destiny is not written for us, but by us.” Trumpism calls for everyone to defer to one person who alone can halt the slide into chaos that is already present as ubiquitous “American carnage”. Trumpism reminds me a little of McCarthyism because of its potential to divide us using fear and inuendo, but Trumpism is much more developed and uses the power of the office of the President and not just the investigative powers of a junior senator from Wisconsin who perverted his power as the chair of the Senate Permanent Subcommittee on Investigations to ruin the lives of many people. The truth is that whatever Trumpism is, none of us can be sure of what it might yet become, and there is no consensus about how to safely embrace it or resist it. We are in a period of uncoordinated resistance to an undefined risk, and we are bombarded on a daily basis with juvenile tweets and episodes of bizarre executive behavior interspersed with executive orders and high level appointments engineered to radically reverse the progressive agenda of much of the last century, fueled by fear and economic frustration.

Despite the fact that Donald Trump is president, Trumpism runs against the grain of our national self image of equality and opportunity. Perhaps we have always failed to be what we say we are, but our history is one that has been a journey toward the highest ideals of tolerance and opportunity. Now Trumpism seems to suggest by the sum of its parts that we should depart from that road and move toward actions driven by anger, fear and self interest. Trumpism seems to invite the crowd to express its anger against intellectuals and minorities and those whom it has identified as the personification of the current Trumpian interpretation of the root cause problems that are the source of frustration for the beleaguered “everyman” of the forgotten heartland.

I am encouraged by the massive reaction to the President’s executive order on immigration. At airports, in the streets, in the Congress, in board rooms, in academia, and on editorial pages across the country the responses have been encouraging for those who fear the ultimate direction of “Trumpism”. I am most encouraged by the response of young adults last weekend and by the personal courage of Acting Attorney General Yates. I am also encouraged by the opinions I read in the media, like the one from conservative columnist David Brooks this week that implies that Trumpism is the “politics of cowardice.” In another piece he suggests that mainstream Republicans have made a Faustian choice and then offers hope that is drawn from the possibility that maybe there are members of the Republican establishment in the Senate that will make the right choice:

Trump exceeded expectations with his cabinet picks, but his first 10 days in office have made clear this is not a normal administration. It is a problem that demands a response. It is a callous, bumbling group that demands either personal loyalty or the ax.

With most administrations you can agree sometimes and disagree other times. But this one is a danger to the party and the nation in its existential nature. And so sooner or later all will have to choose what side they are on, and live forever after with the choice.

I share Brooks’ hope that maybe there will be a small group of Republican senators that exercise the judgement to create some restraint on the growth of Trumpism. I have also concluded that as personally interested and moved as I am by the drama of these times, and although I will follow the events closely for myself, I should give up trying to stay up with events in these notes and shift my emphasis to describing the challenges that healthcare faces in a Trumpian world. Federal policy must be understood and interpreted in the context of a strategic goal of transforming our healthcare system into one that serves every citizen and every person residing here with:

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.

That goal is threatened by a Trumpian philosophy. It is even more threatened by the lack of sound policy development demonstrated by the President and the disinterest he shows to understanding what he does not know. His lack of expertise and experience in policy development make him an easy mark for those who have agendas centered in self interest.

The main portion of this week’s letter attempts to lay out some principles for strategy development that should work locally no matter what comes down from HHS under the leadership of Tom Price or from CMS as steered by Seema Verma. I make some comments about the experience at Harvard Vanguard and Atrius Health when the Triple Aim became the strategic goal. I emphasize the continuing benefits of population health skills, local innovation, and a continuing focus on Lean or other forms of continuous improvement as ways of finding new resources within the waste of current revenue. This advice was sound thinking a decade ago, is sound thinking now in the midst of a climate of Trumpism, and will still be sound advice when President Trump’s time comes to an end, as it surely will eventually.

It is impossible to forget that the Super Bowl will be played on Sunday. I am sure that someone would feel that something was wrong if I did not add my thoughts to the hoopla associated with this national event. No matter which team wins, and whether you watch for the game, the spectacle, or the creative advertisements, my hope is that this year the Super Bowl may unite fans of both parties and both genders in a shared experience for three or four hours when the real business of the world is put on hold.

I am hearing that occasionally some readers suddenly realize that they are not getting this letter. If you hear someone mention that the letter is not coming, suggest to them that they look in their spam or junk. It is best for the letter to be in your address book so that your computer will recognize that you want to get it. If you know someone who is no longer getting the letter, they can always go to strategyhealthcare.com (SHC) and sign up again. I will remind you that a revised edition of the main portion of each week’s letter is published every Tuesday at 3 PM on the SHC site.

Good Strategy in a Trumpian Fog of Uncertainty

There is no challenge like the challenge of creating a strategic plan in uncertain times. What do you do when you do not know what to do? That is a tough question that frequently challenges leaders. Over eight years ago, after Lehman Brothers had failed and the value of the stock market had fallen by almost fifty percent and we did not know if we were facing a deep recession or the second coming of the Great Depression, I was asking myself and the leadership teams of the Atrius Health practices those same questions .

The leadership of Harvard Vanguard Medical Associates had completed a far ranging strategic plan in June, but the world in June was a very different world than the world in October. The plan in June had suggested that we should focus on improving our processes and workflows by expanding our Lean skills. We planned to improve revenue by gaining more income from Lean improved quality and patient satisfaction scores. We planned to invest in our sites to make them more attractive and to expand the quality of our imaging and lab services. We knew that we were fortunate to have high quality lower cost suppliers of hospital based resources and specialty services in our market than the ones we had traditionally used. There were tens of millions of dollars to save in risk based contracts, if we could just use Lean skills to mobilize our clinicians to change their referral patterns. We hoped that those savings would fund even more infrastructure improvements and innovations. We planned to “rescue and reallocate.” We thought we could rescue wasted resources and reallocate those savings from avoidable waste to staff education and the development of better programs of care.

We imagined that if through Lean coordinated efforts we could be the practice with the lowest total medical expense and the highest patient satisfaction and measured quality, we would attract patients and grow. What we did not know for sure was whether these assumptions were valid in the climate of financial loss, recession, and increasing unemployment that was suddenly upon us. There were other questions as well. What would happen to our reserves and to the income that we gained from the investment of those reserves? Should we invest in our development or should we hope to preserve as much money as possible in conservative investments?

In an attempt to bring some clarity to the situation, the senior management team decided to hold a retreat where we could work through several scenarios. I will not bore you with the details of the various scenarios because all of the stories led to the same conclusions. Our work led us to believe that our future would be determined by how well we fulfilled our professional responsibilities to our patients. To serve our patients we realized that we should increase our efforts to:

• Focus on what our patients tell us they need
  

• Improve our ability to engage patients and families in improving their health
  

• Improve our measured quality and safety
  

• Lower our total medical expense by more effective management of our suppliers and internal processes
  

• Improve the timeliness and efficiency of our care making sure that every encounter occurred at the right place, at the appropriate time, with care from the most appropriate provider
  

• Practice team based care and continue to develop the Medical Home
  

• Form closer relationships and more effective partnerships with more select hospitals, post acute providers, and specialists who shared our values and vision
  

• Enhance and utilize home care services to help patients stay at home 
  

• Reduce admissions and readmissions by anticipating patient needs
  

• Develop better clinical and management skills with improved critical thinking among our staff through enhanced training programs and a leadership academy
  

• Improve the workplace environment and the work/life balance of all of our staff
  

• Articulate our value to public and private payers and work closely with legislators and regulators to improve the regulatory and administrative environment
  

The good news was that other practices like ThedaCare in Wisconsin, Virginia Mason Medical Center in Seattle, and Denver Health had all plotted similar courses and were succeeding even in an environment of declining relative reimbursement. The common denominator of all of these organizations was that they were using Lean to improve all of their clinical and business processes.

In those dark days some people were advocating a “wait and see philosophy” while preserving resources by cutting programs and staff. We chose to accept the concept that we could not “cut our way” to success. We needed our staff to be confident that they would be secure and supported so that they could work together to satisfy our patients. We needed to find the time and the resources to invest to create the competencies that would enable us to do more with less and still have a margin for further investment in staff, innovation, and improvement efforts.

We all know that the economy got better. We also got better, but there is never a moment when further improvement is not needed or is not possible. I also believe that there will never be a moment when we will not be challenged by something. No matter what political party or philosophy is in power, I believe that there will never again be a time when we will have more resources in relative economic terms per capita for healthcare than we have now. At 17-20% of GDP or whatever the number really is, we have a health system that provides imperfect care to less than 90% of the population. To move forward toward a better America we need to make large investments in infrastructure, research, education, public safety and cultural resources that are compromised when we spend so much on healthcare and get so little real value from the effort.

Despite the high cost of care and the efforts and intent of the ACA, most of our healthcare institutions have spent the last decade trying to figure out how to increase revenue rather than learn how to reduce their cost in the pursuit of the Triple Aim. In a Trumpian world we see processes developing, like the shift to block grants and tax credits in lieu of direct coverage, that will further reduce resources per capita. The patients most likely to have fewer resources are those with the greatest needs. What I fear is that our national investment in healthcare will provide care of a lower quality to fewer people.

What many organizations do not realize or accept, and I fear most politicians do not understand, is that improving healthcare is more of a systems and engineering problem than an issue of finance. This is what Dr. Robert Ebert must have meant when he said more than fifty years ago:

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.

It was true when he said it in 1965 as we were rolling out Medicare and Medicaid, and it is true in the Trumpian era as Paul Ryan, Greg Walden, Tom Price and Seema Verma are scratching their heads trying to figure out how to repeal and replace the ACA and end Medicare and Medicaid as we have known it. The role of healthcare finance should be to create pathways that encourage innovation and improvement in a transforming process of reengineering. Just spending more money has never made things better for more people. We should not be trying to alternatively finance what we we have been doing because it does not work well. We should accept that simply spending more on a system that doesn’t provide value and works the same way it always did, won’t improve the experience of care for those who will always have it. Those who do not have care would benefit from more money for coverage in the same old system, but this administration,the tax conscious voters who elected it, and the current congress are unlikely to be willing to spend more on the underserved. What is needed is what Dr. Ebert was envisioning, a more effective system of care that is economically sustainable and available to everyone.

Perhaps what the authors of the ACA failed to clarify was that it was a bill that was meant to expand coverage, but more importantly foster changes in the way care was delivered. ACOs, the creation of CMMI for innovation, required coverage of preventative care, and the guarantee of insurability, all encourage redesign and innovation. President Obama may not have initially understood the extent of the transformation that the ACA demanded. One painful and recurrent criticism of the former president was his failure to deliver on the promise that if “you like your care you can keep it.” I have always thought that his “lie” was probably not an intentional attempt to mislead us; that would have be inconsistent with whom I believed him to be. Rather, it was an error based in the fact that he did not fully realize that the ACA disallowed many policies that people liked because they were ineffective. They were essentially junk. They often did not provide coverage for preventive care, did not provide adequate coverage for women, did not cover preexisting illnesses, and had unrealistically low coverage limits. Some policies went away because employers did not want to continue the plan, or they were withdrawn from the market by insurers. The critics of the ACA were correct when they implied that it was a very complex piece of legislation. It took everyone, including President Obama, a while to fully appreciate what it meant and what it was really about.

Why review the past confusion about the ACA? It would be sad if those inadequate pre ACA policies came back. It would be bad for patients and would further roll back the move toward healthcare transformation that produced care that is consistent with the Triple Aim and is also good for caregivers. Burnout will continue to be a heartbreaking hidden loss that destroys providers and harms patients by turning their doctor or nurse into an automaton with little or no empathy because they have no emotional reserve. Burned out clinicians do not have the energy to manage resources.

We will experience higher expense and increasing burnout until healthcare is reengineered to be efficient and effective. Success in every other industry is driven by continuous improvement and competition. Business competition has always been an American ideal but in complex industries, that competition and the products are regulated. Effective competition and innovation leads to “creative destruction” of poorly performing and inefficient products and services, and the same principles of capitalism will eventually succeed in healthcare when we really establish the finance and regulatory principles that allow the process of transformation to occur. I have always believed that those organizations that invest now in developing the prerequisite competencies will succeed both now and in the future.

It is hard to know at this moment whether the long term impact of Trumpism in healthcare will be positive or negative. If we devalue and deform Medicaid and Medicare while doing away with all of the structural gains of the ACA, we will move from having the most expensive and least effect healthcare system in the developed world to having a third world system of care with a decline from our current status of having a life expectancy pretty close to Costa Rica and Cuba. If, however, we can use the momentum of “repeal and replace” to advance the ideas for improvement of the ACA expressed by former President Obama in his recent New England Journal of Medicine and JAMA articles and convince just a few moderate Republican senators to align with revisions that will improve the ACA, then the next four years may turn out to be an exercise that was worth the pain. No matter what happens in Congress the greatest benefit that healthcare professionals can collectively give their patients and themselves is a commitment to the principles of the Triple Aim with real emphasis on lowering the total expense of care. It can be done by reducing waste, improving the processes of chronic care, more effectively engaging patients and families, and embracing more vigorously than ever before our responsibility to always be searching for a better way.

Warm Walks and Pretty Things Before the Big Game

When I am away from Florida I always say that it is a place that I can do without. I focus on the crowds at Disney World or the awful airports and congested freeways, as well as the depressing sight of a multitude of elderly obese people that appear to be wasting time waiting for the express bus to the hereafter. All of those things make me uncomfortable. I forget about the quaint little towns that can be found on the West Coast that are away from the traffic. I had no idea of some of the cultural attractions like the Dali Museum in St. Petersburg where the header for today’s letter was taken looking skyward from the central stairway in the atrium.

My draw to Florida is to see family and friends, not the beaches and amusements, but while here I must say that I have enjoyed long walks on excellent bike paths and the seemingly endless stretches of walkable beaches with fine, tightly packed sand that is so forgiving to my elderly hips and knees. Frequent flyer points and the ability to stay with family and friends, make the idea of a dystopian America with carnage on every corner seem very much like a distortion of reality. If things are so bad why is Florida overrun by so many people from Canada?

It seems like only yesterday that the Green Bay Packers defeated Kansas City in Super Bowl I on January 15, 1967. In the intervening fifty years there have been some amazing games, some heartbreakers for the Patriots with two close call losses to the New York Giants and Eli Manning, and four fabulous Patriot victories. Even people who never watch a game all year and hate football seem compelled to watch and claim that they are watching to catch the creative advertisements that will air. I wonder what the national consumption of pizza is during the Super Bowl?

My favorites Super Bowl games were Brady’s first win against the St. Louis Rams in Super Bowl XXXVI and the last win for the Patriots in Super Bowl XLIX against the Seattle Seahawks following Malcolm Butler’s interception of a very ill conceived pass on the goalline. Who knows what thrills await us this year? I always hope for a blowout win. I do not like late game drama. Have you ever been out on the street while the Super Bowl is on? Give it a try. There is no traffic. The streets are empty and there is hardly a sound. It is like no one is in the world.

The best way to get ready for the Super Bowl is to take a long walk in the afternoon. It is nice to think that perhaps the game will be a respite from concerns about “American carnage” and the dystopian images of America’s future. I hope that the carnage on the field is also limited by good clean play. If the best team wins my granddaughter will be very happy.