30 December 2016

Dear Interested Readers,

What's Inside This Letter Plus Random Thoughts at the End of 2016

Just as 2009 was all about the legislative process that led to the passage of the Patient Protection and Affordable Care Act of 2010 in March 2010, so has 2016 been about the elective process that will undo the ACA early in the presidency of Donald Trump in 2017. Just as we really did not fully comprehend in 2010 what would follow the enactment of the ACA, so are we now entering 2017 puzzled by the ambiguity that lies between repeal and replace. The main content of this letter is my suggestion of some things that enlightened healthcare professionals might be doing in 2017 as they attempt to plot their path into an uncertain future, and develop strategies that I hope many of their organizations might choose to follow.

Around this time last year I began to get worried about the possibility of electing a president who disavowed the ACA. Back then there were still a dozen of the original seventeen Republican candidates who had declared in 2015. Every day I was becoming more and more annoyed by the ads running up to New Hampshire’s “first in the nation” presidential primary.

I now think that back then there were really two things that were gnawing on my subconscious mind. The first was the memory of Ted Kennedy challenging Jimmy Carter in the 1980 primaries. I know that the situation in 1980 was not exactly the same as in 2016, but when Kennedy challenged Carter it revealed the vulnerability of a sitting president and a divide in the Democratic Party. When Bernie Sanders challenged Hillary Clinton it also revealed that the establishment candidate was not the choice of many critical members of the party’s base. It was obvious from the start that the reasons for this disaffection with her were not going to go away easily.

The second thing that was bothering me was that one of my neighbors had mounted a huge Trump campaign sign on the side of his carriage house that faces one of my favorite walking roads. The owner of this substantial property should have been a Bush voter in my mind. What was the reason for his fascination with and effusive support of such a seemingly ludicrous candidate?

As the year wore on toward the fateful day, every time I expressed my worries to one of my liberal walking buddies, they would spend a few miles reassuring me that I was being anxious about nothing. The Brexit vote just made me more nervous, and diminished the faith that I had in the predictive reassurance of the statisticians at the “538” website. In retrospect, I almost put my fears away after the emotional presentation of Mr. and Mrs. Khan at the Democratic Convention and the release of the video of the candidate having a “locker room” conversation with Billy Bush. Jim Comey was the fulfillment of my own prediction in September that the election would be determined by an external event that would shift undecided voters, and not by something either candidate said or did.

What really was unsettling for me more than any logical argument was a fishing trip that I made in late September to the upper Connecticut River. The river arises from a series of small lakes up in Coos County, New Hampshire. Coos County is our poorest county. It shares a border with Canada where there is not much happening in the economy on either side. Its beautiful wilderness areas are home to many moose, just as its rocky streams have plenty of “trophy” trout. To my surprise the roads of Coos County were blanketed with Trump/Pence signs. There were hundreds and hundreds of Trump’s signs compared to one little lonely Clinton/Kane sign.

And then all of my fears were realized. The evening of November 8 and the early morning hours of November 9 were like a slow motion train wreck, or like watching the Red Sox fall apart in the ‘86 World Series. I became sicker and sicker as Hillary Clinton’s “blue wall” fell state by state. It felt like such a personal loss that it took me several days to fully appreciate that my feelings were shared by tens of millions of people. The election was a sorrow to more Americans than it was a joy, at least three million more. He was right, he could have walked out onto Fifth Avenue and shot someone and not lost voters.

Since the election, each cabinet and high level nomination that will require a confirmation in the Senate has been upsetting. I am most upset by the healthcare appointments, Representative Tom Price for Secretary of Health and Human Services and Dr. Seema Verma, a conservative consultant for Administrator of CMS. I am yet to hear of a nomination that is not a thumb in the eye of some progressive interest. The appointments that will not require confirmation, like that of Steve Bannon as advisor, are even more distressing.

My wife and I were fortunate to be able to enjoy Christmas and the presence of three of my four sons with their wives, my grandchildren, and the in-laws of one of my sons. We had a terrific time that was not spoiled by Dr. David Torchiana’s commentary in the Boston Globe on December 19. I was lucky to have missed the article entitled “First Do No Harm” until I saw a couple of letters to the editor yesterday. The first letter was written by the author of the House of God under his nom de plume, Dr. Samuel Shem. The second, “Favorable view of Mass. health costs undone by the data” - was written by Boston University School of Public Health’s Professor Alan Sager who is the director of BU’s Health Reform Program.

Both of the letters reflect my opinion of Dr. Torchiana’s thesis, explained below, which I have noted at least twice before in these letters. Dr. Torchiana, who is now the CEO of Partners HealthCare, has been a staunch defender of Partners' excessive charges for many years. I first heard his line of thought in 2011. His thesis is simple. The taxpayers, employers, and healthcare consumers of Massachusetts should not complain about the expense of their care. He does acknowledge that as a national problem the cost of care is high, but sites data which Professor Sager contends he has misrepresented, to make the argument that since the median income in Massachusetts is high then it is justifiable for the cost of care to be high. In this piece he goes further and argues that if Massachusetts attempts to do things that lower the cost of care [think force Partners to accept a lower pay] then irreparable damage could be done to the state’s economy since Massachusetts is the world’s leader in research and the biomedical industry. Partners HealthCare is by far the largest employer in Massachusetts.

...When polled, 75 percent of our residents believe that we have the best hospitals in the country for clinical care. We also lead the nation in life science research funding per capita (nearly double the next most successful state). Unlike the rest of the country where nearly all of the research funding goes to universities, in Massachusetts most of the life sciences research is done at hospitals. This strength in research is an important contributor to employment and the local economy that is unmatched in the nation. When you add all this up, our health care system is one of our state’s greatest assets across multiple dimensions — affordability, access, quality, and scientific and economic productivity. Portraying our health care environment as causing a perpetual state of crisis, with a need for aggressive intervention, is simply not supported by the present context or trends...Proposals for government intervention in hospital payments with regulations that sanction our teaching hospitals, already reimbursed at rates that are lower than national competitors, will threaten some of our most important regional assets for both complex clinical care and research.

Dr. Shem’s response is that Massachusetts does not need Partners now and never did. He implies that Partners was created to demand more money from payers (some people would say extort more money) and that the affiliation provides no benefit to the public beyond what the Massachusetts General and Brigham and Women’s provided as independent institutions. He believes that what we need is not Partners but a single payer. You may remember that the Massachusetts Attorney General and courts did decide that we do not need Partners to be bigger, primarily because if it were the public would pay even more without demonstrated benefit.

So what is wrong with Dr. Torchiana’s thesis and reasoning? First in my mind is that it lacks empathy for Massachusetts residents who earn less than a “median income”. Many individuals are financially harmed by the Partners pursuit of income. All of Massachusetts’ taxpayers and most employers are directly or indirectly harmed by a medical marketplace with a dominant player who seeks to maximize income at a time when the challenge to all of healthcare is to lower the cost of care. Partners has billions of dollars of assets and its current price structure is substantially higher than other Massachusetts hospitals. The Beth Israel, Tufts, Lahey, and Boston Medical Center all do research, train world class doctors, and provide care of equal quality and safety for substantially less payment and fewer assets than Dr. Torchiana’s operation. What prevents Partners from leading the way in a piece of research we all desperately need which is a demonstration of breakthrough success in lowering the cost of care?

If Dr. Torchiana is not going to lead a world class Partners effort to lower the cost of care, perhaps he will use his access to President Elect Trump to help preserve the gains that others have made in the struggle to provide

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.

If you missed last week’s letter, let me suggest that you take a look at the part of it that was revised and put up on strategyhealthcare.com. Even if you did read last week’s letter you may want to check out the revised offering, “Must the AMA Always Be On the Wrong Side of History?”

As the year comes to a close, I want to thank you for being a reader and also thank Russ Morgan who is the person who is responsible for getting the letter and the blog out to you every week. These letters would not be possible without the support and generosity of Russ who has become a true friend of mine and a wholehearted supporter of the Quadruple Aim. I also want to thank my son, Jesse Lindsey for his help with the header each week. I like to send him a few pictures and let him decide which one works best. Finally, I want to thank my wife Nancy for her edits and candor. She is a retired nurse, nurse educator and nurse practitioner. She has delivered care that has made a difference in the lives of many many people for over forty years and her sense of what is appropriate is valuable to me. It also helps that she is a better speller than I am and a stickler for the rules of structure and punctuation.

What To Do When You Don’t Know What To Do

Focus on getting better. That is the short answer. With or without the ACA the challenge to create

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 does not go away. The Triple Aim long predated the ACA and the Quadruple Aim will stand as our continuing and even more important objective after the ACA has been repealed no matter what replaces it.

One of my first insights in my medical practice as I moved from the protective environment of the robust Harvard training programs into practice was that I needed to know what to do until I knew what to do. Ambiguity is the constant companion of the physician who is presented with clinical problems to solve every day. It is not a problem that “procedural” physicians or physicians who read diagnostic tests and images encounter quite as often.

My opinion arises from having lived in all of those worlds. My work as a cardiologist doing cath was oriented around completing a specific task just as the work of an orthopedic surgeon repairing an ACL is a specific task. Difficulties do arise in surprising ways, but it is not quite the same as trying to decide what to do based on the significance of an atypical chest pain in a forty year old woman. I loved reading echos. What you see is what is there. The test itself is done to reduce ambiguity. In contrast, there is nothing more challenging than sitting in a primary care practice and listening to dozens of stories every day about various symptoms and trying to decide which ones are best managed with reassurance and observation, and which ones require immediate intervention.

Now as an industry and as individual professionals we must decide what to do in very uncertain times. Many of us will be just fine if we work in well established internationally known academic medical centers. The President Elect met with the CEOs of the Mayo Clinic, Partners Healthcare, Johns Hopkins and the Cleveland Clinics. The main agenda was to ask their advice about the VA system of care but journalist suggest that there were other subjects of mutual concern. I would have preferred him to meet with the CEOs of New York Health and Hospitals, the Boston Medical Center, San Francisco General, and Cook County, or perhaps Dartmouth Hitchcock or Maine Medical. I wonder what the CEOs of Geisinger, UPMC, Swedish, Georgetown and Stanford are thinking.

As a board member of Guthrie Health in the twin tiers of Pennsylvania and New York and the Whittier Street Health Center of Roxbury, Massachusetts, I wish that the President Elect had met with Dr. Joseph Scopelliti and Ms. Frederica Williams, the CEOs of those organizations. Mayo, Partners, Hopkins, and the Cleveland Clinics are fabulous institutions that are famous for the work they do, but their CEOs live in a rarified world that may or may not inform them of the challenges that confront patients and caregivers in many of those “red states” that gave President Elect Trump his majority in the electoral college. My wife worked for many years as an NP at the West Roxbury VA Hospital taking care of veterans with cardiac problems. She may have a better feel for the real issues that face the VA system than Dr. Torchiana who was an able cardiac surgeon at the MGH and now can demand virtually unlimited resources for his organization from the insurers doing business in Massachusetts.

There is one thing that is not uncertain about the future. There will be continuing downward pressure on revenue for practices, hospitals and health systems. This is as it should be. Medical care is too expensive and wastes resources. There should never be more revenue per patient relative to the GDP than there is now. This is a reality for Partners and Guthrie. I am not so sure it should be true for many of the systems that serve the underserved.

If you need to ask why, the answer is simple. Employers need to have the ability to shift funds to salaries or to reduce their prices to be more competitive. Taxpayers need to be investing more in infrastructure and other services like education and social programs for the disadvantaged. Consumers need to retain money to make other purchases, save for retirement, buy homes, and educate their children.

For the last decade and longer we have been transferring financial risk to patients in terms of higher insurance rates, higher deductibles, and higher drug prices and copays. They really can not take on much more expense. Now we are transferring risk from insurers and public funders of care to care providers. Care providers are theoretically capable of managing costs down but in the moment lack the desire, the competencies, or the insight that they can and should accept this risk. Like it or not that risk is increasing and the rate of change has been accelerated by MACRA.

Nothing that Donald Trump, Paul Ryan or Tom Price has proposed makes the reality of the pressures of finance on patients, employers, taxpayers or providers less. Actually most healthcare economists would suggest that their proposals will make the pressure on operating budgets of practices, hospitals and health systems greater. If many of the twenty million plus newly insured under the ACA lose coverage, the pressure on institutions and practices with marginal operating surpluses will be enormous. Many critical systems, like Dartmouth Hitchcock near me, are already in trouble and fighting a rising tide of red ink.

The answer to downward pressure on revenue is efficiency and waste elimination through process improvement. Lean and the other system of continuous improvement are agnostic to public and political realities. They work to improve the experience of care and the finance of care in any environment. For most of the history of the practice of medicine physicians have accommodated to the financial realities of those in need. It is not a good system of care for care to be dependent on “the kindness of others”. “Charity care” and pro bono practice are antiquated concepts, though circumstances may force us to revisit them.

A system of universal access in a society that values the health of everyone of its members is a much better concept, and a system that most developed countries prefer and expect, but we may lose ground to that objective. Our most potent strategy to promote the possibility of universal care is to improve the efficiency and effectiveness of care delivery so that the expense of care will come down while we improve the experience of providing care.

One interested reader who is well grounded in the fundamentals of Lean and continuous improvement and has been a “guru” for me, responded to the discussion of a few weeks ago that was initiated by Dr. Paul DeChant’s advocacy for a more eloquent expression of the Quadruple Aim. He wrote:

The two fundamental principles of Lean are “continuous improvement” and “respect for people.” The latter is often interpreted as respecting / putting the customer first, or as is often heard “the customer defines value.” That interpretation is correct. But our Toyota coaches also taught us that the concept of driving out waste or non-value adding work, when coupled with respect for people, means that we as leaders should never ask our people to perform non-value adding work.

Hence our responsibility is to put people first, and most importantly the “workers” who deliver value to our customers, as it is understood in a Lean culture that this is what the pillar “respect for people” really means. Thus “… in settings that support caregiver wellness” would be applauded loudly by those of us who work at enabling Lean in healthcare (while our Toyota mentors would probably just smile and say that’s a given in their culture … and clearly we have a long way to go before that’s ingrained in ours.)

And there you have it.

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

The strategy that we should adopt no matter who is leading now on at anytime in the future is a strategy that derives its power from the respect for people. We must focus always on providing value, not expense for patients, and supporting those that do the work of improving care. That is an endorsement for a strategy that is not dependent on finance and need not vary when there is a change in political philosophy or control.

Whether you are the CEO of an internationally prominent academic medical center or a medical assistant in an ambulatory practice serving the underserved, it would be best to start each of these days over the next few years until the way ahead is certain, by personally committing to creatively contributing to the work of continuous improvement that is driven by a respect for the people who need the care, who provide the care, and for those that support the delivery of better care. I am certain that this is the most productive way to make progress in times that are volatile, uncertain, complex and ambiguous. The finance and the politics may change but the human needs and the professional responsibilities are constant, and our need to rise to the challenge is inherent in our roles as professionals.

It Was A Great Week!

My grandchildren and I had a great time this week. I hope that you had a similarly wonderful time with family or friends. One of my favorite walks is around the “other” lake in our town, Pleasant Lake. Pleasant Lake is almost exactly the same size as Little Lake Sunapee but is on the south side near Wilmot and Andover. There are plenty of interesting things to see along the way on the six mile walk around the lake, but none more interesting than Skyeview Alpaca Farm. Sue King started her herd in 1992 so that she could have plenty of fiber for her spinning and knitting after she moved to New London from Wellesley. When I walk the lake I love to look in at Skyeview just to see the lovely alpacas, the exotic chickens and the angora rabbits that are on the farm. We often bring our visitors to see the alpacas if there is time during their visit. If you are ever passing through Sue will welcome you, too. The views of Mount Kearsarge from Skyeview are spectacular. When my grandchildren and I visited this week the late afternoon sky hung low over the mountain and the remnants of our “white Christmas” were looking a little drab. If you look closely at the picture you can see some of the alpacas at the lower lower left and near the middle on the right side.

Now is a good time to set your goals for 2017. I set a mileage goal every year. Like a Lean project “bowling chart”, I keep a running log so that I can stay on schedule to meet my goal. This year the goal was 1500 miles or about 28 miles a week. I was on schedule until August and September when I got behind on my charting and walking while traveling. I never caught up after getting behind. I’ll finish this week around 1450. It’s not bad, but I will have to do some box 9 thinking about why I missed my goal by about one mile a week. It is easy to correct for a mile a week in March and not so easy in October or November.

I wish you a very successful 2017 at work and in all of the other challenges that you accept. My advice is to set goals and measure your progress against those goals, making the course adjustments necessary to achieve your objectives. I am setting my goals for 2017. I hope that you will too! Have a great New Year!