30 September 2016
Dear Interested Readers,
Description of This Week’s Letter
I had planned to give the election a rest this week but in the aftermath of the first debate I find that I do have some observations and concerns that I would like to express. My comments are not about who won the debate or who is the best candidate to be our next president. My comments fall into two categories. First, I comment and complain once again that healthcare is not being discussed. Secondly, I focus on what the election seems to be saying to me about America.
Never fear. I am not going to suggest how you should vote. I encourage you to be interested and to vote. I will understand if you pass on reading this section because you are beyond saturation with all things political. You may not share my obsession with the election process as a mirror that gives a reflection of our country that is worth considering. If you are so tired of the election that you want to scream or have already made up your mind and know for whom you will vote and do not want to read any more that speaks to the issues then just pass over the first section and begin reading the section entitled “More Thoughts on the Future of Practice in the Two Americas”. If you do read the section, my hope is that you will be surprised by what it says and that it will enable you to look beyond Hillary v. Donald toward the question of how do we get back from the edge of the abyss.
The second section was triggered by a conversation with one of my walking companions. He has become very concerned about the future of healthcare in the Upper Valley. The geographical and economic area where I live is referred to as the “Upper Valley”. That is short for the upper valley of the Connecticut River. Hanover and Lebanon, New Hampshire, White River Junction and Norwich, Vermont plus the Dartmouth Hitchcock Medical Center lie at the heart of the Upper Valley which runs for about about a half an hour north and south of Dartmouth Hitchcock in New Hampshire on Interstate 89 to the east of the river, or a half an hour north and south on I 91 to the the west of the river. The chief resource for this section come from The Valley Voice, the daily newspaper of the region.
As usual the letter ends with a combination of praise and apprehension about my favorite baseball and football teams. In my world almost everything is a metaphor or symbol for something. This year both of my sports of greatest interest present the opportunity for success and the sense of vulnerability that the possibility of success induces. At the end of the letter there is more of this theology of sport to read as well as a recreation of the moment when the picture in today’s header was taken.
I know that if you began to receive these letters during the last two years you have made at least one trip to strategyhealthcare.com because that is where you signed up. Perhaps you are a long term reader who goes back to the time before strategyhealthcare.com was created and for that reason you have never needed to visit the site. If that is the case, take a chance. One click on either of the last two links will take you to the revised form of these letters. It has been an interesting exercise for me to trim out 50% of what I have written and then hope that what remains is more effective. Take a look. It is also extremely easy to quickly leave a comment. Finally, it remains my hope that more of you will submit pieces that you would like to see on the site. Do not fear. I will not ask that you spend a lot of time writing and rewriting your thoughts. I think that there is an urgency in the conversation about the future of healthcare and the Triple Aim that makes participation and not perfection the objective.
Looking Into The Mirror of The Election
I am sure that most of you listened to the debate last Monday night. There was some concern that the option of watching the New Orleans Saints lose to the Atlanta Falcons on Monday Night Football might reduce the audience. Despite the football option, more people watched the debate than have ever watched a Presidential debate. The previous record of about 80 million viewers was set by the first Carter-Reagan debate of 1980. This Monday’s debate drew about 83 million that could be counted and many more who viewed the debate in bars, together at parties (like I did) or on their cell phones or computers. That’s a lot of viewers but last year’s Super Bowl drew more than 110 million. Maybe this debate was not as important as the annual spiritual renewal that we collectively anticipate from the Super Bowl.
The larger viewership for the debate is understandable if you anticipated more cross body blocks, sacks, and “bell ringing” hits at the debate than on the football field this last Monday night in a game between two mediocre teams. Perhaps the possibility of real time viewing of the meltdown or failure of one or both presidential candidates is the sort of theater that draws us to the flame. I must admit that I could not not look.
My first response was to root for my team. I was eager for the other guy to make a fatal error. The fact that the polls were showing the race to be dead even enhanced my interest as well as my apprehension. The pre debate analysis suggested that a “C minus” performance by Trump would be graded on the curve as an “A plus”, and a “B plus” performance by Clinton would be a functional “F”. My last look at Nate Silver’s site “538” before the debate revealed that on the day of the debate Trump had a 45+% and rising likelihood of winning the election. Six weeks earlier on August 14, just after the conventions, Clinton had topped out at 89+% and Trump was hopelessly (not really) behind at just under 11%. Things were changing fast.
I need not recreate the evening for you, nor do I think that it really makes a difference who the pundits think “won” the debate. I was definitely amazed and disappointed that there was no reference to healthcare. Perhaps that will happen in a later debate, but even the New York Times has shared my concern that healthcare is getting no attention. I was pleased recently to see that the Commonwealth Fund has done a great job looking at the healthcare proposals of both candidates. The Rand Corporation sees billions of dollars of expense and millions of covered lives being lost if Trump wins. Is this not an issue that is more important than what Hillary has not done over thirty years of public life or alternatively, a review of just how many subcontractors Donald has stiffed?
Both candidates declare themselves to be the real winner although Trump has needed to invest more time explaining how between malfunctioning microphones and a biased moderator he really did win. I am sure that most of the people who went into the evening emotionally committed to one candidate or another stayed with their preferred candidate no matter what was said or done, whether the rest world thinks that person either won or lost. The debates were theoretically staged for those mythical undecided voters who are still pondering their decision. That may be true in most years, but this year the outcome will possibly be determined by whether or not a candidate’s supporters care enough to show up and vote.
My greatest concern has been that the outcome of the election will be determined by some yet to occur event. Will Russian hackers give Wikileaks some bombshell to drop on us the week before the election? Perhaps some disaster will occur in the middle of some busy urban center somewhere in America or in some heavily populated city in Europe. My worries intensified during a debate where the subject of the weight gain of Miss Universe of 1996 seemed to have more importance than the health of today’s urban and rural poor.
Three very mundane events since Monday have given me a new perspective on the debate and the election. The anxiety that I felt at the end of the debate has stayed with me, but over the past few days I sense that the idea of what it all means may be changing. As it does I have an enhanced sense of connectedness to my neighbors at home and in the world beyond our borders. I am beginning to realize that any strategy for the future that does not responsibly consider the best interest of the whole world is a strategy that will ultimately fail.
The first event occurred on my walk Wednesday morning. I was still pondering all that I had seen and heard on Monday night. The commentary from the talking heads on TV and the wits on the editorial pages who tried to explain to me what they thought it all meant had done nothing to settle my nerves. Near the end of my walk, about noon, less than a mile from home, I decided to stop at the public boat landing for a moment. This is where the folks not lucky enough to live on the lake can access it with their boats. On a weekday morning late in September I was surprised that there was someone there. I saw his truck first. On the tailgate of his truck there were a half dozen Trump/Pence bumper stickers along with other political and social statements that suggested to me that we had little in common.
His truck was pretty typical of thousands that I see as I drive around New Hampshire. They are often in the parking lots of Walmart and the other “big box stores” in West Lebanon, or parked in front of “double wides” on the back roads I ride while accessing fishing streams. Others are easy to see in the parking lots of the few remaining manufacturing sites in tired little towns like Newport and Claremont. There was a huge chest behind the cab that I was sure was full of tools. Here he was, the everyman of the angry Trump demographic. He was white, middle aged, probably with a high school education or less. Perhaps he was a self employed tradesman, a subcontractor on a construction job nearby, or a guy hustling to generate an income doing odd jobs for upper middle class guys like me. Whoever he was, he was looking out at the beauty of the lake and munching on his sandwich. He looked my way and smiled as he gave me a brief wave, even as I was beginning to ponder what a misguided jerk he must be. Suddenly, I was wondering who the jerk really was and then realized that I had no real clue why he saw the world in such a starkly different way than I did.
After returning home I could not stop thinking about the working guy in the truck with the load of Trump stickers as my wife and I prepared to drive to Boston where we had plans to hear Justice Stephen Breyer at the Boston Speakers Series at Symphony Hall on Wednesday night. Justice Breyer’s speech was the second lesson. His objective was to open my eyes to the reality that much of the future work of the Supreme Court would require a new “world view”. He asserted that we are dependent on numerous international treaties and trade agreements as we face the challenges of the interconnected world. He believes that we are just beginning to understand the extent to which our affairs are inextricably interconnected to all of the problems of the world. Many of our greatest challenges go far beyond our shores and borderers. We can not solve the issues as domestic concerns.
We are threatened by changes in the environment, terrorism, international commerce, healthcare, the Internet, and so many issues that all have ramifications beyond our shores and borders. These issues go to the ends of the earth and back again. We are a minority in the world with a leadership opportunity. As I listened to Breyer and reflected back on what I had heard on Monday night, I felt short changed and wondered why Lester Holt had not pushed these issues harder. Monday’s debate had seemed to be about how to put what was best for America in the moment first over the long term best interest of all of humankind. After listening to Justice Breyer that did not seem so smart or even to be the best self serving strategy.
Yesterday, the morning after listening to Breyer, my wife and I met with our financial advisor for an annual review. I would rather have a root canal than this sort of meeting. His objective seemed to be to explain that without his help the painful losses of the last year would have been much greater. I did not realize how my financial future in retirement was so connected to the economy of Europe and Asia. I did not even get to vote on Brexit! It seems that a painful economic reality is that a world that is not creating opportunity for everyone is a world that will ultimately fail me. America must be able to buy and sell in a stable world for my wife and I to be able to imagine that our children and grandchildren will have anything close to the same opportunities that we have had. Deleted emails and unreleased tax returns have almost no bearing on the issues that will really impact the future of anyone in the world.
Something has happened to me this week. Perhaps it was triggered by realizing that I am connected to my neighbor who is a Trump supporter, or that the economic issues of Southern Europe may eventually impact my future in a way that is just as real as the civil unrest in Syria. What disturbed me more than the debate between the two wannabes on the screen in front of me was the sense of separation and estrangement from about half of my American brothers and sisters and the sense that our issues trump the concerns of any other population on the planet. I realized that the outcome of the election was as much about the pain of the many billions of people around the world living now, and even some as yet unborn, who have no voice in the outcome but are perhaps even more vulnerable to the result of the election than I am. The sense of loss and separation that grew on me replaced the anger that I had previously been directing at the candidate that I did not favor.
My problem is unsolved and my anxieties are unresolved. I realize that fixing what worries me in healthcare and in international affairs will require much more than an election. No matter who wins most of the questions will remain. Our problems can not be solved by one “big man” or one very competent woman. No matter who wins, the great sense of division within the country and the world will likely persist. Complex problems do not bend to simple solutions. They are aggravated by personal anxieties that make us unable to appreciate the things that join us all together. We must someday understand that we have a shared destiny that is threatened as we focus only on our own concerns.
More Thoughts on the Future of Practice in the Two Americas
Last Sunday I met one of my new friends at the Post Office parking lot in Elkin which is actually a “suburb” of New London. Elkin is the remnant of a nineteenth century mill village that was sustained by the water power that was generated by the harnessed outflow of Pleasant Lake. We frequently enjoy walking the hilly six mile road that runs around the circumference of the lake. He greeted me with a manilla envelope that I could see contained a folded newspaper and a magazine. I tossed the envelope onto the seat of my car knowing that I would learn what was on his mind as we walked.
To my surprise he asked me if I had met a certain man in town who was a retired general surgeon. In fact I had met him. He did not remember that it was he who had introduced us. He continued by saying that our mutual acquaintance had announced to him that in the future there would be no need for primary care, or if there was a need for it we should get over that need because there were not going to be enough primary care doctors for everyone to have one.
My first reaction was to announce that our friend was definitely half wrong. I assured him that we will always need primary care. In our conversation I learned that my walking buddy gets his primary care from an NP employed by a practice affiliated with Dartmouth Hitchcock. He also regularly sees a cardiologist and an orthopedic surgeon that D-H sends to our little local hospital. After I understood the stability of his situation, I confirmed that we did face an impending shortage of primary care talent. That is when he told me that he was really concerned about Dartmouth since he got his care from doctors who were connected to the Dartmouth system. The envelope contained an article from The Valley Voice, the daily newspaper of our region. The headline on page one of the Friday (9/23/16) paper was “D-H May Ask Physicians to Pick Up Pace”.
As you know from these notes, Dartmouth recently withdrew from all Medicare ACOs because of losses. The article reported “leaked information” that suggested that the system was looking for $100 million in “improvements” in the current fiscal year. The system lost $23 million in the quarter that ended on June 30. Up to 460 employees could be laid off. Dartmouth Hitchcock employs about 9000 Upper Valley residents. I was surprised by the sophistication of the reporter which you can assess for yourself if you clicked on the link to the article. The article suggests that Dartmouth is abandoning efforts to move away from RVU based compensation and will refocus on volume. Doctors will be held accountable to hitting volume projections. The article ended with a quote from a physician that summed up the reality:
....the doctors interviewed, while not pleased, said they understood the need to make changes to address D-H’s financial problems, even it meant a slowdown in the systems reform efforts.
“We’ve got to take care of people and the organization,” one doctor said. “The organization has a beautiful vision but the world is not there yet.”
The commitment to reform ended up putting D-H in a bind, according to another doctor.
“Dartmouth was trying to change the game a little bit,” that doctor said. “Ultimately, the game didn’t change.”
I am unable to comment other than to say that this reality feels close to home. My friend feels threatened as do I, although my wife and I continue to get most of our care by driving the one hundred miles to Boston. Any reading of the Internet healthcare news reveals that across the country there are many systems that are in various forms of distress. Dartmouth has financial reserves and I am sure that some way will be found to resolve the issues short term. It would be inappropriate for me to criticize the Dartmouth board or management for doing what it thinks must be done, but I fear that a focus on volume and cutting personnel is unlikely to be a positive long term move.
John Edwards introduced the term the “two Americas” way back in the 2004 election. There are many “two America” dichotomies. In healthcare there are markets that have traditionally enjoyed huge reimbursements. I think Boston, Miami, and McAllen,Texas when I think about expensive healthcare markets. There are other markets that have always had low costs. The Upper Valley is one such market. As we look at the financial realities of healthcare reform, it is clear that mistakes have been made in the creation of the mechanisms of financial transition from volume to value for traditionally low cost markets. Recently Rick Gilfillan and Peter Orzag and others have advocated for these inequities to be corrected. Gilfillan is calling for ACA 2.0. The doctors and patients of the Upper Valley and many other smaller markets need ACA 2.0. It is hard to imagine ACA 2.0 without a major shift in understanding and performance within Congress. This election could be a start in reshaping Congress toward a body that is willing to productively engage in the healthcare concerns of real people like my friend. He is ok for now. We still have time for the reengineering necessary to ensure that we will all have the care we need into the future, but it will take all of us working together to get the job done.
Good Bye Big Papi
As we were driving home from Boston yesterday and listening to the radio my wife asked me why David Ortiz, a player who was a so so performer early in his career, had become so great in Boston. The radio commentator had mentioned that this weekend was going to be David Ortiz’s final regular season homestand in Boston. The answer took me about thirty minutes to deliver. Perhaps it is just best to say that this weekend there will be speeches given, bridges renamed, and tears shed for a wonderful time that is quickly passing. Everyone has been amazed that he is going out with such an incredible year.
I am getting a little concerned. The Red Sox lost Wednesday night on a walk off grand slam homer and simultaneously backed into postseason play as the AL East Champs when the Orioles beat Toronto 3-2. It does not feel good that the Sox lost again last night to the Yanks making it three loses in a row. I hope that they can get it together to finish with a series of wins over the weekend against Toronto. It now seems possible that the Red Sox will be playing Cleveland in Cleveland on October 9 while Tom Brady is making his return to football on the same day in the same town!
The World Series is a fall classic and up here in New Hampshire the air is getting chilly and it really does feel like fall. I took this week’s picture at sunset earlier this week. I do not know why, but one extra benefit of chilly autumn evenings is the opportunity to view gorgeous sunsets. On another evening this week I watched an eagle circle the lake and then take up a prolonged roost on a tall skinny white birch on the point of land just a few yards from where I was fishing. Was he going to let me do all the work?
It is a busy changing world. There is a lot to ponder and a lot of stress to manage. Let me remind you that nothing manages stress better than exercise and there is no time better to “ponder” the fate of us all than while enjoying the great outdoors. I hope that this will be a week end that gives you plenty of time for pondering and exercising.
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