31 March 2017

Dear Interested Readers,


What’s Inside and a Look Back at Last Friday

There is a twist in this week’s letter. Usually, when I ask you to examine Tuesday’s post on strategyhealthcare.com I mention that it represents a further refinement of the dominant idea from the previous Friday letter. Last Friday was a landmark day in the history of healthcare legislation with a blockbuster event that occurred after the weekly letter went out at 3 PM. I waited as long as I could to see what would happen, but things were still uncertain at mid morning when I needed to finalize the letter. As I prepared the posting for SHC (strategyhealthcare.com) on Tuesday, I realized that reposting the conjectures of the previous Friday before Paul Ryan pulled the AHCA added no value. The article that was finally posted focuses on what has happened after 3 PM last Friday. I focused on the threat to the ACA and healthcare stability that the president made in a phone call reported by Robert Costa of the Washington Post, and then repeated almost verbatim in the statement he later made, flanked by Mike Pence and Tom Price, from the Oval Office.

“As you know, I’ve been saying for years that the best thing is to let Obamacare explode and then go make a deal with the Democrats and have one unified deal. And they will come to us; we won’t have to come to them,” he said. “After Obamacare explodes.”

“The beauty,” Trump continued, “is that they own Obamacare. So when it explodes, they come to us, and we make one beautiful deal for the people.”

The point of my posting on Tuesday was that the president and the Republican majority in Congress did not have the votes to “repeal and replace” the ACA, but they easily predict its explosion because they can light the fuse. I was particularly annoyed by what I considered to be the disingenuous nature of Paul Ryan’s comments in his press conference after he pulled the AHCA.

“Obamacare is the law of the land. … We’re going to be living with Obamacare for the foreseeable future.”

I did not believe for a second that either Ryan or the president would passively move on and accept as final the continued acceptance of the program that they campaigned against so vigorously, and that has been a central cause of alignment for Republicans for seven years. Over the weekend the president began to mix reassurance with his dire forecast in his tweets.

Donald J. Trump ‏Verified account @realDonaldTrump Mar 25
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ObamaCare will explode and we will all get together and piece together a great healthcare plan for THE PEOPLE. Do not worry!

Although he did not let up on his blame game:

Donald J. Trump‏ Verified account @realDonaldTrump Mar 26
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Democrats are smiling in D.C. that the Freedom Caucus, with the help of Club For Growth and Heritage, have saved Planned Parenthood & Ocare!

By midweek there was growing evidence that “repeal and replace” would be back before long. This time the strategist may be Steve Bannon and not Paul Ryan. There were also articles discussing just how the president and Secretary Price can further foster the predicted “explosion” of the ACA.

The first section of the letter continues the saga of the “repeal and replace story” with a discussion about how Trump and Company can and will blow up the ACA as a fulfillment of the president’s prediction that the ACA will explode. Tom Price knows where the fuse is, and he has a match. The section continues with an examination of a potentially useful but unlikely coalition that could emerge if the president really did want to fulfill his promise of great affordable healthcare that only he was smart enough to negotiate.

The second section moves beyond complaining, predicting, and hoping to offering some observations about a feasible objective drawn from the history and experience of Atrius Health, the current legacy practice of Dr. Robert Ebert’s attempt to find a conceptual framework and operating system that will provide optimally for the health needs of the population.

Since the election and the escalation of the politics of “repeal and replace,” I have been in a conversation with Dan Burnes, who has been my colleague for many years and who followed me as CEO of Harvard Vanguard Medical Associates. Dan has been trying to organize current and past leaders of Atrius Health and its legacy organization into a positive coalition to advocate for real change and clinical innovation that would move the nation toward the Triple Aim. Dan’s objective may sound audacious to you, but history is replete with examples of positive outcomes that began as the actions of a few who had only the power of ideas and no formal political responsibility other than being a concerned citizen. I am delighted to sign on to Dan’s effort. In the second section of today’s letter I try to answer Dan’s request to expand an outline that he has generated from the experience of our organization into something that could be used as a framework for how to proceed into an uncertain future.

Once again, the final section of the letter is a ratatouille of ideas and impressions related to exercise, anticipation of things to come in sports, and a celebration of life as enjoyed through grandchildren. It’s long, but I hope that you will find the letter to be thought provoking, and I hope that you will be sure to share your thoughts with me. I believe that Dan is right, and the discussion of the future of healthcare in America is far from over with or without the explosion of the ACA.

Considering the Explosion of The ACA That The President Predicts

As if the drama of the death of the AHAC was not enough, our theatrical president added to intensity of the moment by his prediction of the "explosion" of the ACA. Over the weekend he was not always consistent with his blame for the fiasco of the failure which seemed to many outside observers to be the just deserts of a terrible and ill advised piece of legislation. He was correct when he blamed the Freedom Caucus, and he was also correct when he gave some credit to the Club for Growth and the Heritage Foundation; but he was definitely being unrealistic to lay any blame at the feet of the Democrats. Whatever made him think that there was anything in this bill that read like it could have been written by Ayn Rand, whose writings though often misinterpreted, inspire Paul Ryan and Donald Trump, that the Democrats would have ever been willing to accept. The president has served notice:

“As you know, I’ve been saying for years that the best thing is to let Obamacare explode and then go make a deal with the Democrats and have one unified deal. And they will come to us; we won’t have to come to them after Obamacare explodes.”....“They’re going to come to ask for help. They’re going to have to. Here’s the good news: Health care is now totally the property of the Democrats.”

The mantra of the president and the speaker is that the ACA is both the law of the land and it will remain a disaster. Neither the president or the speaker, nor Dr. Tom Price, the Secretary of HHS, seem to recognize that they have taken an oath to enforce our laws and have a moral and constitutional obligation, as pointed out in an article in this week’s NEJM, to support the ACA as long as it remains the law of the land if they can not repeal it and are unwilling to improve it.

We should take the president’s prediction very seriously because his administration does have the ability to blow up the ACA or kill it by a combination of benign neglect and active assaults. The bill has already been wounded by actions that most people do not recognize. Marco Rubio tried to use his successful attack on the ACA as one reason that he should have been the Republican nominee for president. Robert Pear’s article in the New York Times in December 2015 was a prediction of the disruptions and difficulties experienced in the exchanges this year that Rubio enabled:

A little-noticed health care provision slipped into a giant spending law last year [2014] has tangled up the Obama administration, sent tremors through health insurance markets and rattled confidence in the durability of President Obama’s signature health law. ...Mr. Rubio’s efforts against the so-called risk corridor provision of the health law have hardly risen to the forefront of the race for the Republican presidential nomination, but his plan limiting how much the government can spend to protect insurance companies against financial losses has shown the effectiveness of quiet legislative sabotage.

Rubio was unable to capitalize politically on the fact it was his insight and legislative cunning and not anything that Ryan or Mitch McConnell had done that created the instability in the exchanges that became a campaign issue in October, but Donald Trump did. What was amazing to me was how little useful discussion of the real issues in healthcare occurred during the run up to the election. Post election, President Trump began his attack on the ACA shortly after his inauguration as many of us noted with horror and as Noam Levey documented in the LA Times in late January.

The Trump administration’s decision to pull television ads urging Americans to sign up for coverage under the Affordable Care Act is stoking fears that the White House is trying to sabotage the nation’s insurance markets in an effort to hobble the program, jeopardizing coverage for millions.

The move, which comes just days ahead of a critical enrollment deadline for Obamacare health plans, follows Trump’s executive order last weekend in which he suggested his administration wouldn’t implement rules crucial to sustaining viable markets.

And it coincides with a concerted effort by Trump and Republican congressional leaders to portray the law as collapsing, despite evidence to the contrary from independent analysts.

The Washington Post published an article this week about two impending barriers to the success of the ACA. I expect that the president and Secretary Price can do a lot of damage to the future of the ACA depending on how they respond to these and other issues, and how Secretary Price is aware of the “1400 administrative options” the ACA gives him to affect the success of the ACA, as described by one of his former colleagues in the Congress before the failure of the AHCA,

“There are 1,400 references [in Obamacare] saying ‘the secretary may’ or ‘the secretary shall,’ so he has great latitude to fix a lot of things on his own,” Rep. Bill Flores (R-Texas) said. “That leaves us with the rest.”

It is easy for the president to be clairvoyant and be certain of the failure of a program when there are so many acts of omission and commision that are available to Dr. Price as Secretary of HHS and to him as the chief executive. It will be a lot easier for President Trump and Dr. Price at HHS to undermine the ACA than it will be for them to defend it, improve it, and to strive to making it work because it is the law. What will happen? The president knows that the explosion he predicts will occur because he knows who will light the fuse. We live with the ACA in a metastable moment.

What else do we know? We know that the AHCA was not a legitimate path toward

...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.

Nothing was a clearer demonstration of the fact that Paul Ryan’s AHAC was a thinly veiled attack on Medicaid and an attempt at tax relief for the rich than were his attempts to gain the support of the “Freedom Caucus.” The president and the speaker were caught between their promises that they made to their base to make the repeal of Obamacare job #1, and the reality that despite all of its imperfections the ACA is a remarkable initial piece of social legislation that more and more people were finally recognizing for the lives it was saving and improving everyday that it survived.

The AHAC, as it was proposed, took deep whacks at Medicaid. As its passage seemed less and less likely Ryan and Trump were willing to sacrifice the Essential Health Benefits for all Americans that the ACA required in every policy. What those last minute attempts to get the AHAC through the House revealed was that access, quality and lowering the cost of care were not the objectives of the president despite all of his words about his ability to give us care better than we had ever had for less money. Lower taxes were the objective. The big winners would have been those who get their care from their employer along with a six or seven figure income. Most Americans came to realize finally, as the debate occurred, that the losers would be the underserved and the nation’s safety net institutions. Many respected economists believed that in time the bill would have also increased the cost of care for all Americans compared to what they could expect from the flawed ACA.

The withdrawal of the AHCA was a retreat but not a defeat for those who do not believe healthcare is an entitlement worth the best efforts of the nation, but rather is a consumer choice to be purchased by those who have the means. That mindset persists and it controls HHS. The ACA is the law of the land, but its guardians don’t much care for it, or for the ideas upon which it is constructed.

Former President Obama laid out both the reasons and plausible paths for improvement of the ACA in articles published earlier this year in the New England Journal of Medicine and JAMA. If President Trump was inclined to learn more to enable him to deliver on his campaign promise to the American people that as president he would guarantee them fabulous healthcare, I would suggest that he consult a recent article in the Harvard Business Review about ways to improve the ACA written by David Blumenthal and Sarah Collins.

By midweek the story was beginning to change. Robert Pear and Jeremy Peters wrote in the New York Times that it was “game on” again. Perhaps this time the quarterback will be Steve Bannon, the Darth Vader like shadowy adviser who seems to have masterminded the president’s victory. That move may make sense since Bannon is not an ordinary Republican and probably has nothing but a utilitarian interest in the divisions that exist in the Republican Party and are the real cause for the failure of the AHAC. Bannon is a self described economic nationalist and populist. In his own words in a CNN interview:

"Like (Andrew) Jackson's populism, we're going to build an entirely new political movement," he [Bannon] said. "It's everything related to jobs. The conservatives are going to go crazy. I'm the guy pushing a trillion-dollar infrastructure plan. With negative interest rates throughout the world, it's the greatest opportunity to rebuild everything. Shipyards, iron works, get them all jacked up. We're just going to throw it up against the wall and see if it sticks. It will be as exciting as the 1930s, greater than the Reagan revolution -- conservatives, plus populists, in an economic nationalist movement."

Jobs, from rebuilding infrastructure, and good, cheap healthcare are populist causes that would not have interested Ayn Rand and will probably drive the Freedom Caucus nuts, but those ideas could be a place where Trump and Democrats could find an intersection of interests. Forty four Democratic senators are reported by the Washington Post to have signed a letter that describes how they are willing to work to repair the ACA, if only President Trump and Secretary Price stop trying to blow it up. We will see. We can hope. The man says he is a negotiator and despite being president, he does not hold the cards to do anything positive on his own.

A Proposed Future State

The challenge of providing affordable, quality care to all Americans has flummoxed politicians, healthcare policy experts, clinicians, healthcare administrators, insurance executives, employers, and the public for more than seventy five years. The ACA brought us closer to the goal of universal access to sustainable, affordable quality care than any other single piece of legislation since the passage of Medicare and Medicaid more than fifty years ago. Jost and Lazarus commented on the intent of Congress when it passed the ACA in an article first published by the New England Journal of Medicine in February and again in this week’s NEJM “Perspectives” section in an article entitled “Trump’s Executive Order on Health Care---Can It Undermine the ACA if Congress Fails to Act?”

Congress explicitly indicated that its priority in adopting the ACA was to “provide affordable health care for all Americans,” primarily by expanding access to health insurance and Medicaid for consumers with low or moderate incomes or preexisting conditions.

For many years I have tried to stress the continuing wisdom expressed by Dr. Robert Ebert, Dean of the Harvard Medical School, in 1965 when he wrote:

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.

This remarkable statement requires some dissection to fully appreciate what time and experience have clearly proven.

• Despite decades of effort and investment in highly trained personnel and possessing fabulous facilities full of technology, the problem of sustainably affordable universal access to care, has not been solved. Training and investment are probably necessary but insufficient components of the ultimate solution.
  

• He stresses the importance of systems engineering in solving the problem. Since the statement was made we have made great strides in the science of continuous improvement and have a better understanding of how to create systems that produce quality. Healthcare is behind other industries in adopting these principles that have a proven ability to create efficiency in production and improve distribution of products to larger markets. 
  

• Long before concepts of population health were commonly considered in practice design, Dr. Ebert recognized the benefit of solving systems issues for the individual by recognizing the unique needs of the population from which the patient came, and the necessity of applying solutions that considered all populations. In other writings Dr. Ebert expressed particular concern for the urban poor and rural populations. 
  

• It is important to note his reference to finance. He was clear that finance influenced processes of practice. He frequently spoke about and wrote about the conflicts of interest and the process limiting realities of financing healthcare through fee for service payment schemes.
  

Dr. Ebert’s era predated “Lean thinking” by several decades, but by nature and his background in medical research utilizing the scientific method, he understood and used the basic principles that are codified in Lean methodology. He was not content to just express his ideas. He was determined to test them. Dr. Ebert was well aware of Kaiser’s prepaid and totally integrated approach to health maintenance and care delivery. He wanted to see what could be accomplished using those principles in an academic environment. He correctly surmised that care delivery could be improved through the methodology of the scientific method. His writing also suggests that he believed that moving to a better system of care would require significant shifts in how doctors were trained, and the evolution of a culture of collaboration that elevated our attention to ambulatory care and prevention, and capitalizing on the explosion of possibilities with more effective collaboration between doctors, nurses and other providers of care. Perhaps he even understood that the transition he envisioned would require several decades, if not several generations.

The quote above which I love to reference was written as part of Dr. Ebert’s reasoning behind a request for financial support that he made to the Commonwealth Fund in 1965. He was eventually able to launch Harvard Community Health Plan in 1969 with the institutional support of Harvard President Nathan Pusey, and the financial support of the Commonwealth Fund, the Department of Health, Education and Welfare (now several departments, principally HHS) as well as the administrative and programmatic cooperation of Massachusetts Blue Cross.

Dr. Ebert was asking multiple “what if” questions and knew that it would take great organization and focus to hold the experiment together in an environment of resistance. He experienced first hand that if the goal was to introduce a better “operating system” that required fundamental changes in finance, the project would require a new culture and would be mightily resisted by the status quo. If you want to change practice methods, finance, and professional culture, expect resistance from the status quo. Before he became the dean, Dr. Ebert’s experiment had been blocked by the faculty practice leaders at the MGH where he was the Jackson Professor of Medicine and the Chief of Medicine. His ideas were resisted by elements within the Harvard Medical School for years. Indeed, there are still elements that reflexly line up against the principles he advocated. Ironically, he found more encouragement from leaders at the Harvard Law School and Harvard Business School than in the political environment of the Harvard Medical School.

As he expected, a lot was learned. Changes did occur and many of those changes were absorbed in part by the rest of healthcare, but culture and the status quo do not change easily. The outcome of the story remains a work in progress, perhaps because the external challenges of a complex world also continue to evolve as well; but it is the belief of many people who have spent all or part of their professional lives working at the legacy organizations of Dr. Ebert’s dream that what has been learned and proven are foundational to the dream of the Triple (Quadruple) Aim.

...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.

When that better future comes, and I believe it will, many of its foundational ideas about quality, like NCQA and HEDIS, as well as value based reimbursement, will be traced to Kaiser and the exceptional medical leaders in the Permanente Medical Group. Other organizations like Group Health in Seattle (now Kaiser in Washington State) and Dr. Ebert’s experiment, Harvard Community Health Plan will also be remembered for their contributions. I would also argue that the Institute for Healthcare Improvement arose from these same creative forces. At this time the experience of these organizations should be revisited for the insights and direction they can offer in the continuing journey toward better care.

Perhaps it is simple minded to say that the distillation of several decades of this work in these innovative organizations was the famous book, Crossing the Quality Chasm (2001). I do not mean to diminish the leadership of the IOM and others but I believe that the organizations that believed in and tried hardest to follow the philosophy and processes of prepaid healthcare, early on, recognized the importance of care that was patient centric, safe, efficient, effective, timely and equitable, and they made these attributes core to their business plans in ways that many other organizations and institutions neglected. Their experience was foundational to the wisdom of the book. Much of the fascinating history of the evolution of the quality movement in healthcare is chronicled in Best Medicine (2008) by Charles Kenney.

Given the fact that after thousands of years the wisdom of the world’s religions as recorded in the scripture and literature of the various faiths has been frequently ignored, misinterpreted, never been understood by many, or forgotten by leadership, and has not led us to the realization of a perfect world, it should be no surprise to us that at this confusing moment in the search for solutions in healthcare, the wisdom and experience of what has been learned over the last 75 years in healthcare is rarely mentioned by those who have, for the moment, the responsibility to lead. All they can say is, “Who knew healthcare was so complicated?”

If there was ever a time, place or arena where “leading from behind” was appropriate in healthcare, that time would be now. I would also add that those leaders who are making an attempt to be leaders from behind or within healthcare, and who have gained their insights working in organizations that have operated on the innovative edges of healthcare delivery like Kaiser, Group Health, and the legacy organizations of Dr. Ebert’s ideas, are familiar with all of the issues of adaptive change, and have developed the skills and patience required by the difficulties associated with trying to establish a “new order.”

Dr. Dan Burnes, former CEO of Harvard Vanguard Medical Associates, now a part of Atrius Health, has put out a call inviting the “sons and daughters” of Dr. Ebert into a collaboration with the objective of making a clear concise statement of the values and key principles that are the building blocks of a world class healthcare system. You may ask if that has not already been done. It has, but it needs to be done continuously and more effectively by those who have lived and worked in systems that have held the principles of the Triple Aim as their mission and reason for existence.

The collective experience of these organizations was captured in Crossing the Quality Chasm. To lower the cost of quality care so that it is sustainably available to all Americans, we still need to accept the six systems assertions that Don Berwick, who began his career at Harvard Community Health Plan, outlined in his 2002 article, “A User’s Manual For The IOM’s ‘Quality Chasm’ Report.”

1. Better systems for identifying best practices and ensuring that these best practices become organizational standards
   
2. Better use of information technology to a) access information and b) support clinical decision making
   
3. Greater investment in workforce training and skill development
   
4. Better team coordination
   
5. Improved care coordination across and within services and organizations, particularly for patients with chronic conditions
   
6. Better performance measurement
   

Experience working within an organization that is trying to make a difference has shown that the advocacy for change that was made more than fifteen years ago in Crossing the Quality Chasm and further explained by Berwick and others, is still good advice for those who have recently discovered how complicated healthcare is. Many have seen the graphic below which dramatically demonstrates the shifts in thinking and practice that experience has taught would facilitate better care at a lower and sustainable cost.