| 4 March 2016
Dear Interested Readers,
Inside This Week’s Letter
This week’s letter begins with comments that were stimulated by Super Tuesday and the fact that there is now a growing possibility that Mr. Trump will be the Republican candidate for president. My discussion includes some reflections back on the “War on Poverty” which was launched in January 1964. That failed effort was followed by Nixon’s “War On Drugs” in 1970. Both of these “wars” against social concerns lost momentum and were affected by wars that are somewhat more traditional military events: Vietnam, Iraq, Afghanistan, and the war against terrorism as manifested by Al Qaeda and ISIS. All of the above will surely have an impact on our struggle for equity and sustaining efficiency in healthcare. I hope that you will follow the connections that I try to make between healthcare and either “Make America Great Again” or “Make America Whole Again”, which ever is your sogan of preference.
The second topic in this week’s letter is a gift from Dr. Joseph Scopelliti, the CEO of Guthrie Health. Dr. Scopelliti thinks language is important and believes that our movement toward value from volume based revenue would be facilitated by a change in language.
It would be a real missed opportunity to let the first full week of Spring Training pass without some comment about the prospects for a spring, summer and fall of baseball! Perhaps this summer baseball will be more than “America’s favorite pastime”. It may be a collective relief from watching politics or a way to channel our frustrations away from a very stressful campaign year that may be more than just a threat to our individual concerns. It could be yet another step down in a long process of our society’s unravelling.
A shortened version of last week’s piece about concierge medicine is in the pipeline for strategyhealthcare.com, perhaps by the time you check it will be posted. As I say each week, the site is where your friends can sign up to get this weekly letter sent to their own email.
So What Will Happen?
Pundits have been asking that question since last June when Donald Trump announced his candidacy for the office of President. At first, the prediction was that this was a self limited process of narcissistic personal promotion. Now, in almost every opinion column, I read the writer is in a process of self flagellation for discounting Trump’s potential. Nicholas Kristof, a liberal pundit at the New York Times, has announced via an imaginary conversation with a “voter” that we should begin getting used to the phrase “President Trump”.
Voter: In the past, Trump was an entertainment personality, so he said outrageous things. From now on, he’ll be more presidential and more moderate, reaching out to Democrats — which he can do better than Cruz or Rubio, because he’s not so conservative. And for all your naysaying, he’ll be elected president, and he’ll show that all your anxieties are as imaginary as I am. Get used to the phrase: President Trump.
I interrupted my writing of this piece yesterday to watch the speech that Mitt Romney delivered from the Hinckley Institute at the University of Utah. Perhaps you have seen clips of the speech since it has been on all of the news programs. I have rarely contemplated applauding the former Governor of my former home state, but his speech was a point by point documentation of events in Mr. Trump’s record and his imprudent comments and behavior during the campaign that are matters of public record. In normal times Mr. Trump’s lack of experience in public office and his unconventional campaign behavior would have finished off his candidacy. Ironically, the “talking heads” that I heard on CNN after the speech predicted that it was too late and that the speech would probably add momentum to Mr. Trump’s “scorched earth” march to the White House.
For a select 2 minutes of the speech and written NYT commentary click on the link below.
http://www.nytimes.com/politics/first-draft/2016/03/03/mitt-romney-to-make-case-against-donald-trump-in-utah-speech/
To hear the entire Romney speech click here:
https://www.youtube.com/watch?v=RhfdF9bA-lg
Mr. Romney offered a strategy for mainstream Republicans to use to deny Mr. Trump the nomination. He suggested trying to create a “brokered” convention by denying Trump the necessary 1237 delegates required for nomination by voting for Marco Rubio in Florida, John Kasich in Ohio and Ted Cruz wherever he had any chance to win. The Republicans have not had a “brokered” convention since 1948 when Thomas Dewey was nominated to run against President Truman. The last Democratic convention without a nominee on the first ballot was in 1952 when Adlai Stevenson was the eventual nominee to run against the very popular, General Eisenhower.
Donald Trump began to effectively attack Governor Romney in social media a few hours before the speech and by an hour after the speech his Facebook posting had been viewed by over a million people. You can see the video attacking Romney, plus read all of his pre speech “Tweets” by clicking below.
http://newyork.cbslocal.com/2016/03/02/trump-romney-facebook-video/
What will follow this moment is anyone’s guess but knowledgeable predictors like Nate Cohn at 538 are nodding in favor of a Trump nomination.
David Brooks, a conservative and Republican thinks that the Republican Party is on life support.
http://www.nytimes.com/2015/10/13/opinion/the-republicans-incompetence-caucus.html
If you clicked on the link, you read his diagnostic assessment early in the article.
Republicans came to see themselves as insurgents and revolutionaries, and every revolution tends toward anarchy and ends up devouring its own.
Brooks wrote that line last October. He is thoughtful and analytic and foresaw the possibility of this moment and understands its origins more clearly than most. In retrospect, because of the disarray in the ranks of Republicans, Trump’s bid for president was much more certain as a Republican than as a third party candidate, which in essence he is. He is a populist not a true conservative. In the Republican Party there was no pre campaign consensus candidate. I say that with full knowledge that insiders preferred Jeb Bush, but poor Bush was “devoured by his own”. Ironically, the Democrats discovered that they had a little bit of the same reality, as Bernie Sanders has demonstrated.
So how likely is success for the strategy to block Trump that Governor Romney suggests? Once again, Nate Cohn’s website, 538 Politics, is where I go when I want a political probability. Romney suggested that Rubio must win Florida on March 15, eleven days from now. According to Cohn as of yesterday Trump had a 68% chance of winning Florida. Rubio is behind with a 33% chance of winning. The second part of the strategy to get to a “brokered convention” is for Kasich to win his home state of Ohio in the heart of the rust belt where there are a lot of white men who are angry. Ohio’s primary is also on March 15. At the moment Kasich has a 41% chance of winning and Trump has a 38% chance. Cohn’s analysis makes Trump’s chance to be successful significantly better than a toss up but not a slam dunk, but I wonder what will happen to the voters who have supported him so far if he is denied the Republican nomination. I doubt that they will suddenly have affection for whomever the nominee is that might emerge from a brokered convention.
Before the drama is all over there could be a disruptive third party candidate who would seek the votes of traditional Republicans and “Reagan” Democrats who could make the outcome of an election very hard to predict. You might remember that Bill Clinton won the election in 1992 in a three way race with President Bush and Ross Perot. Events like a third party totally disrupt the certainty of the predictive models.
Since there are too many variables ahead to be certain of anything, it may be reasonable to search for a higher level of understanding by looking back in time for clues rather than looking forward. One thing that many people are saying is that Trump’s success is built on a very accurate assessment of the mood of the country. How did the mood get to be so sour and how did so many voters come to the point where they are willing to even consider a candidate who would say the things Trump says as he panders to their mood, fears, and anger over real personal losses and frustrations?
Loss in dozens of different ways is clearly part of the picture. In 1964 when Lyndon Johnson launched his “War on Poverty” as a stroke of genius as a part of a more complex plan to secure the 1964 nomination, just six weeks after President Kennedy’s assassination, he realized that 20% of Americans were in poverty. Some of the machinery of those bold and ambitious programs still exist, buried in the Department of Health and Human Services, but the Office of Economic Opportunity that was the quarterback of the effort died in 1981 when Ronald Reagan promised tax cuts and trickle down success for everyone by another route. It is hard to say that the War on Poverty was lost since the official level of poverty is now about 15%. It is also true that many of the people who are really in poverty often do not vote.
The loss of opportunity that drives the most anger is found in the middle class. Definitions can obscure realities. Although the official “poverty level” is lower than in 1964, the lower class is growing. If you clicked on the last link you saw the figure below: |
| | It is my sense that it many of the agitated voters who have not yet fallen out of the middle class but can feel themselves “slip slidin’ away” (apologies to Paul Simon) are full of affect. These are the people who make it possible for an authoritarian figure on the right or a socialist savior on the left to have a chance to be president.
We have lost a lot of “wars”. In the memory of the majority of living Americans, there is not a war that has been won. Korea was the first confusing confrontation without a definite win after we “lost” China to the Communists. Then there was the humiliation of Vietnam, followed by the confusing first Gulf War, and the thirteen years of continuing “War on Terrorism” confusion since 9/11. Do not forget that we have not won Nixon’s “War on Drugs” and we seem to have lost ground with the recent opioid epidemic. In the mind of the angry, these are manifestations of the failure of the “establishment”, whatever that is. They lost their jobs and homes in 2008 and in their minds the criminals made a profit at their expense and were not held accountable.
We will never fully understand what has produced the Trump success, if we look only at labels like conservative, liberal, or progressive. If your sense is that others have failed you, you are drawn to the person who matches or best expresses your anger. The draw of Donald Trump is best seen in the very large turnout of “independent voters” for the Republican primaries. Trump’s voters do not want to be “made whole”. Their sense is not that they are defective and in need of repair. They just want to be “great again”. When your anger is from loss and you feel vulnerable to further loss you are likely to express your anger and you may well vote for the person who spends more time reinforcing and justifying your anger than presenting you with rational solutions for a volatile, complex, uncertain and ambiguous future that was not what you believed was your birthright.
So what will happen in healthcare if our next president is either Donald Trump or the product of a brokered convention? My best guess is that it will not be good for you if you have recently gained access to healthcare through the ACA. If you are still one of the 30 million uninsured, the good news is that you will not die in the street, but that has been the law of the land since 1986 when EMTALA was passed while Reagan was president. What you will be vulnerable to is the loss of any money or property you have in bankruptcy. What you will not have is care for your chronic disease until you are so sick that you can go tot the EW. You will also not get any preventative care or regular health screening.
What if you are one of the tens of millions of underinsured ACA beneficiaries? Then there is some possibility that you may again find yourself uninsured. Just yesterday the editors of the NYT documented the risks that women of childbearing age will experience under Mr. Trump or any of the other Republican candidates. We have a lot to fear if the opinions and misrepresentations of facts about the ACA expressed in the Republican debates give us any preview of the future.
I tried to listen to the debate last night but turned it off when instead of talking about the economy, foreign policy, or healthcare, they began to discuss anatomy including height and the size of various body parts as if that discussion had any bearing on the issues of our day.
Let’s Stop Worrying About Revenue...and Think Instead About Funding
Last week the board of Guthrie Health had its strategic retreat and regular board meeting in Cooperstown, New York. I enjoyed the picturesque drive and was looking forward to visiting the Hall of Fame which I was sure had changed since I was last there in 1989. After an intense morning of strategic discussion and debate, the meeting broke to spend a little time after lunch at the Hall of Fame.
Not much had changed since my last visit except for the fact that there seems to be a movement to rehabilitate the reputation of Ty Cobb. History does not doubt that Cobb was one of the greatest baseball players of all time. He was the first player inducted into the Hall of Fame. Until recently there was general consensus that the “Georgia Peach” was also a violent racist, possible member of the KKK, was said to be guilty of domestic abuse, was reported to have confessed to murder on his deathbed, and was generally disliked and avoided by everyone from his children to anyone who ever had the misfortune to meet him. He came from a rough family and grew up in a rough part of the world at a rough time. He did not care what you thought of him as long as you feared him and he could beat you. Maybe there is hope for Pete Rose, Roger Clemens and Barry Bonds.
After the interlude at the Hall of Fame, we returned to the discussion of the future. The issues and concerns at Guthrie mirror the issues that worry physicians and other healthcare professionals across the country. “Moving from volume to value” has become a cliche, not a road map. Most organizations fear the uncertainty associated with a transition in healthcare finance. Much of the concern is the worry that there will be some sudden moment when “revenue” drops or they lose the ability to earn more by doing more. They are concerned that like the temperature that can fall rapidly when a weather front moves through, they could see their margin drop into the cellar. It seems very difficult for many people who are successful in the current paradigm of fee for service payment to trust that they will be fairly compensated when payment changes.
Like many other organizations Guthrie has been diligently tracking the changes in the market and in the regulatory environment for several years. Change has not hit every state and every market at exactly the same time. Guthrie is a good steward of its resources and remains successful on “curve 1” and has been thinking hard about when and how to move to “curve 2”. That was essentially the subject of this retreat. |
| | The strategic plan of the previous five years had been about building clinical lines, acquiring new hospitals and improving care coordination. Guthrie has all of the infrastructure that so many other health systems would envy. They have Epic and use the patient portal. They own over twenty primary care sites spread over eleven counties in two states. They have a data warehouse and a progressive quality program. They began their Lean journey two years ago and have recently given it a big boost with further investment. Guthrie has a dominant market share in many of the counties where it operates. Despite these attributes and competencies Guthrie is apprehensive about when to electively shift to “curve 2”. They have passed so far on becoming a Medicare ACO or a commercial ACO.
The board is composed mostly of very committed members of the community and a few physicians. The gender diversity on the board is improving. The Triple Aim is an exciting concept for both the physicians and the community members of the board. As the strategic discussions unfolded it was clear that the next five years would not be about acquiring real estate unless the real estate expanded the population of patients who would get their care from Guthrie. The board was most excited about strategies that would bring more value to the community and would expand the community that they served. Despite the fact that there are resources to invest and opportunities to investigate that could easily advance the mission of Guthrie, there was a persistent sense of apprehension about revenue going into an uncertain future. Would the good work that they wanted to do be economically sustainable?
Near the end of the day Dr. Scopelliti, the CEO, moved into the middle of the room from the table where he had been sitting. I was expecting a quick “wrap up” and a move toward the dinner that was planned at the end of a long day. Good leadership will surprise you, and with simple words, can sometimes change the way a group thinks.
Dr. Scopelliti is a very genial and soft spoken man. He is a dedicated gastroenterologist and has practiced at Guthrie for over 25 years. He is a diligent student of healthcare. He is committed to the clinical values that have sustained the organization and made it an asset to the community for over a hundred years. In a very genial and half joking way he said something like, “I’ve been thinking that we worry too much about revenue. I wonder if we would see the world and the future differently if we talked about funding our mission.”
He took my breath away. Was there a difference between thinking about the resources that are necessary versus the margin to be made? I think so. At a technical level funding certainly provides new freedom in providing care to a population. The old finance of managed care comes to mind. There is a big difference thinking about the PMPM (could we say per person per month?) resources necessary to provide care for a population versus volumes of surgery and consults needed to be done to raise the revenue to sustain a practice.
As I thought about Dr. Scopelliti’s question, it seemed to me that he must be contemplating a shift to thinking about what competencies would be necessary to be successful in a world of risk and global payment. He was inviting the board to follow him into that conversation. The meeting ended quickly after his question. I do not think that he meant to pursue the question in the moment. He had more thinking to do and he was inviting the board to think with him. Moving a large and successful organization into an uncertain future is not for the faint of heart and it should not be done without deep reflection. The management team has a lot of work to do before the next meeting of the board. The stage will be set for a very good discussion. I can hardly wait. Guthrie and Dr. Scopelliti are poised to make a difference that could have an impact far beyond the “Twin Tiers” of Pennsylvania and New York!
Somewhere Warm They Are Playing Ball
I hear that the NFL and Tom Brady are back in court and I could not care less. What I am interested in is whether the disappointing investments that the Red Sox made last year in Pablo Sandoval and Hanley Ramirez will pay off this year. My guess is Pablo, no; Ramirez, maybe. More interesting will be whether David Price and some of the young arms that came up last year can be shaped into a solid pitching rotation. What will be the contribution or distraction of Buchholtz? As a Trump supporter will Buchholtz be more intimidating to hitters and return to his former winning ways?
These issues do not keep me awake but do serve as good subjects to substitute for politics when I go for a walk with friends. One of my favorite local walks is up and over Burpee Hill. From the top of Burpee there is a great view down the length of Lake Sunapee to Mount Sunapee in the West. To the North you can see Croyden Peak and Grantham Mountain. For about a month, going back to a week or so before the New Hampshire Primary, one of the nicest properties on Burpee Hill Road that sits just where you can begin to see Mount Sunapee in the distance, has sported a big political banner. I have tried hard to avoid it. You can see the picture in today’s header.
I admit that I do not understand it. I struggle to remember that it represents free speech and that I owe respect to the family that seems so proud to display it. I just hope that they are equally respectful of my wife’s bumper sticker that says “Not a Republican”, and that at “town meeting” next Wednesday we will all participate in a process that has been good for our community for the last two hundred years. |
| Be well, be generous with your good will for others and stay in touch,
Gene
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