| 4 September 2015
Dear Interested Readers,
Inside this Week's Letter
The first section in this week's letter builds off of the realization that we have learned a lot over the last 30-35 years. What we have learned should give us real hope that the Triple Aim Plus One is a reachable objective.
The second section follows as a logical extension of the first section. I celebrate the recently reported successes in the Medicare ACOs that were achieved using the concepts discussed in the first section. I also attempt to put those achievements into a realistic context. We have made progress but we have just started. The second section also recounts recent news that is disappointing. My disappointment is somewhat similar to the blues and apprehension I feel when the Red Sox lead early in the game but fall behind in the middle innings, making the possibility of a loss as likely as a win.
The last section tries to make sense of the surprises offered to us by Judge Berman. Who knows if all the drama is really over or if TB12 will use 2015 to win a fifth ring or will some further surprise go the way of Roger Goodell?
What I do know for sure is that I hope that you will visit strategyhealthcare.com if you have not done so already. Please tell your colleagues that strategyhealthcare.com is where they can sign up for these letters.
Quality, Access, Professional Satisfaction and Cost: We Now Know That We Can Have Them All
In my presentation to trainees last month at the Tufts Health Care Institute entitled “The Evolution of the U.S. Health Care and Insurance System”, I included a slide that was derivative of what I had been told was the truth back in the seventies and eighties. Back then the three points on the slide were considered virtually axiomatic and were treated like a law of nature until we developed new tools and new concepts. In a way the evolution of thought that I was describing was similar to Newtonian physics being replaced by quantum physics and eventually “string theory”.
My objective beginning with the slide was to show the trainees that after we had evolved systems thinking to improve quality and safety and began to use Lean and other approaches to continuous improvement of quality, safety, service and cost we could discard the limited thinking that had forced us to make difficult choices in the era of HMOs and rudimentary capitation. Here is the slide:
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| | My words were aligned with the slide to demonstrate to the trainees that what we consider to be fact at one moment in time is turned upside down when new concepts and tools evolve. The advent of rudimentary concepts of process improvement and quality management that evolved in healthcare in the late eighties and through the nineties are still evolving and spreading. I wanted to convince them that as we become more and more competent with our new tools and new thinking, we are creating greater opportunities to expand access, improve quality, and control costs. I wanted to recruit them to add their efforts to the quest for the Triple Aim Plus One.
These enabling ideas from manufacturing and other industries were transferred to healthcare by students of Deming and Juran (who lived to be 103!). Don Berwick, Paul Batalden and an army of other others at organizations like the IHI have shown us that if we couple systems thinking and the techniques of quality management with the evolving thoughts about safety from people like Lucien Leape, we could be more hopeful about our goal of turning a dysfunctional system of care that did not serve everyone into a higher quality, less expensive system that might serve everyone.
Lucien Leape’s paper in 1994 started changing the way we think about the origin of error in complex systems. Leape argued that errors were usually not manifestations of individual failure; rather they were evidence of systems failures. Change takes time and the old way of thinking that Leape discredited still persists in tension with systems thinking, as does its companion concept of clinical autonomy. Despite the slow rate of acceptance, Leape’s work and the early work of the IHI, IOM and others that launched the new era of systems thinking in healthcare put us on a new path. I summarized that launch period with another slide that celebrated the two publications by the IOM that documented the work upon which much of what we do today is founded. |
| | | Because of this work we entered this century with the ability to question what we had imagined to be axiomatic before and were empowered to articulate the Triple Aim which has now been expanded to the Triple Aim Plus One.
Recently I began reading an old book, The Reflective Practitioner: How Professionals Think in Action (1983) by Donald Schön. You can learn more about his work in the Wikipedia link from which I extracted:
Much of his later and more influential work related to reflection in practice and the concept of learning systems. He (along with Chris Argyris) maintained that organizations and individuals should be flexible and should incorporate lessons learned throughout their lifespans, known as organizational learning. His interest and involvement in jazz music inspired him to teach the concept of improvisation and 'thinking on one's feet', and that through a feedback loop of experience, learning and practice, we can continually improve our work (whether educational or not) and become a 'reflective practitioner'. Thus, the work of Schön fits with and extends to the realm of many fields of practice, key twentieth century theories of education, like experiential education and the work of many of its most important theorists, namely John Dewey, Kurt Lewin,Carl Rogers and David A. Kolb.
Schön believed that people and organizations should be flexible and incorporate their life experiences and lessons learned throughout their life. This is also known as Organizational learning (Fulmer, 1994).² Organizational learning is based on two things. The first being single–loop learning and the second being double–loop learning. The former refers to the process that occurs when organizations adjust their operations to keep apace with changing market conditions. And then the latter refers to not just adjusting to the market, but also to the creation of new and better ways of achieving business goals (Fulmer, 1994).²
Schön begins his book by identifying that old ways of functioning as a professional were beginning to fail in their ability to solve the problems that were emerging in the period of the sixties and seventies. That failure had been driven home by the disasters of the War in Vietnam. That tragedy in part was made possible by the collective failure of military professionals and the system in which they worked. He was also critical of the failures of city planners as we began to appreciate that their optimistic “urban renewal” efforts contained many unpleasant “unintended consequences”. Schön's concerns also included healthcare. Note the following quotes that are pregnant with the issues that still baffle us now, more than thirty years later. As is my usual habit, I have bolded what I want to emphasize for you.
Around such issues as environmental pollution, consumer exploitation, the inequity and high cost of medical care, the perpetuation of social injustice, scientist and scientifically trained professionals found themselves in the unfamiliar role of villain.
...these troubles seemed, at least in part, attributable to the overwhelming pride of professional expertise
...the long-standing professional claim to a monopoly of knowledge and social control is challenged-- first, because professionals do not live up to the values and norms they espouse, and second, because they are ineffective.
These quotes sound harsh when lifted out of the book. Schön is actually sympathetic to the plight of the professionals that persists today; individuals are not capable of contending with what I frequently label as our “VUCA” world. Schön used a similar concept more than fifteen years before the War College evolved the acronym VUCA. He said:
...professional knowledge is mismatched to the changing character of of the situations of practice--the complexity, uncertainty, instability, uniqueness, and value conflicts which are are increasingly perceived as central to the world of professional practice.
He was reading the mail you are getting a third of a century before you opened it today! It was precisely at the same time, in the early eighties, that I realized that just my being a good doctor was not going to deliver the results my patients needed and that I had been inadequately prepared to face the real challenges of delivering the care that I wanted to deliver. My childhood medical heroes, my relatives who had been physicians, my PCP, and even the heroes of my medical education had functioned in a world that had suddenly disappeared. Fate had placed me in an environment (HCHP) where leaders were beginning to find language to manage the more complex problems that we were facing, but their efforts were to become discounted by the harsh economic environment of the fading status quo.
While I was preparing the talk at Tufts I took a journey back in time in my mind to when I first emerged from just trying to be a good doctor. When I joined the Harvard Community Health Plan in 1975 I was interested in some of the new concepts of practice that they espoused; but there was still no concrete process to teach me a “new way to walk”. My metaphor for a new way of walking in the early eighties was driven from memories of the 1962 Rooftop Singers version of the old 1929 tune Walk Right In and Sit Right Down by Gus Cannon. I can still hear the invitation:
Now everybody’s talkin’ ‘bout your new way of walkin’, do you wanna lose your mind?
My “old way of walking” were the concepts of practice that were the “standard issue” set of concepts gained from my previous eight years at Harvard Medical School and the Brigham. I had been trained to focus on personal responsibility and autonomy. I had good bedside skills, a reasonable understanding of the science and practice of medicine, and could function at a high level in the practice environment of an academic medical center. I was clueless about how that set of skills worked in the ambulatory world where the environment was less controlled and less predictable.
My real education for the rest of my career occurred through practicing in the relatively unsupported environment that I found in local emergency rooms and from the profoundly positive experience of being taken under the wing of an exceptional clinician, Barbara Taylor, NP. In last week’s letter, I digressed to talk about my second practice partner, Maxine Stanesa. Perhaps I should note in this letter that from 1975 until her death in 1987 from ovarian cancer, I had the enormous privilege and good luck to have been assigned Barbara as my practice partner.
I call Barbara one of the “founding mothers” of HCHP. She assessed my inadequacies and supported my learning curve with the attention of a caring big sister. I think that it is remarkable that in 33 years of intense practice I had the good fortune to share a practice with only two colleagues. Barbara supervised my evolution from 1975 until 1987. Maxine picked up where Barbara left off, continuing with me until 2008 when I gave up most of my practice time to become a CEO.
It was Barbara’s efforts that gradually and gently moved my focus from my own autonomy and my reliance on individual skills and capabilities to my early realization that I could accomplish more of what I wanted to do for patients working as part of a team rather than as a “Lone Ranger”. It took me until the early eighties to begin to understand what Barbara had known for a much longer time. It is amazing to read now that Schön was describing at exactly the same time what I was learning in the supportive environment where I practiced.
Schön wrote further:
The role of the physician will be continually reshaped, over the next decades, by the reorganization and rationalization of medical care…
He quoted Russell Ackoff, one of the founders of the field of operations research.
...managers are not confronted with problems that are independent of each other, but with dynamic situations that consist of complex systems of changing problems that interact with each other. I call such situations messes. ...Managers do not solve problems: they manage messes.
That does not sound very hopeful but Schön noted that:
Ackoff argues that operations research has allowed itself to become identified with techniques, mathematical models and algorithms, rather than with “the ability to formulate management problems, solve them and implement and maintain solutions in turbulent environments.”
...the active skill of “designing a desirable future and inventing ways of bringing it it about”.
I come back now to where I started. In the eighties as we were beginning to lose confidence in the ability of HMOs and capitation to give us the elusive operating system that Dr. Ebert advised us to look for when in 1965 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.”
Experience was suggesting that we were trapped in a situation where: - If you want higher quality and better access, expect higher cost.
- If you want lower cost and better access, expect lower quality.
- If you want high quality and lower cost, expect restricted access.
It is my thesis that many of our colleagues as individuals and in their institutions are still limited in their degrees of freedom for improvement because they are still tied to old ways of thinking. They are still trapped in the struggle with the very small playing field that you have if you still embrace the concepts of intense clinical autonomy and measurement and change at the individual level. Things are not much improved by joining group practices, hospitals or health systems if those organizations are still controlled by autonomy and self interest. The new tools that enhance quality and collaboration through continuous improvement and a focus on the benefit of designing care for populations are ignored in many places as clinicians still practice “together alone”.
It has been written that it takes 15 to 20 years in medicine for a new treatment to be accepted and become widespread in its effectiveness. If you use the publication of Crossing the Quality Chasm (2001) as the zero point on the timeline, I think that the next five years may be a period of dramatic progress toward the Triple Aim Plus One. I love to dream of a better future. What if we could find the political will to give up attempts to repeal the ACA and focus instead on creating an improved ACA 2.0?
The improvements should be based on the observations of the outcomes of the experiments in care that are in place now, like the Pioneer and MSSP ACOs. ACO 2.0 will be driven by a politically neutral collective desire of “reflective practitioners” who want to further the gains and improve the yield from what was an experiment in “rapid prototyping”. The surge will be fueled by widespread competency using the tools of continuous improvement. Many of our colleagues do not realize that the quality and systems improvement work that we imported from Japan as Lean has its origins in the thinking of Deming and Juran who were greatly influenced by the PDCA (Shewhart Cycle) work of Shewhart in American industry almost a hundred years ago. They also do not recognize that the work is closely related to our own foundations in scientific method which is a thousand years old, or at least five hundred depending on to whom you wish to give the credit for applying process to the acquisition of new knowledge.
You might say that the moment we have been waiting for is building, it just takes time for best practices to spread and to overcome old ways of walking (being) that can not work now, even though they were of benefit in simpler times.
Managing Costs, The Ultimate Challenge for Sustainable Universal Coverage: Good News and Not So Good News
Last Thursday CMS announced the results of the efforts of the Pioneer and MSSP (Medicare Shared Savings Program) ACOs for 2014. The headline made for compelling reading: Medicare ACOs Provide Improved Care While Slowing Cost Growth in 2014. I hope that you will click on the link and read the announcement for yourself. Just in case you do not have the time let me help you appreciate the gist of the report.
In 2014 there were 20 Pioneer ACOs that were still in the program from the original 32 who had bravely accepted the challenge three years earlier. The great growth in the ACO world has been within CMS’s MSSP program. In 2014 there were 333 MSSP ACOs. There are many more in 2015. The savings generated by the 355 ACOs were greater than 400 million dollars. That is fabulous but people have a hard time evaluating what big numbers mean. Let’s think about it with some data from:
As the chart below shows the net federal outlay for Medicare was 505 billion dollars, 14% of the federal budget. That means that even more was actually spent on the care of the elderly because Medicare premiums, copays and other expenses of consumers are not included.
How many patients were covered by that 505 billion dollar number? The best numbers that I found are based on projections from 2012. There were just about 50 million beneficiaries in 2012 and that was up about 3.5 million over the previous 2 years. My guess is that, given the rapid increase of baby boomer recipients, there were probably at least 54 million in 2014. That means we spent a little under $10,000 a year for the average patient. There are a thousand millions in a billion so the 400 million savings represented 0.4 billion, about $7.00 a patient if my math is right. If the IHI has been right and 30% plus of healthcare expense is waste then our potential savings is more like $3000 dollar per patient which means that a maximum yield might be as much as 150 billion dollars.
Such a gain is theoretically possible since the best Pioneers, like the Bellin-ThedaCare collaboration in the Pioneer program, had costs that were about a third lower than the average, and have consistently been at the top in quality! They obviously know how to use Lean. There is another way to look at the results that gives us hope. Of the 54 million Medicare beneficiaries only a little over 5 million were in one of the 355 ACOs. That means that if the other ninety per cent had been covered we might have saved more than 5 billion or almost one per cent! There is plenty of opportunity ahead if we can engage the entire world of practice with efforts that match the best Pioneer and MSSP ACOs. Think about it. |
| | | What is more impressive to me than this years savings by the ACOs is that those savings occurred simultaneously with improvements in quality. Going back to what we believed in the nineteen eighties and what I discussed in the first part of this letter, we are doing what we once thought was impossible. That was the conclusion also of CMS.
As the number of Medicare beneficiaries served by ACOs continues to grow, these results suggest that ACOs are delivering higher quality care to more and more Medicare beneficiaries each year.
I hope that you will invest the time to look at the report from CMS. What you will not find in the report is much data about the performance of the individual ACOs. For group related data you must depend on the individual ACOs to describe their experience. Atrius Health, which is close to my heart, has consistently reported their experience to the public. Click on this link, if you want to see what Atrius Health published about its experience as a Pioneer ACO. Here are the high points of their report.
- Atrius ranked as the highest on the Centers for Medicare & Medicaid Services (CMS) overall quality score among Pioneer Accountable Care Organizations (ACOs) in Massachusetts and has ranked third highest nationally, based on 33 ACO quality measures tracked by the CMS.
- CMS chose 33 quality measures to represent patient/caregiver experience, care coordination, and patient safety, preventive health, and risk for patients with diabetes, hypertension, ischemic vascular disease, and heart failure and/or coronary artery disease. On 30 of the 33 measures, Atrius Health scored above the mean as compared with over 300 ACOs nationally.
- More Atrius Health ACO patients surveyed rated their physicians and communication with their physicians as “excellent” than comparable patient populations in 90 percent of ACOs across the country. Additionally, patients rated Atrius Health better than 90 percent of other ACOs in terms of effective health promotion and education efforts.
- Atrius Health was ranked fourth for meaningful use of its EHR across all Pioneer ACOs.
- Atrius Health rated above the 90th percentile on four important preventative measures, including screening for fall risk, effectively identifying patients at highest risk of depression, tobacco use assessment and cessation intervention, and blood sugar control in patients with diabetes.
- The important Diabetes Composite Measure on which Atrius Health achieved well above the 90th percentile includes: glucose control, blood pressure control, and cholesterol control.
- For the 31,000 Medicare beneficiaries served by the Atrius Health medical groups participating in the Pioneer ACO model in 2014, Atrius Health saved Medicare $4.5 million compared to its target, returning $2.8M in savings to Atrius Health. Atrius Health’s target is the lowest among Massachusetts Pioneer ACOs, because of Atrius Health’s already strong historical performance. Atrius Health applied its savings to investments in care coordination, training, data analytics, information technology, and other resources serving its Medicare beneficiaries.
Of all the impressive things that the Atrius report says I am most impressed the statement that:
Atrius Health applied its savings to investments in care coordination, training, data analytics, information technology, and other resources serving its Medicare beneficiaries.
Making money has never been the driver behind the effort at Atrius. Atrius entered the Pioneer ACO because contributing to the the experience of care and pursuing the Triple Aim Plus One has been central to their mission. They are learning and investing to learn more.
The not so good news reported this week in the Boston Globe appeared in the form of two articles. The first article reported that health insurers in Massachusetts will increase their rates more than 6 percent for small businesses and individuals in 2016. That is even more troubling since the goal established by the healthcare law of 2012 (Chapter 224) established the goal that increases in cost would be less than the state’s GDP. The law created a Health Policy Commission to lead the effort and the infrastructure to measure and report the success but created no penalties for not meeting the goal.
There will be around 300,000 people who will experience this failure as an expense. The Globe tried to walk the line between “sugar coating” the failure and raising concerns by saying,
“The increases will hit only a small slice of the state’s overall commercial insurance market of about 4 million, analysts said, but they may be a precursor to premium increases in the broader market, representing a setback to efforts to contain the state’s already high health care costs. They far exceed the state’s goal of keeping total health care spending growth below 3.6 percent a year...The increases come as most of the state’s hospitals, particularly the higher-cost Boston teaching hospitals, enjoy healthy profits. Massachusetts General Hospital and Brigham and Women’s Hospital, both owned by Partners HealthCare, were the most profitable in the state last year, earning $200 million and $152 million, respectively, a state report shows.”
There were a lot of excuses but excuse me; the failure and the profits occurred while Atrius was lowering the cost of care. I am not impressed nor is my disgust assuaged by the explanations that were offered. Read the article for yourself.
About the time I was cooling off from that article I opened the Globe on Tuesday to read
This article reported the increase in cost "blows past a state goal of holding health care spending growth to 3.6 percent annually according to a report to be issued Wednesday by the state Center for Health Information and Analysis."
The article goes on to tell us what we already knew.
In Massachusetts, the growth in costs had slowed over the past few years but recently has begun to accelerate. Last month, state regulators approved an average health premium increase of more than 6 percent next year for small business and individual policies, triple the increase of 2014.
The article suggests that overall spending is up because more patients than expected were covered, perhaps because of the way enrollment was mismanaged to include many who might not have been eligible. Stuart Altman who is the Chairman of the Health Policy Commission is quoted:
“We’re going to need to dig deeper,’’ ... “If it’s the result of a temporary growth in enrollment, if it’s the result of more structural issues — at this point, we just don’t know.’’.. “There are preliminary indications that costs are growing,’’ ... “There are new drugs coming on the market that are very expensive, and new technologies. There are a number of factors that generate higher spending.’’
Yes, those have been the facts for some time. Those facts and market realities also apply to the Medicare ACO patients where cost went down and quality and satisfaction went up. I think that we need to accept the fact that we can do better if we were to focus on understanding how to provide better care to the Medicaid population. Don't you think that we can do better?
The Judge Has Spoken
Patriot's Nation heaved a huge sigh of relief yesterday as Judge Berman became the most popular man north of the Merritt Parkway. In less than an hour after the opinion was announced you could download the judge's opinion in its entirety. I guess this is an obvious example that solutions are dependent on how you look at the problem. Foolish me, I thought the question was whether or not someone let the air out of the balls. Apparently the judge saw that question as secondary to how the process of answering the question proceeds. I like his thinking. The question was not how to measure the pressure in a football but was how you interpret a labor contract. I will continue to ponder the issues and the wisdom of Judge Berman, hoping to gain insights that might be transferred to healthcare that could explain the relationship between increased profits and increased costs in healthcare in Massachusetts.
One of the things that I can be sure of and need no guidance from the judge to explain is that the road ahead in healthcare will remain uphill and interesting for sometime to come just like the little uphill section on one of my favorite walks that I enjoy with my wife. Today's header shows a stretch on the three mile walk around Lake Kezar in Sutton, New Hampshire that my wife and I frequently walk. The weatherman is suggesting that this will be a great weekend to enjoy that trek again. I hope that you will have a super Labor Day experience and will find your own little uphill grade to climb. |
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