Subject: [SHC] Dr. Gene Lindsey's Healthcare Musings Newsletter 5 February 2016

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5 February 2016

Dear Interested Readers,

Inside This Week’s Letter

Last week I began a review of the Triple Aim using the mechanism of “memoir” to advance the discussion. I was telling my own story as a way to set the stage for the review of a complex idea that was at variance with that bulwark of the status quo, “conventional wisdom”. Conventional wisdom, two millennia of medical culture, and the short term self interests of patients and physicians remain significant barriers to realizing the Triple Aim. Like mountains beyond mountains there are barriers beyond barriers.

In the letter this week I continue with some elements of a memoir but I also return to one of the most important medical publications of the last twenty years, the paper in the May/June 2008 edition of Health Affairs, “The Triple Aim:Care, Health, And Costs” written by Berwick, Nolan, and Whittington. In 2008 the Triple Aim was about as generally understood and accepted as the way forward in healthcare, as was the concept that world was round and not flat in 1492 when Columbus sailed into the sunset to get to the East. To help formulate some of my thoughts and methodology I also used some concepts from the fabulous book by Charles Kenny and Maureen Bisognano, Pursuing the Triple Aim, published in 2012.

I will continue my review of the Triple Aim next week, exploring it and its importance to where we are now. If things go as planned I will conclude the study in two weeks with thoughts about the future. Obviously, for that last letter in the series, I will be moving from “memoirist” to “futurist”, or if you prefer, amateur prophet. 

I should say here that anything written by Charles Kenny is worthy of your attention. One of my favorite books is Best Medicine written by him in 2008, the same year I became a CEO. Best Medicine is a wonderful review of the evolution of our concepts of quality. In my very stressful life as a CEO, trying to foster transformation that would enable quality as well as financial survival, I read Best Medicine for inspiration and encouragement and Crossing the Quality Chasm for theory and technical guidance.

As I request every week, I want you to visit strategyhealthcare.com (SHC) this week. After a year of exploring the interplay between these letters and that blog, I have evolved a new understanding for myself. The Friday letter offers me the opportunity to be loquacious and expansive in my exploration of an idea. Let’s admit the obvious, I am a man who loves words. That works only for an audience that has the time and is interested in following the way an idea can develop and the many sundry associated things that an idea might touch.

I know that you are bombarded daily with digital content vying for your attention. My approach is perhaps counterintuitive. If they have more to read and less time to read, give them more to read. A critic might say that I am writing for myself, and there is some truth to that. My defense is that I enjoy reading longer articles that stay with a subject and I think that there is a small readership that shares that pleasure. I also know that there is a larger audience for shorter more “essentials only” treatment of important subjects. I think the same reader may be in one group on a Saturday and in the other group on Tuesday or Wednesday.

For the past few weeks, the shorter and crisper SHC articles have come out on Tuesday or Wednesday. The starting point for each SHC posting is a subject from a recent Friday letter. The content of this week’s posting first appeared last November. With these postings I have the benefit of a few weeks of reflection and can edit out what I see was not critical. In some of the recent posts I have refocused an idea. All of the SHC postings are trimmed to at least half if not a third of their original treatment. This week’s SHC posting is “Lean Supports Healthcare Leadership and Service”. It explores how Lean combats burnout. Please try it and offer it to a friend.

Appreciating The Beauty of The Triple Aim at Its Birth

In the May/June 2008 edition of Health Affairs Don Berwick, Tom Nolan and John Whittington introduced us to the potential benefits and beauty of the Triple Aim by examining how miserably we manage CHF. They reminded us that CHF was the most common reason for a Medicare admission and that 40% of patients who were discharged after a hospitalization for CHF were readmitted within 90 days. What they did that most of us who were managing this revolving door did not do was ask two questions, “Why?” and “Can we do better ?”. They easily answered the second question by reminding us that in carefully managed programs we had already shown that readmissions for CHF could be reduced by 80%.

“Why?” was a little harder to answer but they saw the problem as a systems issue. Care was fragmented. Handoffs were ineffective. The problem was a system that failed both patients and clinicians.

“Patients experience this reactive system as one providing poor service and lacking memory... Caregivers experience frustration, despite their best efforts... [CHF] is a prime example of what goes wrong when a health care system lacks the capacity to integrate its work over time and across sites of care.”

From this position they presented a three point indictment that was news to many people in 2008 and has been repeated so often since that I fear it is now accepted by many as a reality, like global warming, that may be true but that they have little interest in addressing.
  • U.S. health care expenditures are far higher (at times double) than those of other developed countries, our results are no better. 
  • The United States ranks thirty-first among nations on life expectancy, thirty-sixth on infant mortality, twenty-eighth on male healthy life expectancy, and twenty-ninth on female healthy life expectancy.
  • The United States is the only industrialized nation that does not guarantee universal health insurance to its citizens. We claim we cannot afford it.
The next statement was brave. They questioned the effectiveness of previous care improvement efforts. It had been only about five years since the messages of To Err Is Human and Crossing the Quality Chasm had been published, but they were clearly disappointed with the early impact. Once again they asked “Why?” and “Can we do better?”.

They noted that the admonition in Crossing the Quality Chasm to support the six components of quality, which we all know now are safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity, was making very slow progress toward improving the care of individuals and no measurable progress toward lowering the rate at which the cost of care was rising. They were hopeful that the focus on the measurement and reporting of quality, as well as experiments with pay for performance, might be contributing to progress in the cost and quality objectives, but they also observed that patients had not seen much change and that policymakers, payers, and healthcare leaders were still “struggling to make highly reliable and safe health care a norm rather than an exception”.

They were concerned that “too few improvement efforts address defects in care across the continuum, such as those that plague patients with CHF”. They asserted that alignment across the continuum of care would be necessary to “improve site-specific care for individuals”. They noted that the six domains of quality were primarily understood as a description of better care for individuals. They proposed a new approach to advance the pursuit of quality for everyone.

In our view, however, the United States will not achieve high-value health care unless improvement initiatives pursue a broader system of linked goals. In the aggregate, we call those goals the “Triple Aim”: improving the individual experience of care; improving the health of populations; and reducing the per capita costs of care for populations.

A major insight was that the goals of the Triple Aim were interdependent and that interdependence was a benefit in some areas and a problem in other areas.

Changes pursuing any one goal can affect the other two, sometimes negatively and sometimes positively. For example, improving care for individuals can raise costs if the improvements are associated with new, effective, but costly technologies or drugs. Conversely, eliminating overuse or misuse of therapies or diagnostic tests can lead to both reduced costs and improved outcomes. The situation is made more complex by time delays among the effects of changes. Good preventive care may take years to yield returns in cost or population health.

They were insightful about the complexity and the conflicts for specific individuals in the pursuit of equity. Equity would be an outcome of the Triple Aim and is subsumed in the concept of better health for every individual but they recognize that improved health in one population could, but should not, “be achieved at the expense of another subpopulation”.

They asserted that the inherent conflicts between individuals and populations could be managed. Perhaps they were naive but they felt that “a health system capable of continual improvement on all three aims, under whatever constraints... looks quite different from one designed for the first aim only”.

They dropped a bomb with their opinion that “the balanced pursuit of the Triple Aim is not congruent with the current business models of any but a tiny number of U.S. health care organizations”. They recognized that some organizations were interested in one or two of the legs of the Triple Aim, but it was the rare organization that was concerned about all three.

Rereading this statement now makes me feel guilty. I must admit that as a result of the financial traumas that I described in last week’s letter my heart was with the Triple Aim but if you looked where I was walking in 2008 it was down the path of concern about the finance of the organization and, in retrospect, the health of individual patients was something I assumed would follow if we were financially strong. Beyond the impact on our practice and our patients, I had not given sufficient consideration to our responsibility to improve the health of the community or to return resources to those who were paying more and more.

Eliminating waste and being more efficient was consistent with our strategic plan but the motivation was for our survival. Lowering our operating costs was a good strategy to respond to the fear of falling reimbursement, as depicted in the image below. For most of the world in 2008, being concerned about the cost of care was not included in their understanding of quality. Indeed, for many in healthcare expressing a concern about cost threatened concepts of quality care. Improved health of the population was initially thought by me and many others to mean the sum of making more individuals better. We were growing in our understanding of the many interdependencies between quality and cost and the tensions and synergies between the care of individuals and improving the health of the population, but when this paper was published we, or at least I, really did not understand the complexity and depth of its message.
The authors understood our organization, indeed most healthcare systems, better than we understood ourselves:

For most, only one, or possibly two, of the dimensions is strategic, but not all three. Thus, we face a paradox with respect to pursuit of the Triple Aim. From the viewpoint of the United States as a whole, it is essential; yet from the viewpoint of individual actors responding to current market forces, pursuing the three aims at once is not in their immediate self-interest.... Rational common interests and rational individual interests are in conflict.

They used Garrett Harden’s concept of the “tragedy of the commons” to further explain the tension that existed between the individual and the community or between one practice and all practices. Their solution is a shared vision that was larger than self interest and encouraged collective action.

...the Holy Grail of universal coverage in the United States may remain out of reach unless, through rational collective action overriding some individual self-interest, we can reduce per capita costs.

The authors were very clear about the barriers that would still exist even if we got beyond the issues of self interest.
  • Supply-driven demand; new technologies including many with limited impact on outcomes.
  • Physician-centric care
  • Little or no foreign competition to spur domestic change, as it does in manufacturing
  • Too little appreciation of system knowledge among clinicians and organizations, leading them to suboptimize the components of the system with which they are most familiar, at the expense of the whole.
Their hope was that our ability to innovate as a response to challenges would lead to changes in how care was delivered that might support the realization of the goals of the Triple Aim. This implies that they knew that without a willingness to embrace change that was transformational, we could not improve the efficiency and effectiveness of our traditional approaches to care delivery enough to ever finance universal coverage and deliver better results for the whole community. They were agreeing with Dr. Ebert when he said:

“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.”

Much of the remaining content of the paper is spent suggesting the components and competencies of a system of care that could produce the Triple Aim.
  • Transparency
  • A balanced set of systems wide performance measurements to track the experience of care, patient engagement, clinical practices, health status, continuity of care, and costs.
  • Indexing of measurements to appropriate local market circumstances. 
  • Measure actual costs in a care system where pricing and discounting create obscurity.
  • Develop the capabilities for registering and sampling defined populations
  • Implement electronic health record systems
The authors cited the IOM’s concern that in 2008 the “measures of both cost and care across the continuum, impeded by the fragmentation of delivery itself, still need much more developmental work”. They further expressed their concerns by asking about the preconditions or “mindset” that would support achieving the Triple Aim. Again, against the background of what has actually happened since 2008 their ability to see the future has proven to be breathtaking.

We suggest that three inescapable design constraints underlie effective accomplishment of the Triple Aim: (1) recognition of a population as the unit of concern, (2) externally supplied policy constraints (such as a total budget limit or the requirement that all subgroups be treated equitably), and (3) existence of an “integrator” able to focus and coordinate services to help the population on all three dimensions at once.

It has certainly been my experience that few clinicians possess a real understanding of the breadth of the population concept. At Harvard Vanguard between 2005 and 2007 we tried to develop a new care model based on our sense of the variation in our population of patients. Our first attempt was to use the EMR and our data warehouse capabilities to sort our patients into four large buckets that were color coded.
  • The green population was healthy and had no active concerns. Their need was for health maintenance and continued education about healthy choices and a healthy lifestyle.
  • The yellow segment had at least one medical or social concern that required ambulatory intervention such as the management of depression, hypertension, diabetes or smoking cessation, as examples. Many of these patients looked, lived and acted like they were “green” but careful scrutiny revealed that they had more risk in their future. It was a large population and designing more effective programs for their care was a challenge, particularly if the issues were social or behavioral. Obviously, many of these patient had multiple issues of concern but all of them were active and ostensibly healthy in the moment.
  • The red patients had experienced a need for an active intervention like a hospitalization for management of one or more of their problems. There was an urgency to focus resources on their management. The goal was to reduce the likelihood for further events and if possible return them to a functional status that would make them appear “green” or “yellow”. We developed programs of chronic disease management that were patterned after the Wagner Chronic Disease Management Model and deployed for problem specific subpopulations. 
  • The blue population was composed of those patients for whom palliative and supportive programs directed at “care and comfort” were most appropriate. Obviously there was overlap with the “red” population and many patients with their families and others on whom they depended often defined themselves into or out of this population.
I wish that I could say that the effort was a success. Like many first efforts it was resisted with complaints about it being “top down” or an intrusion that threatened “clinical autonomy”. In retrospect it was a difficult learning experience for all of the management team about the challenges of “adaptive change”.

Berwick, Nolan and Pennington went even further to anticipate the confusion about “populations” and then introduced the utility of registries. Our green, yellow, red and blue populations were primitive examples of registries as were the chronic disease management programs for the red and blue populations. They wrote:

A “population” need not be geographic. What best defines a population, as we use the term, is probably the concept of enrollment. (This is different from the prevailing meaning of the word enrollment in U.S. health care today, which denotes a financial transaction, not a commitment to a healing relationship.) A registry that tracks a defined group of people over time would create a “population” for the purposes of the Triple Aim. Other examples of populations are “all of the diabetics in Massachusetts,” “people in Maryland below 300 percent of poverty,” “members of Group Health Cooperative of Puget Sound,” “the citizens of a county,” or even “all of the people who say that Dr. Jones is their doctor.” Only when the population is specified does it become, in principle, possible to know about its experiences of care, its health status, and the per capita costs of caring for it.

The authors cited “policy constraints” after “populations” as a second concern.

The policy constraints that shape the balance sought among the three aims are not automatic or inherent in the idea. Rather, they derive from the processes of decision making, politics, and social contracting relevant to the population involved.

Between 2006 with the passage of Chapter 58 (Romneycare) creating a mandate for universal coverage in Massachusetts, and 2008 when I became CEO and of necessity needed to present a strategic plan to my board, we were just beginning to imagine how policy, new laws and regulations, and the complaints about poor service and value from the market would shape so much of our future consideration. A series of laws in Massachusetts between 2008 and 2012 created an unavoidable external necessity to focus on quality and cost.

I served on the Advisory Group of the Cost and Quality Council in Massachusetts which was working hard in 2008 and was replaced by Chapter 224 in 2012 with the Health Policy Commission on whose Advisory Council I now serve. Policy has become law and regulation and the ideals of the Triple Aim are driving the evolution. In retrospect, after you discount the noise of adaptive change and the self interest driven resistance to the ACA, it is clear that the ACA is built with the objective of fostering the Triple Aim. Concern and need begat laws. Overcoming policy constraints becomes a necessity in the creation of an environment where transformation and innovation are necessary if you are to have any chance to achieve the ideals of the Triple Aim. Do you think that we could ever have had the ACA without the vision of the Triple Aim? Is a single payer the next logical step? Don Berwick ran for Governor of Massachusetts with that idea in mind in 2013 and few could understand the message. Now Bernie Sanders has picked up the cause even after Vermont had put it on hold.

Those questions brings us to the third important consideration in the evolution of the Triple Aim that was mentioned above, “the integrator”. What is an ACO if not an integrator? If their was any premise that I had completely accepted long before the Triple Aim was spelled out with the clarity of the vision in the 2008 paper, it was that the practice of medicine in our time was a collaborative endeavor, and if there was not great attention to planning and system development the outcome would be the chaos and expense that existed in 2008 and still exists in most places today. Harvard Community Health Plan had been Dr. Ebert’s integrator. Remember his “conceptual framework and operating system that will provide optimally for the health needs of the population”?

He was close. HMOs did have a chance to lead, but HMOs were not great integrators after the model was coopted and perverted by the insurance industry. IPAs were also close to the image of the Triple Aim, but still too grounded in self interest to be real facilitators of a search for solution. The ACO concept of Fisher and McClellan first articulated in 2006 and was in my mind a model that we could call “Integrator 2.0” and designed to replace the failed structures of the first era of “managed care”. By the end of the nineties HMO had become a four letter word. It is amazing in retrospect to see how concepts evolve!

An “integrator” is an entity that accepts responsibility for all three components of the Triple Aim for a specified population. Importantly, by definition, an integrator cannot exclude members or subgroups of the population for which it is responsible. The simplest such form, such as Kaiser Permanente, has fully integrated financing and either full ownership of or exclusive relationships with delivery structures, and it is able to use those structures to good advantage. We believe, however, that other models can also take on a strong integrator role, even without unified financing or a single delivery system….In crafting care, an effective integrator, in one way or another, will link health care organizations (as well as public health and social service organizations) whose missions overlap across the spectrum of delivery. It will be able to recognize and respond to patients’ individual care needs and preferences, to the health needs and opportunities of the population (whether or not people seek care), and to the total costs of care.

Wow! That pretty well defines “integrator” in a way that provides the flexibility for innovation and the specificity to be sure that all of the solutions contribute to or achieve the Triple Aim. Such allowances of variation are absolutely necessary if you consider how variably resources are deployed across the nation by region and by the divide between urban and rural communities.

Knowing when to break a discussion is a skill that I am still developing. Continuous improvement is even a possibility for septuagenarians. The in depth discussion of the 2008 description of the “integrator” deserves more words than I should probably force on you here. The effort to lead Atrius Health to be an integrator consumed most of my time and energy between 2008 and my retirement at the end of 2013. There is plenty of “memoir” opportunity in the retelling of that experience. I think it is an important testimony because so many organizations are just beginning to stand where we stood in 2008.

So just like the serialized films of Zorro that I saw in my childhood at the Saturday Afternoon Matinee at the 25th Street Theater, you will need to come back for at least two more weeks to find out what happens next. To finish this segment,I will jump ahead to the last page of the paper because reading the last page was something I frequently did when I was reading as a child and could not stand the suspense. The authors did finish with a hopeful forecast that we should remind ourselves of regularly since we have covered a lot of ground since 2008 and much of what was hope then is reality now. The work is not done but it has advanced. The “pain” of adaptive change persists and for some has gotten even worse, but the theory and concept of The Triple Aim is holding up and possibilities seem greater than ever before.

From experiments in the United States and from examples of other countries, it is now possible to describe feasible, evidence-based care system designs that achieve gains on all three aims at once: care, health, and cost. The remaining barriers are not technical; they are political. The superiority of the possible end state is no longer scientifically debatable. The pain of the transition state—the disruption of institutions, forms, habits, beliefs, and income streams in the status quo—is what denies us, so far, the enormous gains on components of the Triple Aim that integrated care could offer.

Against that background, it is no longer audacious to hope for a day when we have healthier communities where we enjoy….

Care better than we have ever seen, health better than we have ever known, cost we can all afford, …for every person, every time.

Walking in The Woods and Dreading the Super Bowl

I have spent a lot of time in my life setting goals and then trying to achieve them. Toward the end of the summer I bought a map and a trail guide for the Sunapee Kearsage Ragged Greenway. If you clicked on the link you have discovered that the SKR is a 75 mile loop that goes through the woods and over the mountains that surround my home in New London, New Hampshire on Little Lake Sunapee. On many of my walks I cross the trial but I had never really followed the trial.

I saw, examined and bought the map and trail guide for the SKR last August in our little local bookstore, the Morgan Hill Bookstore, where I often go just to hold what is new and interesting and read book jackets. Amazon is great but a good bookstore in a small New England town is a joy many times over in comparison. My needs as an impulse buyer who sees value in immediate gratification are nicely met at Morgan Hill. I live in fear that the owners will give up the struggle. Why not since much larger stores have?

The summer was busy with our son’s wedding and plans for our trip to South Africa so after looking at my map and my new trail guide, I decided to begin the project next spring. I thought it would be great fun to try to see how fast I could do it on sequential days. In a way it was a way of considering longer walks where I could not sleep in my own bed, and had to carry everything on my back, like the 160 mile John Muir trail along the Pacific Crest from Mount Whitney to Yosemite.

It never occurred to me that I could get a feel for the trail in the winter (or whatever this season is) until a new friend suggested that I buy some “microspikes” for my boots and join him now on a nice segment of the trail that goes over the hills from near Little Lake Sunapee to Pleasant Lake on the other side of town. That was last Saturday’s walk and you can see a glimpse of the trail in the picture in today’s header. As you can see, the trail passes a series of frozen waterfalls collectively known as the “cascades”.

On all my walks this week I am struggling with my dread of the Super Bowl. I have no interest, but great interest. I am as torn by this as I am whether to cast my vote for Bernie or Hillary next Tuesday. I have “felt the Bern” but then the fire doesn’t stay lit when I hear her voice of experience and consider how her knowledge from the school of hard knocks could be an asset in the future. I am also perplexed, as I said a few weeks ago, by why it seems so hard for a grownup like Bush or Kasich to get any consideration on the other side of the ledger. I like to contemplate being able to “live with” any outcome and there are some potential outcomes that could make me worry about the future of the nation and the world. In the end leadership, experience and civility are assets in a VUCA world that the next President better have.

Getting back to my feelings about the Super Bowl, I am reminded of the description in the Scriptures of the corrosive damage from harboring hate and resentment in one’s heart. I am sure that it is a mark of great personal deficiency that under no circumstance could I ever wish Peyton Manning any success. He has already had his full measure and some of what he has gotten must belong to someone else like Tom Brady.

My dilemma is heightened by the fact that I can’t force myself to root for Carolina and Cam Newton. I should be a Carolina fan. I have deep ancestral roots going back to pre revolutionary days on both sides of my heredity that branch out in almost almost all directions in a short radius of the Panther’s stadium. It is hard to go to a country cemetery along the Charlotte- Greenville, S.C. stretch of I 85 and not find a relative of mine. I just can’t stand Cam’s little dances in the endzone which is further evidence of my lack of grace and generosity.

I hope that your life is much less complicated and conflicted than mine, but if you are struggling, take it from me, the best way to get relief from this level of anxiety is a five mile walk in the woods with a new friend.

Let me hear from you, even if you root for Denver or plan to vote, when the chance comes, for Trump, Cruz or Rubio. I will try to understand that you are entitled to those choices plus respect and the benefits of the Triple Aim.
Be well,

Gene


The Healthcare Musings Archive

Previous editions of the "Healthcare Musings" newsletter, by Dr. Gene Lindsey are now archived and available to you at:

www.getresponse.com/archive/strategy_healthcare

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