6 January 2017

Dear Interested Readers,

What’s Inside This Letter and Thoughts on the Transitions to 2017

I for one was not sorry to see the ball drop in Times Square this year, marking the end of a year that will be remembered for its recurrent sense of loss. Mariah Carey’s year end difficulties on the ABC network New Year’s celebration from Times Square in New York were symbolic of a year when things just did not go as hoped or expected. Her lip syncing fiasco was witnessed by a bleary eyed New Year’s Eve audience composed of oldsters like myself who were struggling to stay awake and younger people who had nothing better to do. A mess at the end that botched a “tradition” seemed appropriate for a year that I wanted to treat like an unwanted guest with a rude, “Don’t let the door hit you on your way out!”

My wife and I have a running joke about the woes experienced during a “retrograde Mercury.” When something goes wrong in an unexpected way we will say, “Oh, it must be a retrograde Mercury!” If you do not know what I mean and did not click on the link, let me ask you to put your tongue in your cheek and read the piece that I lifted from the link that explains why things go wrong during a retrograde.

Why is that? It’s because Mercury rules communication, clear thinking, truth and travel, so when the planet goes retrograde — which means that it looks like it’s going backwards in the sky — all those things go backwards. They start to get ugly and tangle up. Mercury isn’t really going backwards, it’s just hanging out by the sun, but from Earth, that makes it look like it’s in reverse. It typically runs for a couple of weeks, a few times a year.

You might want to check your records or some old newspaper clips to decide if many of your woes of the last year occurred during these periods. Since Mercury rules communications, clear thinking, truth and travel, it is good strategy never to travel, close deals, plan big events, make big purchases, sign contracts or conduct any avoidable business during a retrograde. If you must travel, expect delays. If you sign a contract during a retrograde, expect that it will be settled for a loss after a long court dispute, and if you are Mariah Carey don’t be surprised when your “mike pack” doesn’t work.

The fact that we are in a retrograde should be obvious to you if you are following the convoluted conversation about the expectations of “repeal and replace” as Congress begins its new term this week. No one knows what to repeal, how to phase in the repeal, what to save and how to go about crafting that replacement, so those poor “red state folks” that are now dependent on the much abused “Obamacare” will not lose what they love to hate but would hate to lose. The Commonwealth Fund’s publication, The Connection, published several pieces this week that nicely document just what these folks in places like Kentucky are about to lose. They make the point that even in those states that refused the Medicaid expansion we have “come a long way in a short time.” The states that have the highest continuing rates of uninsured have made progress but they are all “red states.” The Commonwealth Fund also offers the best review that I have seen of the big healthcare events and issues of 2016.

Here is their list that was compiled by David Squires and David Blumenthal:

1. Trump (and the Republicans) emerge ascendant. President-elect Donald Trump will take the oath of office on January 20, 2017, joined by Republican majorities in both houses of Congress, 68 of 99 state legislative chambers, and 31 of 50 governorships.The Republican Party’s commitment to repealing and replacing the Affordable Care Act could not be clearer, but stubborn political realities and technical issues are already forcing Congress to consider delaying the effective date of any repeal by up to four years. Though Republicans can accomplish a repeal without any help from Democrats (using the budget reconciliation process), patching together a replacement package will require eight Democratic votes in the Senate. That will be a challenge, as will managing the transition and finding consensus among divided Republicans on how or whether to cover the more than 20 million Americans who will likely lose insurance if the ACA is repealed.
2. Uninsured rate hits historic low. During 2016, the proportion of Americans lacking health insurance reached an historic low: 8.9 percent. Since 2010, the number of Americans without insurance has fallen by more than 20 million. The result: fewer medical bill problems and more accessible and affordable care for patients, and less uncompensated care for providers.
3. Premium increases and insurer exits raise concerns about ACA marketplaces. This was a turbulent year for the individual health insurance market. A number of high-profile insurers exited the marketplaces created under the Affordable Care Act. Double-digit premium increases in some marketplaces added to concern about their stability. However, the impact of these premium spikes on marketplace customers was dampened by federal subsidies that absorbed the costs for more than 80 percent of purchasers...Another point to keep in mind: in the employer-sponsored insurance market, where the majority of Americans get their insurance, premium growth has actually slowed since the passage of the Affordable Care Act.
4. With MACRA looming, value-based payment spreads. The Centers for Medicare and Medicaid Services issued the final regulation implementing the Medicare Access and CHIP Reauthorization Act (MACRA) in 2016. MACRA will transform how Medicare pays clinicians and accelerate trends toward value-based payment, which is designed to pay for the value rather than the volume of services. As of early 2016, 30 percent of Medicare payments were tied to “alternative payment models,” as were 25 percent of private insurers’ payments. Whether the new administration will be as committed to payment reform as the departing one remains to be seen.
5. CMMI takes off the gloves. One player driving this payment transition assumed a more prominent role in 2016. The Center for Medicare and Medicaid Innovation (CMMI), created under the ACA, has broad authority to experiment with how our largest public insurance programs pay for services. ...Rep. Tom Price (R–Ga.), Mr. Trump’s nominee for Secretary of Health and Human Services, has been a vocal critic of CMMI and its mandatory payment demonstrations. He seems likely to scale back some of its programs, and a repeal of the ACA could eliminate CMMI altogether. 
6. Bipartisan bill reforms FDA, increases R&D. The 21st Century Cures Act, a rare bipartisan initiative, was passed by Congress and signed by President Obama in 2016. The bill increases funding for the National Institutes of Health, including for pioneering cancer and genomic research, and reforms and boosts funding for the Food and Drug Administration’s approval process for pharmaceuticals and medical devices. The new law also dedicates $1 billion over the next two years to fight the opioid scourge devastating much of the country. Little-heralded features of the law promote interoperability among electronic health records, and consumers’ access to their own digital health records.
7. Insurer mergers prompt an antitrust reckoning. Four of the country’s largest insurers are trying to become two, but not if the current Justice Department has anything to say about it. In July 2016, U.S. Attorney General Loretta Lynch sued to block the Humana-Aetna and Anthem-Cigna mega-mergers, arguing that they would reduce competition and raise prices for consumers.
8. Outrage over drug pricing yields smoke, but no fire, at least not yet. Sovaldi, Daraprim, Epipen—a spate of drug-pricing stories continued to grab headlines in 2016. Resulting congressional inquiries yielded numerous verbal floggings for drug company executives, but no concrete action to quell Americans’ rising anger over their out-of-pocket spending for pharmaceuticals. President-elect Trump has pledged to control drug prices. 
9. Americans’ lives are shortening. Finally, we learned this month that our life expectancy is going in the wrong direction. Though the change was small—a decline of about one month—it is just the latest evidence of disturbing deterioration in the general health of Americans, particularly working-class whites. The idea that for the first time in U.S. history our children may be less healthy than we are is deeply alarming, and should make improving the health of Americans a major national priority.
   

That last depressing reality, discovered in 2016, again primarily relates to the working class white majority in “red states” that gave the President Elect his Electoral College victory.

Just to help you avoid problems in 2017 let me offer you the opportunity to click on a link that identifies the Mercury retrogrades for 2017. The site also offers advice about how to survive next year’s retrogrades. Paying attention to real facts, like when the next retrograde will occur, may make as much sense as trying to follow ill considered changes in policy announced by our new President on Twitter a few minutes after a new idea pops into his consciousness fresh from generation in his limbic system. In 2017 we will need to develop a new approach to strategy development as we contemplate how to make progress toward the Quadruple Aim during a Presidency that David Brooks believes will be more like a Snapchat experience where appearance trumps workable solutions as he explains:

Trump doesn’t think in this way, either. He is a creature of the parts of TV and media where display is an end in itself. He is not really interested in power; his entire life has been about winning attention and status to build the Trump image for low-class prestige. The posture is the product.

All facetiousness aside, as we contemplate a transition that is more than the usual transition from one party to the other, a quantum next step in a process in America described by George Packer as “the unwinding”, we may feel as if communication failures and unexpected challenges occur at rates that would exceed the usual blips associated with a “retrograde”. There is no doubt that on January 20, not during a retrograde, there will be a big shift in the way the business of our government is conducted. Despite oceans of ink spilled by healthcare commentators at every level of media analysis, what will ultimately happen to you as a consumer or as an important player in the lives of those who depend upon care is impossible to know with anything close to certainty.

As we go forward we may need to transition back from the way we have tried to do our national business through a collaborative processes that we ratified in 1789 toward earlier eras of pioneer self reliance. Is that what the President Elect meant when he promised to make America great again? If we are going back to a pre constitutional mindset, then a focus on self reliance and working closely with our neighbors to insure our collective safety is the reset point in our national process of rebooting our society.

The wisdom of Rudyard Kipling’s advice from another era comes to mind. In his poem “If” he provides us with advice to ponder during times like these. If you are a long time reader you may remember that I cited it in a letter several years ago as Atrius Health faced enormous challenges. I would love to lift just a few lines for you but this poem is so rich with pertinent advice that I feel compelled to give the whole thing to you even though I realize that you probably have also known it since the ninth grade. If nothing else, it is a pretty good description of the President who will leave office on the 20th.

If you can keep your head when all about you
     Are losing theirs and blaming it on you,
If you can trust yourself when all men doubt you,
     But make allowance for their doubting too;
If you can wait and not be tired by waiting,
     Or being lied about, don’t deal in lies,
Or being hated, don’t give way to hating,
     And yet don’t look too good, nor talk too wise:

If you can dream—and not make dreams your master;
     If you can think—and not make thoughts your aim;
If you can meet with Triumph and Disaster
     And treat those two impostors just the same;
If you can bear to hear the truth you’ve spoken
     Twisted by knaves to make a trap for fools,
Or watch the things you gave your life to, broken,
     And stoop and build ’em up with worn-out tools:

If you can make one heap of all your winnings
     And risk it on one turn of pitch-and-toss,
And lose, and start again at your beginnings
     And never breathe a word about your loss;
If you can force your heart and nerve and sinew 

     To serve your turn long after they are gone,
And so hold on when there is nothing in you
     Except the Will which says to them: ‘Hold on!’

If you can talk with crowds and keep your virtue,
     Or walk with Kings—nor lose the common touch,
If neither foes nor loving friends can hurt you,
     If all men count with you, but none too much;
If you can fill the unforgiving minute
     With sixty seconds’ worth of distance run,
Yours is the Earth and everything that’s in it,
     And—which is more—you’ll be a Man, my son!

Building the future on the exercise of exceptional individual virtues is a romantic concept that is not nearly as likely to lead to collective success as is good process management within a group that has a culture of respect for all people and the environment they share. We must work with what we have. That was the mindset behind the Grand Rounds presentation that I gave yesterday at the Whittier Street Health Center in the Roxbury neighborhood of Boston. The main subject of this letter covers those thoughts.

I hope that you were able to check out this week’s posting on strategyhealthcare.com, “What To Do When You Don’t Know What To Do.” This week’s letter is a practical continuation of that discussion. I have been quite gratified by the many responses to last week’s letter. Your responses suggest that there is a continuing role for these essays to serve as support to you as you try to do your part to ensure that we continue to make progress toward the common goal of:

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

Thinking About ACOs Again For the First Time

I am proud to be a member of Whittier Street Health Centers Foundation Board and was delighted when our very able CEO, Frederica Williams, asked me to talk to the organization about ACOs at their Grand Rounds. Whittier Street is an exceptional example of a practice that will be sorely tested by the chaos that Jonathan Oberlander describes in his “Perspective” article in this week’s New England Journal, “The End of Obamacare”. There is no certainty about the path organizations should follow over these next four years in the era of “repeal and replace” or to quote Oberlander

A host of health system stakeholders — hospitals, doctors, insurers, and others — will be anxious about the current uncertainty in the health policy landscape and worried about any changes that substantially reduce insurance coverage and adversely affect their bottom lines. Much of the health care industry supported the ACA as part of a broader coalition that included consumer groups. Whether that coalition can reassemble to effectively resist the ACA’s demise is unclear.

That is the question that faces us all, but is of a very great concern for organizations like WSHC where the care of a majority of its patients has some element of public funding. To prepare you for the discussion I need to give you some information about the recent proposals for Medicaid coverage in Massachusetts, demographic and organizational facts about Whittier Street Health Center (WSHC), as well as some background information about Federica Williams, who is a remarkable healthcare leader.

Shortly before the election Massachusetts successfully renegotiated its Medicaid waiver with CMS. The process seemed like a huge step forward because it granted the state over 52 billion dollars over five years to restructure the Medicaid program, Mass Health, as an ACO product. It was a heady moment before the confusion created by the election a few days later. WBUR reported:

In statements, [Governor] Baker said the waiver represented a "major step toward creating a sustainable MassHealth system for the people of the Commonwealth," and federal Health and Human Services Secretary Sylvia Burwell said the waiver was "another step forward in the American health system's shift toward value."

Whittier Street Health Center is a Federally Qualified Health Center. Forty two percent of its nearly 40,000 patients identify as African American, forty two percent as Latino, five percent as white, one percent as Asian, and eight percent as “other” (i.e.,more than one race). Within this diverse population there is substantial poverty. Sixty percent of WSHC patients live below the poverty level, and ninety two percent live below two hundred percent of the poverty level. There is also substantial chronic illness. Seventy percent of Whittier’s patients have one or more chronic conditions including diabetes, hypertension, cancer, HIV, or weight disorder. Twenty seven percent have two or more of those conditions. The life expectancy of an individual living in Roxbury, where most of WSHC patients live, is less than 60 years compared with a life expectancy of over 90 years in the different world of the Back Bay neighborhood of Boston, less than three miles and a few subway stops away.

Frederica Williams is the energetic woman who has led WSHC since 2002. She was born in Sierra Leone and educated in Great Britain before coming to Boston in 1984. Since she assumed the position of President and CEO in 2002, WSHC has grown from about 12,000 patients to an expected 40,000 sometime in 2017. Whittier Street moved to a beautiful new Silver LEED-certified health facility on Tremont Avenue in 2012. In 2015, WSHC inaugurated its innovative Health and Wellness Institute to help address chronic diseases in inner-city Boston and to provide affordable access to a state of the art exercise facility and community gardens for thousands of residents and patients in need. Ms. Williams has led a vigorous attack on the social determinants of disease and has spent the last decade preparing WSHC for the transition to value based reimbursement. Despite the preparation, most of WSHC’s revenue up to now comes through fee for service payments. A minority of the patients who get care at WSHC have coverage through a commercial source or a value based contract.

WSHC has close relationships with several area hospitals: Boston Medical Center, Brigham and Women's Hospital, Beth Israel Medical Center, and Children’s Hospital as well as Dana Farber Cancer Center. Through its relationship with Boston Medical Center, WSHC now has Epic as its EHR and also has its own data warehouse capabilities. WSHC has assets, and it has huge aspirations to improve the care of its populations with challenging needs. WSHC has the willingness to make the Quadruple Aim a reality for its patients and professionals; what it does not have is much experience as a practice with value based reimbursement. It has not been a part of an ACO, although it has prepared for the future by achieving NCQA level III Medical Home certification, and is also certified as an NCQA PCMH Prime practice by the Commonwealth of Massachusetts, which means that it has successfully integrated primary care with behavioral health. WSHC’s approach to appropriate care has been organized into a discrete set of programs and objectives which it has identified as the Boston Health Equity Project.

Against this rich background of accomplishments one could not imagine how an organization could be better prepared to be an ACO, but Ms. Williams is concerned that just having the desire, the assets, and the competencies locally does not insure that they will be successful as an ACO. The challenge is to organize the aspirations, assets, and competencies of WSHC into processes that will deliver the Quadruple Aim and the benefits it offers to patients, families and providers.

Long before Atrius Health became a Pioneer ACO, one of our board members showed me a short article in the August 17, 2011 JAMA written by Singer and Shortell, “Implementing Accountable Care Organizations: Ten Potential Mistakes and How to Learn From Them.” Over the years I have gone back to that list many times, and each time I have been impressed with its wisdom. As I thought about the challenges ahead for WSHC and all of the other organizations that want to work to make the MassHealth ACO opportunity a success, I realized once again the importance of this list for any organization that hopes to be a successful ACO. If you do not have access to JAMA, the list is available as part of another Internet article.

1. Overestimation of Ability to Manage Risk

An ACO must realize that all of the potential pitfalls are interdependent, and must be avoided holistically to succeed.

I have attended dozens of meetings about and with ACOs. I have spoken to many audiences about the experience of leading an ACO and what I learned from the experience. I have worried that most people consider the ACO to be a method of finance and not a philosophy of collaborative care. Through my worries I have come to believe more than ever before that the core to success is the ability within the organization for clinicians to adopt team based efforts to deliver care to the individuals of a population, and their ability to coordinate their own activities with the work of their colleagues in specialty practices and in the hospital to eliminate waste.

“Management by process” across the internal silos and the competing interests of external institutional partners is only possible if all parties to the process realize that the best way to protect their self interests is to make the concerns of patients and the community their own primary concern. At this time the interlocking concerns of patients and the community are access, quality and cost. Obamacare has been criticized because costs appear to remain high although there have been improvements both in cost and quality that health policy experts can demonstrate. A growing number of patients have found it to be an improvement to what they have had, if not exactly what they wish it could be. Whatever the repeal and replace process turns out to be, it will be a failure that will demand accountability of the party in power if it does not expand access, reduce cost and improve quality.

Massachusetts and the committed clinicians and healthcare leaders who care about the dream of... 

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

...will be challenged over the next four years, but I remain hopeful that just as it led the way to better care before the ACA, Massachusetts and its healthcare professionals and organizations will continue to lead the way to better care through the swamps of repeal and replace. I hope that across the state and around the country there will be hundreds of organizations like WSHC where leaders and clinicians are willing to change together as they learn how to deliver the dream.

Winter Walks In the Woods

Friends can make a difference. My usual walks are on the roads near my home and sometime at the track. Basically, I approach my walking the same way I once managed my training for running road races and marathons. Most of the time these days I just walk the routes that I once ran. Sometimes I do an old man’s shuffle that creates a temporary illusion of running.

Recently a couple of friends have invited me to join them on the many trails that go in virtually every direction through the extensive wilderness and park lands that are near our homes. I do not cover as many miles, but it is a more strenuous work out. Each new snow storm is a chance to improve the experience by adding snow shoes. This week’s header comes from a picture that I took of the trail map at the juncture of the Webb Forest Trail and Cocoa’s Path which come together near Pleasant Lake. Cocoa’s Path is part of the Sunapee-Ragged-Kearsage Greenway.

One goal that I have set for 2017 is to walk the entirety of the Sunapee-Ragged-Kearsage Greenway. It is a 75 mile loop that surrounds my town and incorporates the peaks of the three highest “mountains” of our area in a series of fourteen very doable hikes. None of these peaks are over 3,000 feet high, but all of them are beautiful and their granite tops offer unobstructed vistas of the lakes and forests of our area. Best of all, none of them are more than a few minutes away.

Whatever the weather, I hope that you will be lucky enough to have a friend challenge you to a walk in the woods this weekend. I would hate to hear that you wasted a perfectly good Sunday afternoon watching an NFL playoff game between two teams that have little or no chance of ever beating the Patriots. If you drive north to ski, let me suggest that you consider driving north to snowshoe or hike. For less than a couple of lift tickets you can get snowshoes that will be the source of “free” pleasure for many winters to come.