7 April 2017

Dear Interested Readers,

What’s Inside This Letter, an Apology, and This Week in Washington

It was never my intent to write a letter last week that was nearly seven thousand words long or sixteen pages, if you printed it out to read. I understand that a few of you did read it all, and for that I am grateful even as I apologize for the excessive verbiage. I was able to reduce the second section describing principles for future practice from over three thousand words to a little under two thousand for the Tuesday posting on strategyhealthcare.com. If you didn’t have the stamina to get through the ideas last week, perhaps the shorter version will be more appealing to you. Thanks to a relatively quiet healthcare week in Washington, the letter this week is much shorter.

On Sunday I was delighted and encouraged by an opinion piece in the Sunday New York Times that was written by Don Berwick. It feels good to know that Don and I see the current situation in a similar fashion and that I am not being reactionary or paranoid about the likely actions that Trump, Ryan and Price will take since “repeal and replace” is beyond their reach for the moment. Here are some clips of Don’s wisdom:

What will Paul Ryan and the Trump administration do now that they have failed to repeal Obamacare? They’ll try to sabotage it.

After their legislative debacle, they said they would let Obamacare explode on its own, after which, they hope, the Democrats will come crawling to them, pleading for a new plan…

But Republicans, who have tried for years to stop the government from expanding health care coverage, will not wait passively for a disaster to happen...

Now that the Republicans are in control of both elected branches of government, they are in a position to undermine the Affordable Care Act from within — and then to blame the law, rather than their own sabotage, for its failure.

Congress, the Trump administration and Tom Price, the secretary of health and human services, could do a lot of damage without overturning the law. This has already begun…

Fortunately for the millions of Americans who get their health coverage through the Affordable Care Act, the Republicans are probably going to fail. The program is much stronger than they’d like us to believe. It is not in a death spiral and, if left alone, will continue to meet patients’ needs for the foreseeable future.

But it does need improvement...

Unfortunately, it’s unlikely that any of these fixes will happen anytime under Republicans, who have already staked their reputation on the prediction that Obamacare will soon “explode.” It is hard to imagine that they won’t try their best to make that dire prediction a reality.

Will they succeed? Probably not. The law does too much good for too many people for doctrine to override evidence. But the Affordable Care Act’s opponents have been undermining it for years, and we, its defenders, drop our guard at our peril.

I hope that you click on the link and read the entire piece for yourself if you have not already seen it. I am always amazed by Don Berwick’s ability to be positive. He always shows us that we have the power to improve the moment, especially if we work together. He always generates a positive answer to the question, “What can we do to make healthcare better?”

I was nervous earlier this week when it looked like the administration that can’t shoot straight might go back for another attempt to get a healthcare bill through the House before the Easter recess. Tax reform was slated to be the next item to be tackled on the payback list for Trump voters after the AHAC was withdrawn without a vote. Most of the pundits were saying that tax reform would be harder than healthcare. We all remember the president’s surprise when he learned how difficult healthcare would be. Perhaps Ryan and the president have reasoned that if healthcare is theoretically easier than tax reform maybe they should not give up so soon and try again before they fail at tax reform. Fortunately for the ACA by Wednesday it seemed that healthcare was still too difficult, even if huge concessions on coverage were made by shifting “essential coverage” control to the states. Fortunately for all of us, blowing up the ACA from the inside remains the only active option for those who find it so difficult to imagine extending quality healthcare to all Americans as a human right rather than as an alternative consumer choice to a cell phone.

I am looking forward to a few weeks of relief from the wars over healthcare. During this time, and as the main section of this week’s letter, I am going to move beyond lists and formulas describing better healthcare to the examination of optimal relationships between healthcare providers in a high functioning integrated system as described in last week’s letter. I am also including my own experiences and a letter from an interested reader. After discussing professional relationships we will move on to recent experiences that illustrate the importance of integrated systems that have been shared with me by family members. My goal is be more descriptive about the changes that must become widespread if we are ever going to have

...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.

At the end of the letter I share grandfatherly observations from the West Coast and make an embarrassing confession of residual gender bias in sports. Ouch!

The Joy of Receiving Integrated Care From a Team That Is Continuously Improving

I believe that better care that is economically sustainable and available to everyone while producing healthier communities without unacceptable personal sacrifices from individual health professionals is only possible in a professional environment and culture that respects the contributions of all health professionals. When I use the phrase “I to we” I am talking about everyone who is employed in healthcare from the staff that parks cars and cleans the building to the most senior physicians and managers. The optimal use of resources and the best patient and provider experiences require harmony, cooperation and respect across the entire team. The best systems of care are not physician centric. Team performance, not individual performance, is leveraged to efficiently achieve the objectives of the Triple Aim. When I was employed by an organization that liked to say that it was “physician led” I would tie myself into verbal knots trying to walk the line between promoting harmony and reminding physicians that it was not “all about them.”

I believe that one of the greatest challenges to be overcome in the search for the Triple Aim is the redefinition of the role of physicians in the process of care in an environment that needs to have everyone “working at the top of their license” to make their best contributions to the care of the patient. In the discussion last week I continued to go light in my treatment of the subject of the harmony and respect that is required from all members of the healthcare team that is foundational to our best efforts. I avoided exploring in detail this most sensitive subject, but Jennifer Gries, a former Atrius manager, called me out in a letter this week.

Hi Doctor Lindsey,

I anxiously anticipated your weekly letter after the one last Friday so closely missed the pull of the AHCA. As always, I was impressed with your analysis, and the extra-credit reading you provided.

Specifically, I wanted to comment to you about [the] key points for a world class health care system. While I heartily support all of the outlined objectives, I was a little disappointed that I did not see more emphasis on collaboration within the entire system of care. While one point identified the importance of what I assume is physician collaboration (quoted from your letter: "Physicians must be leaders and fulfill the expectations of patients by working with other healthcare professions to drive organizational development and performance").

As a former Medical Assistant turned Process Improvement Leader at our very own Atrius health, I can vouch for the importance of collaboration, not only between clinicians, but between all staff, all departments and all health care sites.

I cannot provide hard evidence, but in my own personal experience the respect that the clinicians showed me when I was a Medical Assistant in Kenmore Pediatrics changed the way we provided care. My dedicated physician treated me like a colleague and like we were a team. It took time to build our relationship, but our mutual trust was evident at every patient interaction.

I am no longer with the company, but I still get my care at one of the sites. I had a recent experience where I had to get some x-rays done. The radiology tech was incredibly kind and respectful, but mentioned offhandedly that she thought the physician had ordered too many images. What we were looking to diagnose could be done in one instead of six. From that comment I gleaned that there was such inherent distrust between the radiology tech and the physician that she mentioned this to a patient instead of feeling empowered to bring it to the department.

I bring up that example only to show that there is still a perceived or real imbalance in health care. While there was most likely very good clinical reason for additional images, respectful and humble inquiry is not commonplace because of fear. Innovating transparency, control and knowledge sharing are based on behavior change as much as process change; change that needs to be embraced by providers as well as by every health care worker at every point in every process. Fear, resentment, ambiguity and a lack of empowerment contribute to the current state. When we emphasis key points for transformation that have no consideration for the multitude of people who provide care for patients outside of providers, we continue to drive inequality and mistrust.

I suspect that's where [you were going] with the key points, though I can't be sure. All I ask is that we think a little bit more about our language when we propose a world class health care system. It is indeed a system that needs input and collaboration to drive higher performance. I suggest we call out more specifically that collaboration is the trust, cooperation and mutual empowerment of every single person who touches a health care process. Not just physicians, not even just professionals (because many may not define themselves as such), but health care employees, workers, contributors and customers.

I am sure there is a much more concise way to summarize my point, I hope you'll forgive me for my lack of eloquence in expressing my thoughts.

Thanks in advance for taking the time, and thank you for continuing to drive thought and practice in pursuit of the quadruple aim.

Jen Gries

I wrote Jen back to ask her permission to share her letter. I told her that the only part of the letter where I did not agree with her was when she said, “I hope you'll forgive me for my lack of eloquence in expressing my thoughts.” She was more than adequately eloquent.

Jen’s response:

Gene,

You are more than welcome to quote me and/or use my name. Whatever works best for you.

I remember getting your weekly emails when I started with Atrius, and your messaging was always clear. You made me feel like part of something greater, even as a Medical Assistant. Your support for our lean start-up drove the initial transformation in the early days, as did your presence during the RIE week report outs.

Your leadership was appreciated then, and continues now as we enter (or continue through) the murky waters of health care reform. To your point, "I to we" should be the mantra of those working on health care delivery as well as those working on health care reform.

Thanks for taking the time to read and respond to my thoughts.

Jen

Jen’s letter put me into a reflective state of mind. She is correct. I did try to move the organization toward greater collaboration. “I to we” was the subject of many letters, but it is also true that I was always reluctant to be as explicit as Jen is requesting. I never had the courage to turn to some of my physician colleagues and say, “We can’t deliver the best care if it’s all about us!”

When I walked through the door for my first day of practice at the old Harvard Community Health Plan (HCHP) I carried with me the attitude and swagger I had learned at the Brigham. I ran into some gentle but firm resistance. The culture was described by some as “pinko.” The clinicians referred to one another by the non specific term of “provider.” I mused that it might as well be “comrade.” Practices were shared activities between a doctor and a nurse practitioner, coupled with dedicated medical assistants and office support staff. Together we owned the responsibility to serve our patients. It was a “medical home” with an electronic medical record before the term was in common usage. Yes, our records were computerized in 1975 and had been since 1969.

I did not know when I was introduced to Barbara Taylor, the nurse practitioner with whom I was paired, how ill prepared for practice I was after my years at Harvard Medical School and my internship, residency and cardiology fellowship at the Brigham. Barbara was very supportive but tough and expected my respect, as she gently altered my worldview and taught me that every person on our team was essential. She demanded a partnership that would be the source of my most important lessons learned in medical practice. Barbara and I “shared” our practice as equals until she died from cancer in 1987. After Barbara died I was at sea until Maxine Stanesa became my partner for the next twenty years until I left the everyday practice of medicine. Maxine is a Physician’s Assistant and has great skills in surgery, urology, orthopedics, podiatry and gynecology that far exceeded anything that I would ever be able to offer. Practicing as part of a team was a joy for which I will always be thankful.

What really made the practice at HCHP work were the layers of dyads of clinical and administrative partners that were responsible for the coordination of services between practices, specialties, sites, regions and our various hospital partners. It was all about “I to we.” Initially the system was small scale “Kaiser light.” As it matured it emphasized its own unique innovations and adaptations that were necessary in our environment. The progress was possible because we were focused on continuously improving what we did in a competitive market within the discipline of accountability for the good stewardship of resources that was a natural outcome of capitation.

The realities and discipline of capitation, a mission that makes a difference, and competition all drive the need to continuously improve and innovate. The improvements and innovations required the input and acceptance of everyone in any process that we changed. We frequently said that we were “physician led”, but that was wrong. Progress required the eventual acceptance of change by our physicians, but minus the ideas and energy of the other members of the team there would have been much less accomplished.

In 1975 HCHP was developing an ambulatory model of care that was unusual for its day. We were providing telephone advice after usual office hours, walk in urgent care services until late in the evening, and if needed, access to be seen by a physician twenty four hours a day. We were operating with the objective of reducing unnecessary emergency room visits and hospitalizations in a day when most office based practices would direct patients to the hospital for convenience as well as need. We were a prepaid practice and interested in eliminating wasteful use of resources even before the industry began to talk about being paid for “value.” We did not have Lean, but we intuitively practiced many of the principles that we would later call Lean.

My favorite story about receiving care from HCHP that surprises and delights is personal. One of our sons was ill with a croupy cough and we were concerned that it might be a tough night for all of us. We called urgent care and spoke with the nurse who went down a checklist of issues and reassured us that all would be fine. We were reassured. We were surprised when about thirty minutes later the front door bell rang. When I opened the door there was Don Berwick, black bag in hand. He was the pediatrician on call and when the nurse had discussed the call with him he was not so sure that things would be fine and needed to check our son just to be sure that he would be ok. In any other system we would have had a worried night at home or an extended, expensive, and unnecessary visit to the local emergency room.

I frequently refer to Barbara Taylor as one of two “founding mothers” of HCHP. The other “founding mother” was Stella Goldsmith. Barbara and Stella were not “old school” nurses who walked behind the doctor and tried to make suggestions indirectly. They were both accomplished clinicians. Barbara learned her skills working as a VNA in some of the toughest Boston neighborhoods. Stella was an experienced EW head nurse who did not suffer fools and could terrorize house staff and attendings alike if she thought they were off base or not focused on the needs of the patient. Together they created an army of staff that expected the respect that was justified by their contributions and participation.

Throughout the eighties HCHP pushed forward against the resistance of a local market that wanted choice as competitors diminished the reputation of “managed care” by denying care or making it difficult to obtain. The goal and ethic of HCHP had always been to provide the right care, the care that was needed, in the right place at the right time. The best example I can offer of its commitment to meeting need first and budget secondarily was the fact that I was able to refer a patient to Stanford for a successful heart/lung transplantation before either service was offered at a Boston AMC. All expenses were covered by “the plan” and the recipient is still alive today, more than thirty years later.

The nineties were a decade of decline from which we can harvest great learning. By then the original culture had been diluted by substantial expansion driven by employers requesting single source coverage. Traditional insurers could easily expand their networks to cover wide geographies. Our network was both our competitive advantage for quality and cost and our disadvantage in a world that wanted single source coverage with a wide choice of providers over a large area. By the end of the decade some of our pioneers like Don Berwick and Glenn Steele had moved on to other places where they would continue to make huge contributions while the practice found it necessary to exit the insurance function and accept patients from most payers through a variety of contracts including fee for service. The reversal of fortune was accelerated by the financial collapse of Harvard Pilgrim and by January 2000 we were faced with abandoning most of our managed care infrastructure which did not add as much value when the majority of our patients were seeing us through FFS contracts.

Fee for service revenue and practice is antithetical to the environment of respect and collaboration that Jen advocates. In a FFS practice where every department and every clinician is rewarded as a function of their earnings from doing “things” with the hope that better health and outcomes will somehow emerge, the urge to collaborate to create value and be better stewards of the healthcare dollar gives way to the necessity to churn. In a churning environment people who once were creating value are valued for their function in the moment and often become just an expense to be eliminated to maintain a positive short term financial outcome.

It is a harsh reality that most physicians who have been trained since the mid nineties have only known healthcare in a fee for service environment. Atrius Health was an organizational response for survival in a fee for service world. Several groups with a past history in managed care came together to better leverage their infrastructure expenses and improve their fee for service contracting. By 2006 with the passage of chapter 58 (Romneycare) in Massachusetts it was possible to imagine that things might change again. In 2008 when I became CEO of Atrius, Massachusetts passed chapter 305 which sought to abolish FFS practice in Massachusetts in five years. That did not happen, but since 2008 the strategy of Atrius Health has been to prepare for the ultimate return of value based reimbursement. That return has been dependent on two things.

First, there was the need to have an operating system that would educate and move current staff back toward the general principles of managed care. To move in the right direction we needed to work together and reacquire the means of “managing by processes of care” across a fully engaged and collaborative staff to produce value for our patients, improve the work life of all of our staff, and eliminate waste to lower our cost of care. To accomplish that task we recognized that Lean was a sophisticated codification of all that had been good in our original efforts and experiences, plus it offered new tools and concepts that were the natural extension of Dr. Ebert’s founding principles.

Secondly, we realized that we needed to improve the professional satisfaction of all staff but realized that the pressure of “today’s work” and the FFS compensation system had become the equivalent of a self administered drug for our physicians that was a barrier to all the “adaptive change” necessary to “get back to the future.” Our hope was that the respect and collaborative focus of Lean would drive the changes we wanted. Later we realized that the process of change might be accelerated by a “compact” conversation with physicians.

Getting doctors to recognize the need to change both for the benefit of their patients and the community is an enormous and daunting task that is complicated by the fact that each day’s work in the current dysfunctional environment leaves them so exhausted that they have no energy “for improvement.” The other professionals of the organization become anxious that their future is dependent upon physicians who are naturally concerned about their own survival and do not have the energy or insight to recognize that their salvation lies in better systems that they can not create alone but do have the professional leverage to ignore or resist. Jen’s letter nicely articulates the feeling of those who want to get on with the journey to better care and often must do the work without evidence that their physician colleagues “get it.”

I have been recently delighted to learn that my next grandchild will be born in a Kaiser Hospital. My daughter in law and son get their care through her employer, the state of California. They live in the Santa Cruz area and she works at UCSC. Until this January Kaiser was not offered to employees because the closest offices were in San Jose and Santa Clara. The choices they had were networks of traditional community practices and the local hospital, or Palo Alto Medical Foundation affiliated with Sutter Health. One was expensive. The other was acceptable quality but not very integrated or coordinated.

Kaiser has three offices now. One is in downtown Santa Cruz near my son’s office. Another is in nearby Watsonville. The third is in suburban Scott’s Valley near their home in Ben Lomond. The best news is that Kaiser with its efficiencies (many achieved with Lean) and culture of integrated care is one hundred dollars a month less expensive than the previous less expensive community option. Their family has health needs that require an integrated practice. They now enjoy the benefits of Epic access to their records. The office staff is more efficient and their appointments are easier to obtain. The staff at Kaiser in Santa Cruz is still getting organized, but already the experience is palpably better.

I offer the information because organizations like Kaiser and Atrius are proof that despite the fact that “healthcare is complicated”, it can be better. Competition does drive innovation and from my family’s perspective, it drive less expensive and more satisfying care. There is reason to be hopeful and realize that the best way to retain the gains of the ACA in the future is for more families to get better care and save more than $1200 a year. The way for us to provide better care is to take a first step of listening to Jen’s plea that we get everybody into the game with the respect they deserve for the contributions that they are eager to make.

The “Other” Gamecock Victory and Other Joys For Grandfathers

In the wrap up of my letter last week I was crowing with expectation about the appearance of the University of South Carolina men’s basketball team in the Final Four of the NCAA tournament. I totally disregarded the fact the the women’s team was also in the final four. The men played hard but lost to Gonzaga when their usual star failed to deliver his typical twenty point plus performance. The women won it all! They beat Mississippi State after the Bulldogs snapped UConn’s amazing streak of over 100 wins. I like to pose as an enlightened man who thinks Title IX was a leading edge action in the long battle for fulfillment of gender equality, but it appears that the facts suggest that I still have some growing to do. I enjoy nothing more than watching a video of my fourteen year old granddaughter nail a jump shot for her junior high school team or being in the stands for an exciting nail biting victory in one of her volleyball tournaments, but I guess I have a lot of growing to do if I am going to live up to my ego ideal.

The other athletic event that I was anticipating last weekend did go off as hoped. I enjoyed watching the game with my grandson in the California redwoods. He will be three in July but is already a baseball fan. When I am visiting he wears his Red Sox ball cap and his Ortiz t-shirt. When his other grandfather comes he dons his Cubs cap and his Rizzo shirt. He loves the video replays where the action is concentrated! We watched Andrew Benintendi’s Opening Day dinger about fifty times.

As the picture in today’s header suggests, we have also been doing some hiking. I have never seen California so green! My little buddy loves the trails in the state park that backs up on his home. There is nothing more majestic than a stand of coastal redwoods. I will be enjoying them again along with more baseball this weekend. Wherever you are, it is my hope that you will also be engaged in something that gets you out and about in a spring world.