7 July 2017

Dear Interested Readers,


What’s Inside This Week’s Letter and a Variation From My Weekly Political Catharsis

Having Congress go home for the Fourth really cooled down the discussion of healthcare this week. As the long Fourth weekend approached, the New York Times gave us an overview of the Mika, Joe and Donald feud as most of the rest of the “fake news” machinery seemed tired of the story. Now all the excitement has pretty much been filed away as another jaw dropping event in the short history of this presidency. Each new bizarre event and falsehood spouted and catalogued for posterity seems to make the next occurrence seem like less of a surprise and more like business as usual.

As I woke up in the calm of no big news stories on Saturday, I felt like I did when I was a child and stepped off a merry-go-round. For a day or so my head continued to spin and I was a little dizzy, but mercifully it did not last long. I was delighted to discover that for a few days it is possible to ignore the crazy conversations and game playing on the edge of disaster that has been going on in Washington since late January. That has ended now and things are getting back to the new normal as the president sallies forth into the international arena to proclaim himself the defender of “Western” culture in Poland on his way to the G20 meeting and his face to face meeting with Putin.

The main portion of this week’s letter got its genesis last week when I got together over a very pleasant and relaxed dinner with three experienced healthcare professionals to muse about the future of healthcare. We quickly decided that beyond writing letters to Republican Senators who seem undecided and were concerned either about a backlash that would eventually hurt their careers or had the higher motivation of seeking to do the right thing for the underserved, there were no obvious maneuvers available to us that could make a certain difference. It seems that the greatest hope for the preservation of the benefits of the Medicaid expansion and the other crippled innovations of the ACA might come from a push back by the public that would prevent anything from happening.

What we need most goes far beyond preventing the loss of Medicaid and further erosions of the exchanges fostered by administrative actions designed to create a sense of failure. We need a true upgrade and repair of the the ACA, not its repeal and replacement. What did seem like a wise way to use the evening was to debate a few actions that groups, hospitals and health systems might take to manage an uncertain future. What organizational “mindset” might be most beneficial and preserve some of the gains of the last seven years? Should large “independent” groups of doctors remain independent or seek to become apart of health systems that included hospitals and insurers? How do you maintain “productivity” without the over productivity of RVU based fee for service income in a system that is losing money now and in the future will be compensated for value and not volume? How do you change the expectations and engagement of both healthcare professionals and patients as a step toward improved quality and economic sustainability? How do you do all this in an environment of regulatory uncertainty and falling revenue? In total we were asking a simple question. How do we continue the journey toward the Triple Aim in the midst of growing uncertainty and fatigue? Where do we find the energy, leadership and hope for such a struggle when we live in a time of such divisiveness?

Before getting on to such a tough discussion let me give some advice that is derivative of my experience of seventy two years of, to steal a phrase from Churchill, doing all the wrong things before trying to do the right thing. I have discovered that minding my personal mindset, motivation and internal resources are foundational to being part of an effective effort. The best efforts have a group of people at their core who have their energy and focus sharpened by their collaboration. When such a core group exists and when they can work effectively together, others are attracted from their own despair and failing efforts by the hope that emanates from the core. Personal fatigue and despair function like receptor site blockers for improvement on the psyche of many of our colleagues. Each wearying day, each announcement of organizational belt tightening, each new onerous internal pronouncement, and every round of pink slips affecting valued colleagues drags them down further and makes them vulnerable to the burnout that my friend and colleague Paul DeChant is so valiantly trying to fight with the principles of “Lean done right.”

My guess is that those at the core of the organizations that will find a way to thrive will be individuals who know how to renew themselves. There is much truth and good strategy to the concept of responding to the announcement that the plane is going down by putting on your own oxygen mask before you help someone else put on theirs. My own strategy for self maintenance has been to look outside healthcare for self preservation and growth. I try to bring the energy that I get from a wider world to the more focused task of doing my part to make the world of healthcare work better.

My walks in nature, my forays into music, my interest in sports, and my continuing interest in searching for spiritual meaning in and above all these activities are an attempt to find effective antidotes to the anhedonia that is the derivative of working toward a distant dream within a compromised environment. Some of the energy that I have gained from these activities allows me to write these letters and will drive some of the thinking in the main section of this letter this week. On my walks recently I have been listening to a combination of Robert Sapolsky’s Behave: The Biology of Humans at Our Best and Worst and my son’s most recent music.

As an example of the process, I used one of my son’s songs that I had recently re heard with “new ears” on one of my walks in one of these letter a few weeks ago. In response to the use of the song I got an interesting comment from a new reader:

Gene,

...I love how you weave words from your son's own prolific song writing.

Is this the shape of things to come?
Is this the ground we walk upon?
Is this the way we live and die and carry on?
Is this the day we hoped would come?

The last line reminds me of a Francis de Sales quote: We cannot help but conform ourselves to what we love.

Is this what we want? Is this the day we hoped would come?...Yikes.


I find that in these times healthcare is one of many shared issues that leave so many of us with a sense of despair. The angst we feel from these issues is heightened by our personal fears and insecurities. Many of us are confused about the mindset that is most appropriate for these times. I was encouraged by the reader’s quote from the saint that: We cannot help but conform ourselves to what we love.

So, I decided to go back to the well and see if there were more words of wisdom that I could extract from the body of Jesse’s work of the last year. One year ago we were moving toward the conventions with the certainty that Donald Trump had won the Republican nomination in the primaries. Starting last July and rolling forward I have extracted bits from a dozen songs that form a poetic reaction to much of what we have experienced together this year. If you want to hear the song or read more about any of lines below, just click on the words. The name of the song and the date it was posted on the Internet are below each passage. I hope that you will take the time to listen if one quote catches your imagination or triggers a memory from this turbulent year.


Oh what walls we build
Who’s to tear them down again?

Who’s to Tear them Down?, July 16, 2016


Oh, so I’ve got a nightmare
And I’ll tell you how it goes
It goes that only the white men vote

October Surprise, October 31, 2016


Think it through
America
Do the right thing
And you know what it is
Let the babes in their cribs
Keep their innocence
Hold the monster at bay

Hold the Monster at Bay, November 7, 2016


It’s morning in America
Anyway, can’t we all sleep in today?
‘Cause all the safety pins and words we say
Aren’t even nearly making up for this mistake
And I wonder, are we strong enough
To stop the coming war?
Is there love enough in our righteousness
To fathom what it’s for?

Mourning in America, November 14, 2016


In the dark of America
Where the poison they poured in the well
Is the only drop you can drink
You hold out

Pondering the Arrival of an Overlong Winter, November 28, 2016


Blame the young
And curse them for their ways
They have no sense of cause
Love only for themselves
And curse the old
For squandering a gift
And boasting all the while
What left have we to keep?
And we’re not sorry
And you’re not sorry

Not Sorry, December 5, 2016


One day we will hear all the tapes that they hid from us
One day we will speak with clarity on this subject at last
One day we will count all the sins that bit back at us
One day we will know who’s to blame
It feels like a dream but it’s not
It’s a trap

Long Year, Part 2, December 26, 2016

Well as a matter of fact
Those ladies throw one hell of a march
I was happy to learn a thing or two from them
About getting somewhere

A Reflection on Resistance, January 23, 2017


I alone can fix this
I alone will speak the truth
I alone can keep you safe
Who else used to talk this way?

I Alone, January 30, 2017


Don’t be fooled when the false spring comes
You’ll be breaking your fall on the walk again
You can calm your nerves on a kinder wind
But never drop your guard in the state we’re in

False Spring, February 20, 2017


Hold to the kindness
The cracks couldn’t breach
You must hold to the convictions
That the chaos couldn’t reach
And you will hold tight to the lesson
That a crucible can teach
And we will hold tight to each other
With the other ever reaching up

The Higher Ground, April 24, 2017


Everyone is counted
Each of us counts in our own way

What We Know, July 3, 2017

At this point in the letter I usually remind you to check out stategyhealthcare.com for the latest posting. Thanks to my good friend, colleague, adviser in all things that relate to the Internet, and wonderful citizen committed to the idea of better care for everyone, Russ Morgan, you probably got an email in the middle of Wednesday night or very early on Thursday that informed you of the latest SHC posting and gave you an index to recent posts. I hope that this will be helpful to you and I am extremely grateful to Russ for his efforts to support this work. It is good to get reminders to support our good intentions!


Continuing The Dream of Better Care For All and Healthier Communities in the Midst of Uncertainty: The dance of action and contemplation


A few years ago Patty Gabow, the retired CEO of Denver Health and a master of using Lean to benefit the underserved, and I were enjoying a dinner together while we were attending a meeting. Our conversation had gotten to the level of sharing and openness where we were trusting one another with thoughts that explored the origins of our strength to maintain hope in the face of mounting adversity and uncertainty. I mentioned my interest in the writing of a progressive theologian, Marcus Borg, who had recently come out with what would be his last book before his death from pulmonary fibrosis, Convictions: How I Learned What Matters Most. We began to discuss our past histories in relationship to personal inquiry and the search for spiritual meaning. That was when Patty revealed to me that she began most days reading the daily letters from Father Richard Rohr, a Franciscan Monk who leads the Center for Contemplation and Action, in Albuquerque, New Mexico. Anything that Patty thinks is worth her time is something that interests me.

I have been reading Father Rohr’s letters and enjoying his way of seeing the world now for about two years. Along the way I have discovered many others who find wisdom in what Father Rohr has to say, including one of the ministers at the Baptist Church that I attend! Obviously his message is not directed at Catholics alone, nor do you even need to have any relationship with Christianity to be moved by his words and wisdom. The first two paragraphs of his post on the Fourth grabbed me as I was thinking about the energy necessary to try to fight for better care and to preserve the little bit of gain we have made toward the Triple Aim. I have been tempted on many occasions to reference Father Rohr in these letters. As I was thinking about this week’s letter on July 4th, I decided that I should share some of the post with you. It begins:

Charles Péguy (1873–1914), French poet and essayist, wrote with great insight that “everything begins in mysticism and ends in politics.” Everything new and creative in this world puts together things that don’t look like they go together at all but always have been connected at a deeper level. Spirituality’s goal is to get people to that deeper level, to the unified field or nondual thinking, where God alone can hold contradictions and paradox.

When people ask me which is the more important, action or contemplation, I know it is an impossible question to answer because they are eternally united in one embrace, two sides of one coin. So I say that action is not the important word, nor is contemplation; and is the important word! How do you put the two together? I am seventy-four now and I’m still working on it! The dance of action and contemplation is an art form that will take your entire life to master. Like Moses at the burning bush, many of us begin with a mystical moment and end with social action or what looks like politics. But it also works in the other direction. Some start by diving into the pain of the world and that drives them toward their need for God.

Thinkers like Robert Ebert and his students that I have known, like Joseph Dorsey and Don Berwick, joined others in both actions and contemplation from the sixties though fifty years of experience to produce the Triple Aim in 2007. Now ten years later and with more action having accumulated, we have more experience to contemplate. Contemplation of what we have learned and what it all might mean allows us to say that our objective is:


...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..


I do not think it is a stretch to say that what began as ideas in the minds of physicians and healthcare professionals in the mid fifties resulted in actions that have made a difference. Those actions have also generated a political conversation.

All movements in history, including “the enlightenment” which gave birth or sustenance to many of the ideals we celebrated on the Fourth and our current efforts to use science to save the planet and improve the lives of all of its inhabitants, have encountered resistance. Processes of transformation and continuous improvement appeal only to those who are suffering the injuries of the status quo. The status quo is the target of improvement and those who own the advantage of the moment have always preferred that we not examine its inequities or consider a more generous and efficient future. In healthcare contemplating the failures of our current delivery system and methods of care has generated actions and new ideas that have met the resistance of the status quo and that is politics! Péguy was right!

Recently, I spent an evening with colleagues who now have, or have retired from, significant leadership responsibilities in healthcare. We met to discuss over a good meal how physician groups and hospitals might work together to preserve the ACA. It was obvious to us that there was little that we could do that will alter whatever the outcome might be. It was clear to us that our focus should be doing what we could to help the organizations where we have influence to prepare for the uncertainty of the future. If Medicare and the ACA were to eventually be the victim of the Better Care and Reconciliation Act of 2017, the path to the Triple Aim would not change much although it would be much more challenging.

Under any law the future will belong to those organizations that can lower the total cost of care through operational improvements and innovations that improve the experience of patients and support the work of clinicians so that both patients and clinicians have a higher level of satisfaction and a new sense of engagement. Over the last fifty years we have developed a great deal of consensus around what should work to improve care. A huge barrier to the implementation of what we think will work is the status quo of healthcare finance. How we get paid for the 85% of citizens who will still have access to us needs to change, and it can change without the passage of any law. The flow of money after you subtract many of the recipients of Medicaid and the participants in exchanges will be controlled by the contracts we negotiate and the way we chose to pay ourselves within organizations. I do not think we can achieve the objectives of the Triple Aim by trying to improve productivity through individual compensation that drives volume work and undermines collaboration. Bonuses designed to entice behaviors that result in the ordering of more tests and procedures for more patients will never support organizational transformation that lowers the cost of care.

If the goal is clinician and patient engagement to promote better behaviors, self management, and improved outcomes with less waste of resources, then we must allow clinicians the time to be with patients and shift many appointments and encounters from perfunctory interactions that do nothing but generate revenue to other professionals or other forms of interaction on line, in groups, or with other professionals who are quite capable of managing established problems. More effective collaboration within teams should be a prime objective of all organizations who care about the future of healthcare in America. We can never do the work of transformation and improvement while we are exhausted from working in dysfunctional and misdirected systems.

We do not need new laws to permit quality improvement. We need leadership. Perhaps if we could lower the cost of care we could enable covering more lives. Beginning with Romneycare in Massachusetts, Chapter 58 of 2006, and continuing on with the ACA in 2010 we have explored the approach of expanding access first and controlling costs second, hoping that we could lower the total cost of care for the country later as an outcome of universal coverage. We may have had it backwards. We needed to develop more effective simultaneous efforts to lower costs as we attempted to expand access. Those who believe we are wasting money are correct even if their motivation is to try to eliminate waste by disenfranchising many who now enjoy coverage and vastly reducing the resources available for those who do have access.

Medical institutions still have resources for investment. Many think that a new bed tower or another piece of expensive surgical or diagnostic equipment or a new medical record will solve their problems. I doubt that they are right. I fear that what Dr. Ebert said years ago is still correct. We do not need more money, more facilities or perhaps even more people. We need individual organizations to realize that they will survive if they can evolve operating systems and finance mechanisms that support the improvement of health through the equitable distribution of what we already have and the benefits of what we have already learned. A good starting place is to engage everyone in the work of care improvement and waste reduction. Call it Lean or call it continuous improvement. Under any name it requires engaged servant leadership that supports and provides opportunity rather than cuts budgets and eliminates services. Everywhere I look I see more cutting and eliminating than I see creating and improving.

Atul Gawande was right. We are not ignorant. We are inept. Perhaps the good outcome of a bad healthcare bill might be that we will be forced to realize that the way to better care is through deep contemplation about why we do what we do, and then rededication to the difficult task of the actions that will yield the outcomes that we say we want. After we pass through this valley of discontent and disruption and contemplate its miseries, perhaps we will have the courage to take action and move to a new order that provides everyone with the care they need. Perhaps then there will be acceptance of the truth that healthcare is an entitlement that has universal benefits that are best achieved by a single payer.


Life Goes On


It’s been a good week at the lake. The header for today’s letter is my attempt to share with you the tranquility of this little piece of nature. I have recovered from the disappointment from the realization that this year we will not have the joy of observing the development of baby loons. For reasons yet to be determined, mother loon sat on the nest for a few weeks and then abandoned the project. Apparently, in time, we will get a report from the state’s wildlife authorities on what might have been the problem.

This week the water has reached the level of chill that invigorates rather than immobilizes and allows me to swim sans wetsuit. Pulling on a wet suit is such a struggle that it represents a real barrier to getting into the water. Swimming has been a greater joy this year because I was not sure that the rotator cuff tear that I suffered last fall would allow me to do much in the water. I am delighted to report that great things are possible through focused and diligent PT. PT may be the most neglected, useful therapy we can offer our patients. PT is the ultimate test of patient engagement.

The other great joy of the week has been the resurgence of the Red Sox, timed with a significant decline in fortune for the Yankees. The joy and optimism has faded just a little as they lost the last two nights. It’s a long season and I expect that there may be a few more reversals of fortune for both sides of the rivalry before the long season is over. If that is true, I can expect to enjoy many more pleasant evenings renewing myself as I peddle my kayak around the lake at sunset while I fish and listen to the early innings of a Sox game.

Whatever your source of personal renewal, I hope that this weekend will offer you the opportunity to enjoy it. I believe that our best ideas find us as we are engaged in the things that add value to our experiences alone and in communion with friends and family.

Be well, take care of yourself, stay in touch, and don’t let anything keep you from making the choice to do the good that you can do every day,

Gene