| 7 October 2016
Dear Interested Readers,
This Week’s Letter
This week’s letter is a “ratatouille” of continuing concerns and worries about the election, now only a month away. The mix includes a discussion of my continuing disappointment about the lack of a substantive discussion of healthcare issues in the election. My concern was heightened by sloppy and easy to twist comments from Bill Clinton. I struggle with ideas about how to think about the future during the confusion of the ongoing campaign. I advance ideas borrowed from other times about how to measure and consider our progress toward the Triple Aim in a complicated world. Near the end of the letter I relieve myself from some of the election tension with anticipatory excitement about a busy weekend of sports, but finally I find the greatest relief in the celebration of the kaleidoscope of the rapidly changing colors and the dancing lights of fall.
Ratatouille may seem a strange choice as a descriptor for a letter, but I think it is an apt word when you describe something that is composed of many things that retain their identity as they meld together into a whole that may be better and more interesting than any one item alone. When you bake a cake the individual ingredients: the flour, the sugar, the salt, the milk, and whatever else you add to the mix, disappear into the creation of something new. In a ratatouille, or likewise with cioppino, things blend to make something that is more flavorful and interesting than the individual ingredients, yet the identity of an individual ingredient is not lost. The description of ratatouille in Wikipedia makes my point:
..."according to the purists, the different vegetables should be cooked separately, then combined and cooked slowly together until they attain a smooth, creamy consistency", so that ...."each [vegetable] will taste truly of itself."
Ratatouille and cioppino share another interesting characteristic with pizza and many stews and brews. They get better as they sit around. As leftovers they are often better than when they were originally offered. Here I am talking about the re examination of ideas and not my writing. I find that I just can’t let go of some ideas, and as I try to move on to something new, the old questions and concerns keep calling me back and asking me to consider them further. I am warning you that there will be some repetition in this letter, but I am also hoping that the repetition leads to deeper understanding.
The most repetitive part of this weekly introduction is my request that you direct colleagues and friends to the strategyhealthcare.com website where they can sign up to get these letters. You can always comment directly to me in an email by just hitting “reply” on this letter. On strategyhealthcare.com your comments are observable by others. Finally, thanks to Russ Morgan, who is my colleague and does so much behind the scenes to make these weekly offerings possible, you can also connect and comment through Facebook. That makes three ways to join the conversation! Let me hear from you!
It’s Hard to Think About Much Else Until After the Election
Ever since the political conventions ended in early August I have been devoting more effort to trying not to think about the election than I have to thinking about healthcare or any other subject. I guess that means that I am obsessed with the election.
ob·sess
/əbˈses/
verb
past tense: obsessed past participle: obsessed
- preoccupy or fill the mind of (someone) continually, intrusively, and to a troubling extent.: "he was obsessed with the theme of death" "he became completely obsessed about germs".
My mind is filled and troubled with at least one possible outcome and the thought of the election leads to a chain of continuous “what ifs” that send me into a downward spiral that I must try to break with walks, fishing or some other temporary distraction. My effort to get the election out of my mind is usually interrupted by some message about the election on my cell phone, a request for a contribution that pops up on my computer, a negative political ad on television or an earnest comment by someone in my company that starts it all over again. It needs to end. My distress has gotten to the point that the pain of waiting for election day has become like the biological urgency that at times can’t be resolved because of some social or physical barrier that makes the facilities out of reach. The urgency and discomfort prevents all other thought until the issue is resolved. I can’t imagine how I will manage the next month.
My hope for partial relief is that the conversation between the candidates and between them and the voters might move away from a discussion of emails, Benghazi, failed businesses, the description and comparison of body parts, and the ethics of avoiding taxes. I would get even more relief if the candidates discussed and debated more substantive things like healthcare which until this week was virtually undiscussed. To my surprise healthcare came back, not as a substantive discussion of the issues, but in the form of an ill advised comment by Bill Clinton about the “craziness of the ACA” that was ripe to be lifted out of context and thrown back into the conversation during the Vice Presidential debate by Mike Pence. Pence continued the opportunity to score more points with the Clinton comment while talking with commentators after the debate. He used Clinton’s comment as evidence that the ACA is a total disaster that should be discarded on January 20, 2017. If you listen to all that Clinton said, he was right and the comment was lifted from his discussion of why a “public option”, as advocated by Hillary Clinton, would be a great benefit to those who are working hard and are just beyond the limit of public assistance.
The sad reality is that not only was Bill Clinton right about the problem; he did a pretty good job of explaining why there needs to be change before he erred by using the word “crazy”. “Crazy” should be deleted from the vocabulary of all thoughtful candidates and their surrogates. Bill was trying to explain Hillary’s solution to a vexing problem that is a flaw in the design of the ACA. The flaw is traceable to the compromises necessary to gain passage of the ACA.
The shortcomings of the ACA are worth analysis and discussion, but to understand either point Bill was trying to make, requires the focused and open minded attention of an electorate that is engaged in the search for thoughtful leadership. Bill’s mistake was to try to explain the nuts and bolts of the insurance market during an election that rarely goes beyond sound bites. He was not announcing a new opinion. His thoughts were an extension of the discussion that originally occurred between Bernie Sanders and Hillary Clinton during the primary process. His comments were consistent with the published opinion of President Obama in an article he wrote for JAMA back in August.
Social change through court decisions or legislation is always difficult. One needs only to review the long and continuing attempts at equity in civil rights that gained a beachhead in the Supreme Court with Brown v. The Board of Education of Topeka, Kansas. That was a beginning and not an end. It was followed by weak civil right laws in the late fifties before the demonstrations and civil disobedience lead by Martin Luther King, Jr and the political courage of Lyndon Johnson and others resulted in a meaningful Civil Rights acts in 1964 and the Voters’ Rights Act in 1965. Now fifty years later we are still struggling with civil rights and the associated issues of equity and justice. Change is slow.
Another example that may be closer to our struggle for the advancement of the goals of the Triple Aim through legislation is the frustration associated with poverty. Poverty surely has components of race, but an important explanation for the emotion in this election is the fear of economic loss and insecurity that threatens many white men without higher education who can no longer count on good paying jobs that match their expertise. The problems of poor white America are not new. Michael Harrington’s description of the problem in his 1961 book The Other America was written 55 years ago and the “War on Poverty” was encouraged by the book and the discussion it triggered before the effort was announced by Lyndon Johnson during the 1964 “State of the Union Address”, shortly after the assassination of President Kennedy.. The easy parts of any social change, put in Lean language, are the description of the current problem and the improved state. The hard parts are negotiating a strategy for solution and then implementing that strategy.
The limited long term successes of the War on Poverty and the continuing frustrations on the road to racial and economic equity should instruct us. Those of us who believe that together we can accomplish big improvements in the life’s experience of every person should recognize that many of our conservative neighbors are not so sure, and at best, the history of the last sixty years argues that the problem lies in the “how” and not in the “why and what”.
Applying the same analysis to healthcare reform we can see that the discussion of the “why” has been largely settled. Few people still hold out the arguments that I was still hearing as late as 2008-10 that on balance our healthcare was not too expensive. Most people now accept that there are problems with healthcare that include expense, certainty of quality and service, and continuing concerns about access. Though most voters probably have not heard the phrase
Care better than we’ve seen, health better than we’ve ever known, cost we can afford…for every person, every time.
I would expect that most voters would agree that it is a desirable objective. The rub once again lies with the "how". The ACA was an initial offering as a “how”. It has accomplished a lot for everyone in terms of portability and a guarantee of insurability, even with preexisting conditions. 20 million people have gained healthcare coverage through its provisions. The sad and frustrating fact, that was at the root of Bill Clinton’s unfortunate use of the word “crazy”, is that 29 million American still do not have coverage. That is about 10% of the population, but the percent is disproportionately higher, up to 25%, in those “red states” that have not taken advantage of the expansion of Medicaid. Some of those who do not have coverage or who are burdened by the continuing high cost of care are the owners of very small businesses and workers who make just enough to fall through the crack between their ability to pay and the limits of subsidy.
Bill Clinton’s “crazy” was an expression of frustration that the problem exists and can’t be resolved in the climate of our current political gridlock. Hillary’s proposed solution is worth consideration, but for it to succeed we must elect more than just a new president. We must to advocate for the election of a Congress that can understood how far we have come and can understand and learn from the mistakes that we have made. Her idea needs consideration along with alternative potential remedies. We need a national “A4” process that reconsiders and redesigns the strategy for improvement and follows in the wake of a universal understanding that trying to do the same thing that has only partially achieved the desired objective does come close to being “crazy”. Continuing with the ACA without amending its flaws seems quite close to Einstein’s definition of insanity which is to continue to do the same thing expecting different results.
The best response from an opposition candidate to Bill Clinton’s comment that the current system is “crazy” would have been a question. A concerned candidate seeking to gain the confidence of an engaged electorate would have probed for understanding or would have produced an alternative solution based on an approach that was plausible. A sneer and a “gotcha!” leaves me longing for more and deeply troubled. I am left with anxiety and concern that strange events could occur. I am troubled that in this strange year there is a possibility that a sneering candidate might win and undermine all that has been accomplished on the road to the Triple Aim. Mining the fears and concerns of people who are moved more by body language and bravado than by thoughtful and respectful presentation is irresponsible in the face of important and complex problems.
I calm myself by making lists of those accomplishments on the road to the Triple Aim that can not be reversed by executive action. The shift from volume to value could be hastened by the addition of a properly constructed public option, but if we elect a president and congress that discards the gains so far just because the whole package is not perfect another strategy may be necessary. We may be forced to try to hang on to our limited gains through the realities of MACRA. It is highly unlikely that there is a political possibility of doing away with Medicare. Certainly if the ACA were repealed there would be even greater variation in Medicaid going from state to state if the alternative idea of financing Medicaid through block grants was adopted. An administration more focused on improving the business and tax environment for the wealthy and perpetuating the myth of trickle down improvement for all is likely not to be as interested in insuring that we accomplish universal coverage.
I also calm myself by realizing that the work of the IHI continues. Lean is spreading. We are thinking about the origins of burnout and new ideas are emerging that offer new concepts about its management. One highlight for me over the last two weeks has been to have the opportunity to read several of the chapters in the book on burnout that will be published soon by Drs. Paul DeChant and Diane Shannon.
Another basis for hope while continuing the journey on the road toward the Triple Aim under the cloud of the election, is a new book soon to be published from Dr. Anthony DiGioia, Eve Shapiro, and Pamela Greenhouse. This book offers tremendous guidance for any organization that realizes the importance of looking at the experience and the expense of care through the eyes of patients and families. I am absolutely thrilled that the book speaks unabashedly and directly to all aspects of the Triple Aim. It breaks new ground by convincingly demonstrating how the power of patient and family centered care intensifies the effectiveness of other forms of continuous improvement.
Finally, I am encouraged by the fact that although the election has not produced much in the way of substantive discussion of the issues of healthcare, it has not been able to avoid the core issues of injustice and inequity that are experienced by everyone of color as well as the ongoing issues of unequal opportunity for women. The ongoing concerns about the inherent diversity of sexual preference and identity, the status of immigrants and those who are refugees from the violence of the Middle East, and our epidemic of gun violence continue to be discussed. Perhaps how to deal with issues of international and domestic terrorism trump the ongoing inequities in healthcare.
I worry most about the persistence of gridlock and the lack of civility after the election is over. I worry about the persistence after the election of the backlash against “political correctness”. My frustration is the continuing discussion of the personalities of both candidates in lieu of discussing the issues. In a better world and at a better time thoughtful debates and campaign discussions of policy would allow voters to judge character and capability based on the discussion of issues and ideas. Whether or not a given candidate has the skill or temperament to be President could be judged on the basis of the observations of voters made while the candidates present their ideas and not as they exchange insults. Change is a slow process.
Serving Up Baseball, Brady and Boorish Boasts
Baseball mirrors so much of the human experience. That is why I love it. One or two individuals can make a difference in each game, but no team can win consistently on the back of only one individual. A great hitter succeeds less than a third of the time, a very average hitter a quarter of the time, and one who is barely hanging on, a fifth of the time. There is a world of difference between 0.333, 0.250 and 0.200, but all of those numbers represent failure on most trips to the plate. In his last home stand Big Papi thrilled us by hitting a game winning homerun in the first game of the series, but then he failed miserably at critical moments in both of the last two games. Had he “delivered” on all three occasions the first game of the five game series that began last night in Cleveland with a Red Sox loss would have been played in Boston.
Sunday will be a busy day. Tom Brady makes his return from the injustices of the exile that Roger Goodell demanded to prove that he is the omnipotent monarch of football. For a while it looked like Bill Belichick would guide the Patriots through the troubled times in a way that would cause people to wonder if Tom was so necessary after all, but last week’s homefield shutout at the hands of the Bills reinforced the notion that there is Brady and then everyone else. Again though, Brady reminds us that in sports great is defined as someone who fails less often than others. Both Brady and Ortiz are reminders that nothing that men do has much permanence, even in memory. Their names and their athletic feats will be remembered by fewer and fewer fans as subsequent seasons come and go.
After Tom performs in the early afternoon, the Red Sox and Indians will continue their best of five series in the late afternoon shadows at Fenway. I consider both the football game and the baseball game to be opening acts for the main event, the second Presidential debate; although I am sure many viewers will opt out of that offering and watch the Giants play the Packers or the Blue Jays play the Rangers. I will be watching the debate and hoping for more substance and more civility from both of these people who have succeeded in getting to the last step before inauguration as President. The winner of any game on Sunday will make little difference to the future of anyone but Robert Kraft, John Henry, their teams and their financial associates, but the winner of the debate could make a life or death difference for almost anyone on the planet. How can that not be of interest to everyone?
Changing Light and Color: Enjoying Fall on the Back Roads and Lake
I know that I have spent the past six months either anticipating summer or talking about how much I loved it and how poignant it was in its brevity. What was I thinking? Fall is fabulous. This week has been a crescendo of visual pleasure.
On Tuesday, after a rainy weekend and an overcast Monday, I decided to see if I could capture fall with pictures while on my afternoon walk. I occasionally take one or two pictures with my phone while on my walks, but I rarely take a walk to take pictures. As I headed up the road on my walk Tuesday afternoon I was immediately impressed by the shafts of bright light that pierced the usual shadows created by the woodlands along the road. The road must have run through open fields at sometime in the distant past because dilapidated stone walls run along its sides and then branch out into the the density of the trees and underbrush. I decided to take the “high road” up and over Burpee Hill and then make a loop by turning down the dirt road, misnamed “Columbus Avenue”, that runs through an even denser woodland area. Over a stretch of more than a mile there are only a few houses hiding in those woods.
As I climbed Burpee Hill I photographed the maples along the stone walls and marveled at the site of Mount Sunapee standing almost ten miles away at the other end of the “big” lake which lay like a large puddle at my feet. Even as I walked it seemed as if the colors were changing around me with each step I took. What was happening I think was that the interplay of the clouds and the low angle of the late afternoon sun kept changing the effect like a moving spotlight from one part of the scene to another.
After cresting Burpee Hill the road dives down at an angle sharp enough to make my old knees ache a little and then bottoms out at the corner with the aforementioned Columbus Avenue. I always chuckle when I see the signpost with its name at the intersection and think about the real Columbus Avenue in Boston or the Columbus Avenue that parallels Central Park West in midtown Manhattan. Today's header is a picture from the farm that sits at the intersection of Burpee and Columbus. Behind the barn is the home pasture of “Thunder”, the old workhorse whom I imagine is passing his retirement days here, just as I do.
The remarkable thing about fall is that you can see the world change in a minute. This is particularly true in the late afternoon. A gorgeous moment of light and color suddenly turns dark and muted as a cloud passes or the sun goes a few degrees more toward its setting. The most beautiful combination of it all is the doubling of the color that occurs when the various reds and yellows are reflected in the glassy water of the lake as a sudden burst of light in the setting sun.
Fall is fleeting. Catch it while you can! |
| 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
Dr. Gene Lindsey
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