8 April 2016
Dear Interested Readers,
An Overview of This week’s Letter, Plus an Assignment In this week’s letter I take on an ambitious task. Discussing healthcare disparities is an easy and intellectually engaging subject. Making progress in improving disparities in healthcare has proven to be as hard as making progress in the “war” against poverty, the “war” on drugs, the “struggle” for civil rights, the “movement” for gender equality, and the “fight” for the rights of the LGBT community. I do not have real answers for any of these social concerns but I do see some commonality in their origins and potential solutions as well as in the barriers to progress.
Ironically, it seems that any progress in any of these areas that has a mitigating effect is then followed by a backlash that can make the next step or ultimate victory even harder and seem further away. I cite some personal experiences and reflect on my own observations for part of the story. My hope is that what I share with you will trigger some reflection on your part and that you will experience a small increase in commitment to community as an outcome.
There is no greater tension in our time than the tension between the desires, concerns and fears of the individual and the woes and concerns that we share collectively. Many of us seek refuge and security for ourselves and our families with the false hope that as an individual we can do better than as a part of the collective. My guess is that the long term math of game theory ultimately proves that our strategies designed to succeed as an individual, even as the group fails, do not really protect us in the end. Game theory may prove that self serving strategies fail, but in the short term they offer some illusion of protection. Who believes in math or theories?
At the end of the letter, I could not pass on the opportunity to talk about Merle Haggard, bad weather and the stumbling start of the new baseball season.
I have shaved down and revised the core of last week’s letter into a posting on strategyhealthcare.com that is entitled “Leadership: More than a position, an activity”. That new posting, along with abridgements of most of these musings, are ready for your review. As always, I hope that you will continue to direct your friends and colleagues to the site as the place where they can sign up to get these Friday letters. Each week the list of readers grows a little and I appreciate your support because it confirms my sense of purpose.
Finally, I would like to give you a reading assignment. As all readers of this letter know, I am a fan of John Toussaint. I believe that no one has worked more tirelessly than he has to transform healthcare. I do not “tweet” on Twitter but I do “retweet” in these letters much of what I have learned from personal conversation with John and from reading his books and articles. I am very pleased and proud that he is an “Interested Reader” of these letters. He has two recent articles that I hope that you will read.
The first link is to the website of John’s organization where you can click on a short article that he published last fall in the Harvard Business Review. The HBR article is a succinct review of his sense of the failure of “management by objective” in healthcare and his advocacy for “management by process” and Lean. You have gotten these second hand from me in these weekly letters. Getting it straight from him would be good!
The second article for you to read is from the HealthAffairs Blog and is also quite succinct. This is a potent response written with Patrick Conway of CMS and Steve Shortell of UC Berkeley to Groopman and Hartzband’s NEJM diatribe and misinformation against Lean in medicine, “Medical Taylorism”, published last January.
I hope that you will read both articles and pass them on to others where you work.
Imagine a World Without Healthcare Disparities
John Lennon’s “Imagine” is definitely on my personal “Top 100” playlist. I hope that you clicked on the link and spent a little over three minutes watching the YouTube clip of Lennon singing. If you did, you will be one of 119 million people who also watched it. I do believe that getting to someplace better begins with our “visioning” and imagining the destination. You may reject Lennon’s suggestion that we imagine a world without heaven, hell, religion, possessions and nations but those politics aside, the melody and the words call us to reflect positively on what could be.
My favorite lines are:
Imagine all the people
Living for today...
Nothing to kill or die for
Imagine no possessions
No need for greed or hunger
A brotherhood of man
Living life in peace...
You may say I'm a dreamer
But I'm not the only one
I hope someday you'll join us
And the world will be as one
No need for greed or hunger
A brotherhood of man
Imagine all the people
Sharing all the world...
I hope someday you'll join us
And the world will live as one
Lennon was definitely a Pollyanna. Heaven, hell, religion, war, greed, an emphasis on possessions, and national interests are still interfering with the world living and sharing as one, now more than thirty five years after his death. That world that Lennon imagined probably had no disparities in healthcare that preclude us from realizing the Triple Aim. We have a long way to go to get to our imagined goal. Said another way, we will never have...
Care better than we have ever seen, health better than we have ever known, cost we can all afford, …for every person, every time.
...until we imagine ways to eliminate disparities in healthcare.
This last Tuesday night my wife and I, as well as a few “Interested Readers”, attended the annual roast which is a fundraiser for the Whittier Street Health Center. WSHC is a leading “federally qualified health center” serving the underserved in Roxbury and the surrounding neighborhoods of Boston. I have been proud to be a member of its “Foundation Board” for the last year. The roast honored Regina Pisa, the emeritus chair of the law firm of Goodwin and Proctor, but the key to the evening was that it was a gathering of a large number of people who were, at least for one night, committed to doing something about the social determinants of health.
For me the peak experience of the evening was a nine minute video that showcased the work of Whittier. The caring professionals there are doing as much as their resources enable them to make a difference. The video is also a call for a renewal of our collective actions to give much more focus to how we eliminate the barriers to health that create a 33 year difference in the life expectancy of someone living in Roxbury compared to their more affluent neighbors less than three miles away in Back Bay. I have reported that fact before but it is a thought that I just can not discard.
I wish that the problem was limited to Boston but we all know that it is our collective dirty little national secret. I got no pushback a few weeks ago as I praised the Cuban healthcare system (you should really check out this link) and the comment that overall they have a longer life expectancy than we do in America for a fraction of the expense. The key to their success is a two fold: equity and a strategy that emphasizes the efficiency and effectiveness of primary care and preventative healthcare.
In Cuba the life expectancy is almost 80 years everywhere. It makes no difference where you live or what you have. Everybody gets the care they need. In America life expectancy varies dramatically by neighborhood and by zip code. We have no equity, whether we are looking at the dichotomy of Back Bay compared to Roxbury or the affluent neighborhoods of Houston compared to its notorious “fifth ward”, which is another world trapped between freeways and in the shadows of the impressive towering new buildings of Houston’s robust economy. Our problem is not ignorance of the issues. It is glaring discrepancies in the distribution of our collective accomplishments. There are complete studies on line to serve as indictments of both Houston and Massachusetts. The problem that we name “healthcare discrepancies” is a collection of complex social problems that are interdependent and will require interdependent solutions.
John Edwards will be remembered for his expensive haircuts and his controversial private life that took him from the Senate to obscurity by way of a failed bid to become the nominee of the Democratic Party for President in 2004, but before he flamed out he gave at least one great speech and nailed the concept of “two Americas”. This year’s jousting for the presidency could spawn the concept of multiple Americas. Getting to the bottom of the conversation about the many Americas is beyond my scholarship and would take more words than many multiples of my longest letters, but I do believe the problem is growing. Telling a story may be better than many links to articles on the Internet or references to books you may have no time or interest to peruse.
Driving down to Boston for an event like the Whittier Street Health Clinic gala is also an opportunity for my wife and me to connect with friends and take care of business. I planned to have lunch on Tuesday with a couple of Interested Readers. I was looking forward to seeing Thomas Rice who was a big contributor to last week’s letter and Nathaniel Foote, one of the authors of Higher Ambition: How Great Leaders Create Economic and Social Value and a co author of an HBR article on essentially the same subject that is well worth your reading. We had all worked together on the “Lead” project that Blue Cross generously funded several years ago.
As friends do, we were talking about our current work and activities. Thomas, like me, continues to write in retirement. Nathaniel surprised me with a question that stopped me short. He asked me if I was optimistic about healthcare reform. My first response was to lecture him on the difference between hope and optimism. I have much hope rooted in the marginal accomplishments of the ACA and the shift that is occurring in health care finance from volume to value. I am encouraged by increasing transparency and increasing engagement of patients in their own care. But, I try not to attach a timetable to the full achievement of the Triple Aim. Perhaps I should get a bumper sticker that says that I hope for world peace and…
Care better than we have ever seen, health better than we have ever known, cost we can all afford, …for every person, every time...but not anytime soon.
I was surprised to hear myself say to Nathaniel that despite my hope, my expectations were that we would not achieve that lofty objective in my lifetime. I told him that I was impressed with the slow progress in civil rights that had been made in my lifetime. Post World War II Harry Truman integrated the armed services in 1948. In 1954 Thurgood Marshall argued successfully against segregation in schools before the Supreme Court in Brown v. Board of Education of Topeka, Kansas. Despite the Supreme Court's unanimous decision, the schools in South Carolina were still not integrated in 1970. The high points in the story were the Civil Right’s Act of 1964 and the Voter’s Rights Act of 1965. But despite those powerful pieces of legislation that have made a huge difference that you can see in every restaurant and hotel in the South, race is still a volatile issue over fifty years as the Black Lives Matter movement demonstrates. If Civil Rights and the legislation of the mid sixties are my sources of hope, you can see why I do not see the Triple Aim achieved in the fifteen or twenty years or less that I may still have ahead of me.
The work of the IHI has been important. The successes of many hospitals and medical groups after discovering the power of Lean in healthcare gives me hope for the ultimate achievement in the distant future, but observing the emergence of the “me” generation and the growing bimodal evolution of the two, three or four Americas makes me skeptical and dampens my hope for a quick move to the Triple Aim. What I see around me, despite all of your great efforts, makes it harder for me to tend my small flame of hope.
I think all of our generations are much more focused on self and it is wrong to place the label of “me generation” on “gen y” or “millennials”. Daniel Kahneman tells us in chapter four of his wonderful book on behavioral economics, Thinking, Fast and Slow, that any time we focus on money we focus on self. He gives just the thought of money or seeing money on a screen saver as examples of the “priming effect”. On pages 55-56 he states,
The general theme of these findings is that the idea of money primes individualism: a reluctance to be involved with others, to depend on others, or to accept demands from others.
That statement resonates with my experience. If there is one thing that is on the mind of most people it is money. If success in healthcare is dependent on collaboration, then nothing kills collaboration like bringing up money. Whether it is a discussion of physician comp, the bottom line of a multispecialty group practice, the margin of a hospital or health system or the tax implications of the ACA or single payer finance, concerns about money can block the “I to We” transition, or what African tribal theology calls Ubuntu, a concern for community.
“I to We” is the transition that is core to progress toward the Triple Aim. We can never make progress toward either the elimination of healthcare discrepancies or the Triple Aim without focusing on community. I love the fact that the IHI almost never talks about money. They talk about quality and safety. In Lean we usually talk about eliminating waste and providing value. The unstated hypothesis is that if you focus on the “True North Values”, the money takes care of itself. The increasing complexity and interconnectedness of our greatest challenges are all dependent on collective action and personal concerns about finance make progress on issues like education, employment, housing, and poverty difficult. Without progress on these shared issues we can forget the Triple Aim.
Consider the chart below that shows the proportional contributions to dying before the life expectancy of your community.
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