9 December 2016

Dear Interested Reader,

Inside This Letter and More Conjecture About TrumpCare

Many of my present and former colleagues and many readers of these weekly letters have spent much of this last week in Orlando at the annual IHI meetings. Most years I would have been there but this year I elected to join John Gallagher at the Population Health Colloquium which was held in concert with the National MACRA MIPS/APM Summit in Washington last week. From Washington I traveled to North Carolina to spend a few days with my father, his wife, and my siblings to help celebrate his 96th birthday! I think that I made the right choices.
I hope that you will benefit from reading about the Population Health Colloquium and what I learned from the experience.

It is impossible to separate the subject of population health and strategies to improve the health of the population from concerns about the uncertainty of healthcare policy under the new Trump administration. Last week I wrote about my concerns related to the nomination of Representative Tom Price as Secretary of Health and Human Services and of Dr. Seema Verma to be the Administrator of CMS. If you missed that letter, you can read the most important points in this week’s posting on strategyhealthcare.com. This week I am equally concerned about the President Elect’s nomination of Scott Pruitt, a climate change denier, to head the EPA. That action is actually a blow to population health as well as to a clean environment. It is hard to imagine improved health in the context of rolling back the regulations on clean air and water and reversing most of the gains developing international cooperation on global warming made during the Obama years.

The choice of Pruitt fits a pattern that is disturbing. First, the President Elect meets with a proponent of progress, as he did when he met with President Obama on healthcare and Al Gore on global warming, afterwhich he makes statements that are encouraging and seem in stark contrast to his comments made during the campaign. After those of us who fear a reversal of progressive policies enjoy a fleeting moment of hope for a more rational policy and a better appointment following what we interpreted as an “I see the light” moment for the President Elect, he appoints a zealot for the ugly work of dismantling progress that he promised his supporters during the campaign.

As is true for the appointments of Price and Verma, Mr Pruitt who is currently the Attorney General of Oklahoma and the source of many lawsuits against the EPA, will now require Senate confirmation. Will there be two, maybe three Republican Senators with the wisdom and conscience to vote against a man who will be determined to allow the unfettered use of fossil fuels? One can only hope and pray that such souls exist within that confused confederation that was once the Republican party.

As one thinks about all of the appointments and looks at the formula that they suggest, and it is easy to do so because the New York Times is doing a wonderful job of keeping a running scorecard of Trump’s appointments, one sees an ugly pattern emerging. The cabinet posts and key appointments are not resulting in a “draining of the swamp,” but rather a reinforcement of the forces that perpetuate the outcomes of inequality that provided much of the emotion expressed by Trump supporters.

For those of us who are worried about the future of the quality of care and believe in addressing the issues of the underserved, there is no more potent issue to be faced in the improvement of the health of the population than the fight against economic and social inequality. We have come to believe that the duo of economic and social inequality are foundational causes of almost every one of the social determinants of health. An appointment like the appointment of Scott Pruitt as EPA administrator is a more subtle, but perhaps more significant, barrier to the Triple Aim than the more obviously objectionable appointments of Price and Verma.

I do not know how deeply you care about these issues, but I expect that I have more time to sit and fret over what I read than do most of you who are still working hard everyday to improve care and advance the goals of the Triple Aim where you live and work. Perhaps one service that I might perform for you is to give you links to the best of what I find as I do my own reading. This week I was very impressed by the concise writing of David Blumenthal and David Squires in an article on the Commonwealth Fund Blog entitled “Crossing the Political Chasm”. The article is short and to the point. It makes many of the hopeful observations that I have tried to make over the past few weeks. Another piece worth your attention is the final Senate speech of Harry Reid, published yesterday as an op-ed piece in the NYT. Finally, I would recommend the blog post of the address that Andy Slavitt, the current Administrator of CMS, made to the conference that I attended in Washington.

I hope that you read these articles as well as many of the other links that I try to sprinkle through these notes. First, the links share a duel purpose of giving you the opportunity to develop your own understanding of opinions expressed directly rather than having them filtered through my possible misunderstanding. Secondly, they serve to give attribution for many of the ideas that I am passing along to you. Thirdly, I hope that together we acquire the information that will enable progress from the links.

In this letter, perhaps more than most, I am trying to blend my opinion on the subjects of population health, sustainability and the Triple Aim with the information from the sources quoted, rather than just give you what others are saying. I will also endeavor to use the conversations that occurred at the Population Health Colloquium to substantiate these personal opinions and thoughts. The Colloquium was an excellent experience that was enhanced by being able to share it with John Gallagher. It is my hope that secondarily it will be a source of insight for you.

Thank you for being a faithful “Interested Reader”. Without you there would be no point or purpose to this exercise. As always, I look forward to hearing your thoughts and comments.

Population Health, Sustainability and The Triple Aim

Perhaps the origin of the greatest challenges of the last twenty years to the traditional practice of medicine and to physicians in general has been the introduction of the “radical” concept of population health. One could argue that the Affordable Care Act is the legislative expression of the tenets of population health. One could also argue, as I will, that sustainability and the Triple Aim can not be achieved without a robust foundation in the ever expanding understand and practice of the methodologies of population health. Perhaps the most proximate target of the new administration, as it attempts to fulfill its promises to the base that led to its election, will be the dismantling of CMMI, the innovation lab for population health created in concert with the ACA.

I reported last week that more than 60% of the physician respondents to a poll conducted by Medical Economics were happy about the impact on their practices of the election of Donald Trump. Does that mean that a lot of doctors are celebrating the imminent demise of the ACA and its focus on population health mechanisms like ACOs and the payment for value rather than volume? Many of us who are interested in healthcare policy and the goals of the Triple Aim forget that the majority of practicing physicians work in either privately owned practices or hospitals where they conceptualize their role as the healers of existing disease. I have facetiously said that their primary interest is “repair care”. I will risk offending many by saying that my conversations with many physicians and healthcare professionals suggest that we have not reached a tipping point where the majority of the industry has accepted that it is their responsibility, indeed that it is in their best interest, to promote the principles of population health.

Many realities and barriers in healthcare can be traced to healthcare finance and fee for service practice. The ACA was a step away from traditional practice and a step toward practice and care delivery built on principles of population health. Until the introduction of “pay for performance” and contracts with bonuses for quality there was little or no reason for most physicians or healthcare professionals to think about population health or the sustainability of access. The financial sustainability of their practices and institutions was their primary concern. For them their personal sustainability was a function of revenue and revenue was a function of volume. When you are producing volume the idea of worrying about collective sustainability becomes about as logical as the idea of a coal producer worrying about global warming.

I can remember thinking twenty five or thirty years ago that although public health was an important concern, it was not my concern. My concerns were the patient in front of me and the problem that they were having that day and the viability of the practice that paid me. If you had pushed me, I would have said that I thought it would be great if more people had health insurance and access to me so that my practice could grow, but I would have not seen it as my responsibility to do anything to make that happen. I would have acknowledged that the combination of my compensation and the resources that I used to do the good that I did for my patients constituted an expense, but my expectation was that when a patient was in front of me that expense was not my concern. My concern was fixing the problem or answering the question that the patient presented.

In truth I wanted to work in a smaller world where I could focus on what I thought I had been trained to do, which was to deliver care. I had joined a group practice to focus on practice, not healthcare economics or the issues of a population. Resources, access, sustainability, public health concerns, what we now call the “social determinants” of health, all were the responsibility and concern of others, not me. I had enough to do just staying current in my field and providing what I considered to be quality care to my patients.

I felt confirmed in my position because I had the luxury of only listening to those grateful patients who thought I was a wonderful doctor and were delighted to be my primary focus. It was not until I realized that the world I valued was unsustainable that I began to listen to the voices of those who were more insightful. People like Don Berwick had begun the conversation about quality and safety, the challenges of equity, and giving every person quality care in a way that improved the health of the community using sustainable resources. Only then did I begin to realize that I needed to be a part of the conversation for the sake of the patients whose well being was the point of my professional purpose. I was beginning to connect the dots and the process convinced me that I had a lot to learn if...

Care better than we’ve seen, health better than we’ve ever known, cost we can afford…for every person, every time…

was to be a goal that could be reached with a sustainable effort.

I think that many of our colleagues in healthcare today are not far from the comfort of the position that I enjoyed thirty years ago. If they are not comfortable now, they long for that comfort that they think they can remember before all the hostile externalities of healthcare finance seemed to be exacerbated by the passage of the ACA. I suspect that for many the phrase “Make America Great Again” translates into “turn healthcare and medical practice back to where it was before all these people preaching quality, universal access, healthcare equity, improved outcomes, patient centeredness and other tenets of population health ruined the business and made my life unsustainable.” PCMHs, ACOs, MACRA, Meaningful Use, Big Data, roster reviews, patient advocates, hundreds of quality metrics, preauthorizations, and dysfunctional EHRs have nothing to do with why they went to medical school. Some will say, when trying to figure out their relationship to the “social determinants of health,” that those are problems for social workers, bureaucrats and politicians, and not their responsibility. There was a time when I would have agreed.

I fear that many in healthcare do not really understand what we mean when we begin to talk about population health. For me population health is a collection of concepts, data based tools that require new competencies, and insights that are fundamental to all three legs of the Triple Aim. Ironically the ultimate goal of population health is a better understanding of how disease, economics, the environment, culture, other defects in society like housing, education, and employment interact to affect the health of both the population and individuals within the population that best describes them. Success requires greater engagement of each individual patient and more effective interactions between clinicians and systems of care delivery. There is no hope without consensus or “social solidarity” around the efforts to improve the social determinants of health. The beginning premise of improvement in the health of the population is universal access to efficient and effective care.

David Kindig discusses the breadth of the concept and how difficult it is to understand the scope of population health in a posting from HealthAffairs entitled “What Are We Talking About When We Talk About Population Health?” Kindig actually proposes two definitions! Most important though is his emphasis on the relationship between the Triple Aim and population health.

The Triple Aim And Population Health Management

In particular, its promotion by the Institute for Healthcare Improvement and the Centers for Medicare and Medicaid Services has led many healthcare organizations to use it to describe the clinical (often chronic disease) outcomes of enrolled patients. And many clinicians and medical managers have begun to use the terms population health management or population medicine. For example, the Symphonycare website defines population health management as “the iterative process of strategically and proactively managing clinical and financial opportunities to improve health outcomes and patient engagement, while also reducing costs.”

I present this information in part to justify the confusion that many in healthcare have about population health while simultaneously arguing that your personal professional future and the future and success of your practice or institution will be functions of your ability to understand and employ the concepts of population health. More important is the fact that the sustainable resources that your patients need for you to have to serve them will be largely determined by your understanding and effective implementation of population health based innovations.

David Nash, MD, MBA is the founding Dean of the Jefferson College of Population Health at the Thomas Jefferson University in Philadelphia. Dr. Nash is also the lead author of Population Health:Creating a Culture of Wellness and was the organizing force behind the conference John and I attended. As the title of the book suggests, Dr. Nash and his collaborators believe that extracting the benefits of a focus on population health is dependent upon a “culture of wellness”. As I think back on my early practice experience, I realize that when I say we were focused on “repair care” I am indicating that we functioned in a culture that focused on illness. Dr. Nash explains:

The population health movement has gained momentum over the past decade, particularly since the passage of the Patient Protection and Affordable Care Act (ACA) and the subsequent implementation of programs aimed at improving the health of the population. In terms of national statistics, population health remains a daunting challenge: however, some practical application of its tenets by companies and organizations across the country show great promise. By enveloping population health in an environment that supports its delivery and sustainability, benchmark cultures of health and wellness are appearing throughout the country...

As you might expect, the discussions at Dr. Nash’s conference, including the keynote address given by Andy Slavitt, the Administrator of CMS and CMMI for the last two years, were greatly different in the context of the election than what anyone was expecting when the conference was scheduled. As a group we needed to review the veracity of what we had believed to be true before the election to determine what was likely to be true after the election. In my heart I know that elections do not determine truth, but I do believe that they can impair implementation of insights based in uncomfortable truths and realities. Slavitt’s speech deserves some review, and just to make it easier I will lift a few key passages.

In reference to the implementation of MACRA Slavitt said:

• We heard the deep dedication that both patients and clinicians have to the Medicare program, but also the many frustrations.
  
• We heard from clinicians who challenged us to prove that MACRA and the Quality Payment Program wasn’t one more check-the-box program and instead allows them to focus on care and quality improvement
  
• We heard from physicians who are fed up that their EHRs do not support patient care. Clinicians want technology that make their jobs easier, match their workflows, and give them access to needed data.
  
• We heard patients who were tired of lugging around or repeating their treatment history — who wanted more time with a physician who knows them personally, so that they can get the right treatment at the right time without unneeded repetition or miscommunications.Our challenge isn’t about accountability or quality or costs or whatever euphemism people use. It’s to recognize that the path forward isn’t through any one model or new three-letter acronym or quick fix, but by addressing the basic things, which lead to bad outcomes, physician burnout, or for patients, particularly needier ones, to feel displaced and not get the right care.
  

At the end of his speech after defending the accomplishments of the ACA, detailing the contributions to the Triple Aim, and describing how CMS is trying to implement MACRA he turned his attention to some recommendations for the future. He is concerned about the potential loss of CMMI as an innovation asset. The bolding of phrases is my attempt to bring certain points to your attention.

So how do I suggest we tackle the next opportunities?

One. Build from a foundation of progress, not head backwards. There can be no delivery system reform without building on the foundation of reaching universal coverage. That means building on the record 20 million people who have newly found coverage and continuing the security and protections Americans have found, including no-cost preventive care, the elimination of lifetime and annual coverage limits, and the end of pre-existing condition exclusions. If we want to fix how care is delivered, so that we’re providing value, then we must ensure that Americans can afford and access quality care at every point in their lives. If we lose even some of the coverage gains made under the ACA, or leave people in limbo, people will lose access to regular care and we will drive up long-term costs. This doesn’t mean we shouldn’t improve how coverage works in a bipartisan fashion. We must always do that and we should now as new leaders bring new approaches and solicit new ideas.

Two. Insist that modernization of Medicare must actually mean modernization. Progress is achieved by ingenuity, innovation, teamwork, and the use of data and technology, not by changing funding formulas.

I’ll say this bluntly: MACRA can’t work as well without a CMS Innovation Center that can move quickly to develop and expand new approaches to paying for care. With changes to the Innovation Center, the advanced alternative payment approaches could slow significantly. We will have a much narrower path with fewer specialty options and approaches, which take in patient and physician feedback. Medicare and commercial payers would then fall further out of alignment, and more importantly, less patients would have access to innovative care methods.

Three. Start to demand technology that can exchange data, that supports care, and that is affordable…. For a variety of reasons, EHRs became an industry before they became a useful tool. The technology community must be held accountable by their customers and make room for new innovators and to give clinicians more freedom and more flexibility to focus on their patients, to practice medicine, and deliver better care....

Four. Don’t forget that people are the heart of every policy made. We are on a journey as a nation towards better health for all. Patients. Care givers. Consumers. You know them better than anyone because you care for them. View MACRA as a step in the journey to develop care together.

With those words he departed for his last fifty days leading change rooted in the principles of population health at CMS and CMMI.

After returning from Washington early this week I did not expect to have my own insights about the relationships between population health, sustainability and the Triple Aim to be underlined by a conversation with a recent college graduate. I had been asked by a friend if I would have a conversation with the daughter of a mutual friend. This young woman had done an internship with a power company and had done coursework in college that had stimulated her interest in the principles of sustainability.

It was a fabulous conversation as we discussed the reality that as we yearn to expand the opportunities enjoyed by the majority of Americans to all Americans and throughout the world, sustainability of our resources become an issue that can be a guiding concept or a monumental barrier. We attempted to trace how an interplay of technology, innovation, social solidarity, the ability to search for “non-zero” solutions and the realities of resource limitations bring us back to the same set of concerns whether the subject is energy, the environment, healthcare, education or equitable economic opportunity.

We also realized that the hoarding of resources, whether they be sources of energy, access to healthcare or the more material benefits of our production capabilities, is a losing strategy even in an authoritarian society. History suggests that the needs and problems of the marginalized and underserved can only be avoided for awhile before even the affluent and well served see the benefits they enjoy at risk. That is what I had discovered in my own professional life. I became open to and engaged in the exploration of the benefits of population health and the Triple Aim because in the end any other philosophy is unsustainable.

Walking the Mall

Before we went to Washington last week, John Gallagher and I had planned that we would use our free time to get in a few good walks. When in Washington I walk on the Mall, if my hotel is anywhere near that national treasure. Whether I am there to take in the cherry blossoms in April, be witness to hundreds of softball games and soccer matches during a summer evening, or endure a chilly drizzle after sunset on a late fall evening just to get in my 10,000 steps, I have never been disappointed by a walk on the mall.

If I am lucky, my hotel is not far from the Capitol. I like starting even better above the dome near the Supreme Court Building and then walking west toward the Washington Monument and Lincoln Memorial. I pass around the Capitol either on the north along the Russell Senate Office Building or pass on the south side going by the Rayburn Building which is one of several buildings where members of the House have their offices. Once I am past the Capitol the next landmark is the Washington Monument.

After the Washington Monument, the next significant stop is at the World War II Memorial. From there it is a walk toward the Korean War Memorial and the Memorial to Reverend Martin Luther King, Jr. on south side, or I head to the north side of the reflecting pool to visit the Vietnam Memorial before approaching the Lincoln Memorial.

As I come up the long stairway to the monument I try to remember the “I Have A Dream Speech” that Doctor King delivered in August of 1963, or the Poor People’s Campaign that Dr. King was planning before he was assassinated in 1968 and that Ralph Abernathy completed. I remember my experience of driving through the squalor of Resurrection City which was a 3,000 person encampment that persisted on the Mall for six weeks after the march. Even though there leader was dead, the people in Resurrection City on the Mall were there as part of a moment when Dr. King would go beyond issues of race to include all poor Americans. In his words:

“We are tired of being on the bottom. We are tired of being exploited. We are tired of not being able to get adequate jobs. We are tired of not getting promotions after we get those jobs. And as a result of our being tired, we are going to Washington, D.C., the seat of our government, to engage in direct action for days and days, weeks and weeks, and months and months if necessary, in order to say to this nation that you must provide us with jobs or income.”

The intent of his idea included America’s poor of all races. He was describing a situation that persists and will ultimately be unsustainable. He challenged the idea that anyone in America should be poor. One wonders, “What if…”

I always stand in front of Lincoln’s statue and try to absorb the majesty of the place and find that I cannot avoid wondering how history might have been different if only… and think about “Abraham, Martin and John.”

This week’s header was obviously snapped from in front of the incredible marble representation of the Sixteenth President. It is his view. Add 250,000 people on a hot August day and it was Dr. King’s view. Fast forward five years to 1968 and let the scene be filled with makeshift shanties and tents and it is a view of Resurrection City.

This is a view that shows us where we have been and continues to be a place where we can visit like a great outdoor national cathedral to imagine and pray for a future that might be a manifestation of the dreams of our mothers and fathers and the hope that we try to maintain for our own children. It is a good place to go. A walk on the Mall is a form of pilgrimage that is good for the whole self. John and I enjoyed a wonderful conversation about “what could be” in an era of recommitment to the idea of universal equity as we walked in a drenching rain that added a little “baptism” to the walk back to the hotel.

Whatever the weather, wherever you are, I hope that you will get a little exercise this weekend to give you some strength for the work to come. We can all benefit by the renewal to propose that a good walk might catalyze.