9 March 2018

Dear Interested Readers,


The Chaos Continues in Trump’s Washington, but...

I still read the Boston Globe everyday but it is not my main source of information. It’s the obits and sports pages that are my primary focus. Rarely does an editorial or a piece by an op ed writer grab my attention, but yesterday was different. Just before I began to write this piece I happened to click on the Globe’s “Opinion” section and was pleased to find an article of interest. It was written by Diane Hessan who is “an entrepreneur, author, and chair of C Space.” She has been in conversation with 450 voters across the political spectrum weekly since December 2016. Her piece is entitled “Burnout in Trump’s America.”

She has recently made a simple request of 450 people who represent all points of political view, “Tell me how you are doing these days.’’ She reports that the universal answer suggested that following the chaos and confusion in Washington over the last year had left them all burned out. To prove her assertion the article is stuffed with quotes from people of all political stripes:

A Republican man from Nebraska says, “I am just freaking exhausted from the constant stress in our country. I mean, how much more screaming and yelling can we take?’’ A woman from North Carolina who voted for Trump because she was desperate for change now says, “I have never been so sick of politics except for when my father and great aunt argued over Watergate many, many years ago.’’ Hessan reports that the woman is turning off her TV, paying less attention to social media, avoiding political conversations with her co-workers, and hoping that it all gets better. The lady continued, “I supported Trump, but had no idea that he would be soooo unpresidential. I knew he wasn’t a politician — which I felt we needed — but he was not my first choice. While I don’t like political correctness, I do expect a higher maturity level and better verbal restraint. Trump went from being tolerable to just annoying and embarrassing, and that has added to my fatigue.’’

A Democrat from California named Arnold said, “Trump says something that I think is racist, and then I turn on the TV, only to be subjected to panels of pundits arguing about whether it is racist or not. It’s madness.” Hassen quotes a Republican woman from Indiana, “It takes tremendous energy for me to keep everything inside, and I worry that someday I will be at work and lose my job when I just explode with frustration. I saw it last week in a nice restaurant when some woman just completely lost it.’’

Hessan believes that some people, like a Democrat from my state, are doing better than others and are not blaming the dysfunction of the moment entirely on the president, but nevertheless express their unhappiness with expressions like: “I am disappointed in Trump, but also increasingly disappointed in the country as a whole. While I did not vote for Trump, I don’t think the Democrats should be rewarded for simply being the lesser of two evils. We just lack courageous leaders across all institutions in this country. I think our country doesn’t have a soul, few know what sacrifice or service really is, and most care (and vote) for what’s in their personal best interest. Honestly, I feel increasingly isolated because I don’t just go along with it.’’ Across the country a Republican from Utah said he was depressed, and he blames “our boorish president,’’ and expanded his blame across the aisle: “The Democrats are being as combative as he is. Something has to change or we will be in this cycle for a long time.’’

Hessan sums up her findings and relates what she sees in the country to the sort of environment in a business that is the origin of burnout at work.

... voters see the same thing in politics: Most believe that the culture of America — and much that we hold dear — is eroding. In the absence of leadership that wants to bring us together, most wonder whether it’s worth being engaged anymore or whether their voices even matter. They stick with people who agree with them, media that reinforce their point of view, and look down at their iPhones for comfort. They lose the initiative and energy to research whether their news is fake. They find it easier to focus on Stormy Daniels than the storm in Syria. They are increasingly aware of their own passiveness — and they worry about what this means for their children.

She is not pessimistic and offers a solution:

While the extremes get the airtime, two-thirds of the voters I speak with report that they are becoming more moderate and walking away from the unbending opinions they once held….If America is to retain its stature as a world leader and its image as a land of opportunity for its citizens, it must regain that vitality and unity of purpose. Just as with any organization, culture change won’t come from the extremes, from partisan wrangling, or from more screaming back and forth. It will come from changes in the attitudes, practices, and values of the top team, starting with those in the Oval Office, the Cabinet, and Congress. It will come from the same sorts of actions any organization would take in the face of burnout: more dialogue, more listening, more compromise, and leaders who are committed to a new way of renewing our collective energy.

This last week was a busy week on the Washington news seen. Those of us who love to wave a Puritan finger at the amazingly puerile behavior of the president got a few chuckles from the persistence of “Stormy Daniels” who seems to have some stories or perhaps embarrassing pictures she wants to share with us if she can just prove that her non disclosure agreement was invalid. More importantly the saga of youthful outrage following the Marjory Stoneman Douglas High School shooting continues and the Florida Legislature finally did slightly violate the will of the NRA, passing something that probably is only the beginning and not the end of what we must do to end our national tragedy of gun violence that is built on an ridiculously expanded and distorted interpretation of the second amendment. It was a start.

It is hard to know what to expect from the proposed talks in Korea. Was it the saber rattling of the president, his equivalent of Dirty Harry’s “Make my day!” that produced what may be a breakthrough, or was it the attitude of the South Koreans at the Olympics or some strange confluence of many events and a weariness that must exist across all of the Korean peninsula with living on the edge of destruction?

The president has given us another gift this week. We are all more knowledgeable about the pros and cons of tariffs and trade wars than we were two weeks ago. We now can see a little daylight between Speaker Ryan and the president. Will that crack of light widen or will the door be shut? One door that was opened even wider this week was the one leading out of the White House for everyone. Gary Cohn and Hope Hicks said their goodbyes, and apparently it won’t be long before General H. R. McMaster “seeks other opportunities.” Will General Kelly, Jeff Sessions and Rex Tillerson hold the fort, or will they be out the door soon, leaving a wounded Jared and Ivanka to guide the guider of the ship of state? I wonder if there will be little gatherings in the West Wing in honor of Hope and Gary with thank you speeches and the passing out of little gifts representing good wishes for future endeavors?

Within the cacophony and chaos I almost missed what may prove to be the biggest event of the week, the speech that our new Secretary of Health and Human Services, Alex M. Azar II, gave to the Federation of American Hospitals on Monday at a small gathering in a Washington Hotel. Perhaps this speech should be viewed as the most important event in healthcare since John McCain turned down his thumb to block the effort to repeal and replace the ACA, or for that matter, since the passage of the ACA.

I was startled by the report of Secretary Azar’s speech that I heard on NPR as I was heading North late Monday afternoon on my drive home from the Manchester airport, the last leg of my weekend trip to North Carolina. I consider it a miracle that I caught the quote that NPR led with from the last lines from the speech:

I assure you: Change is possible, change is necessary, and change is coming.

Without the capture of my attention by that bold statement on NPR it would have been easy to cynically blow off the speech as just another meaningless diversionary expression of a governmental agency that has been taken over by business interests with the intent of maintaining the status quo. Because of those last words I was curious to find out just what led to that pronouncement.

Thankfully, NPR and Kaiser News Service did report on the event since I can’t find evidence that it was picked up by the New York Times or the Washington Post. Politico provides links to both the video of the speech and the transcript and points out how it is aligned with President Obama’s goals, even as Azar says it will happen because of the determination of Donald Trump. I say great to both positions because the way forward is about agreement and not contention over whose ideas dominate.

In the main section of this letter I ask if Secretary Azar’s speech is an inflection point. Was it a moment after which everything will begin to change? That is what he announced knowing full well to expect pushback and resistance. Perhaps this is a Republican take on Don Berwick’s Era 3. There are certainly similarities. We shall see.


Did Someone Quietly Turn A Page in the History of Healthcare Reform?

Several years ago, it was actually back in 1993 when the Republicans joined force with many in the healthcare industry to defeat the plans for universal coverage put forth by the Clintons, I said somewhat facetiously to some colleagues and friends that we would not get universal coverage and healthcare equity until the Republicans decided that it was good for business. I was using Nixon and Kissinger’s opening of China as a reference point. Richard Nixon came to power stonewalling Communism in every conceivable way. The Nixon of the mid fifties would have been flabbergasted by the Nixon who went to China in 1972. In 2006 when Chapter 58 (Romneycare) was passed during Mitt Romney’s governorship of Massachusetts, I said, “See there, I told you so! The Republicans will block all Democratic efforts to improve healthcare until there is a business case they can see.” That thought came to mind again this week as I heard and then read the speech that Alex Azar, the Secretary of HHS gave to a meeting of the Federation of American Hospitals in Washington.

Before reviewing the secretary’s speech let me give you some orienting information. First, Secretary Azar is the second HHS Secretary of the Trump years. You may have already forgotten the very forgettable first secretary, former Congressman Tom Price who was an orthopedic surgeon who had held Newt Gingrich’s old seat from the northern Atlanta suburbs before his appointment. Dr. Price got distracted from his main assignment of cutting the legs off the ACA by making investments in healthcare companies and flying around in private jets at the taxpayer's expense. Secretary Azar’s appointment was resisted by Elizabeth Warren and other Democrats because he was the President of Lilly USA, LLC, the largest division of Eli Lilly and Company, and she feared that he might want to do the type of job at HHS that Secretary Pruitt was doing at the EPA. One positive in his favor was that he had been at HHS for six years under Sec. Mike Leavitt in Bush 43’s administration. He was the Deputy Secretary of HHS for his last two years between July of 2005 and August of 2007.

The speech was given at a meeting of the Federation of American Hospitals which is a trade group, essentially a lobbying organization, representing more than a thousand “investor owned” hospitals. The CEO of FAH is the famous Chip Khan, who is generally credited for producing the “Harry and Louise” television crusade that sank the Clintons’ healthcare initiative back in 1993. I once had the interesting experience of meeting Mr. Khan. At the time I thought he was an intelligent man with a good sense of humor who saw the world very differently than I did, although he was influential in the passage of the ACA. To say the least, he is an interesting and complex man, as it appears is true of Secretary Azar.

Finally, I want to bring your attention to an important opinion piece recently published in HealthAffairs by David Blumenthal and James Morone. You can access the article through the Commonwealth Fund blog. Blumenthal is the President of the Commonwealth Fund and the blog is one of the best in healthcare. Together with Morone, a professor of political science at Brown, Blumenthal published The Heart of Power in 2009. At the time Robert Reich wrote in a New York Times review:

The alternative proposal, starting with Eisenhower, was to create a market for health care based on private insurers and employers; he locked in the tax break for employee health benefits. Nixon came up with notions of prepaid, competing H.M.O.’s and urged a requirement that employers cover their employees. Everything since has been a variation on one or both of these competing visions.

Their book took the saga of the evolution of healthcare up to 2009 as the story of a dance forward between Democrats and Republicans. The story they told was much more complex and informative than my overall assessment of “it will happen when the Republicans are ready.” The article this week continues the theme and shows how the dance has continued at a slower tempo since 2010. The ACA is clearly an evolved form of the “Public/Private” partnership constructed along lines first proposed by Eisenhower as a response to the government managed system favored by Truman. Through the years and many variations of tempo in the dance, we have slowly moved forward toward universal coverage and the Triple Aim. The cost of our progress has been huge and the burden has made many want to abandon the effort as unsustainable rather than as an indication that a new approach is warranted. In their current essay Blumenthal and Morone ask whether or not the music has stopped and the dance is over. In the last lines of the HealthAffairs article which can be accessed through the link, they express some hope that it is not. Perhaps Secretary Azar’s speech confirms that the music is still playing.

Coverage expansions have occurred incrementally-- some might say chaotically-- with stops, starts, and occasional backsliding. But they have continued across the 70 years since Truman refuse to admit defeat. In his memorable speeches, Martin Luther King Jr., paraphrasing the Unitarian minister and abolitionist Theodore Parker, noted that the arc of the moral universe is long, but it bends towards justice. The arc of history is indeed long. At least for now it continues to bend toward coverage.

I have watched the speech which begins about 15 minutes into the video and read the transcript. Azar followed his prepared remarks almost verbatim.

After thanking the FAH and Chip Khan for the chance to speak, Azar assures his audience of the president’s commitment to the private sector part of the Public/Private Partnership.

One of the key commitments President Trump has made across this administration has been to see the private sector as our partners, not as just entities to be regulated or overseen….We at HHS see stakeholders, including our nation’s hospitals, as part of the solution to our country’s many healthcare challenges. We recognize that it’s not just government that wants better healthcare for all Americans. Our partners in the private sector, all of you, want the same.

He then references all the accomplishments of medicine over the ten years he was away form HHS. He observes:

But innovation in payment and delivery systems is simply not proceeding at the same pace... on the delivery side, back in the 2000s, shifting to a value-based system was just getting going as well. And yet here we are today — more than a decade later — and value-based payment is still far from reaching its potential.

For over a decade, we have been on a journey to replace that equation with a new one — paying for outcomes and wellness — but that transition needs to accelerate dramatically.

At this point I am asking myself if he found an old speech of Don Berwick’s in a draw at HHS. He goes on to paint a picture of his view of a future when healthcare “functions the way other parts of our economy do.” He disagreed with the idea that healthcare was “different.”

• Patients would pick providers with the level of information we have when using Amazon or Yelp. 
  
• Consumers would drive quality and cost-effectiveness with information, competition and genuine choice.
  

He sees “Value-based transformation” of our entire healthcare system as one of the top four priorities for his department.

The list:

1. “Value-based transformation” 
2. Combating the opioid crisis
   
3. Bringing down the high price of prescription drugs
   
4. Addressing the cost and availability of insurance, especially in the individual market.
   

He notes that

... “Value-based transformation” has been a frustrating process: Providers have been understandably reluctant to charge into a completely new payment paradigm. Massive new processes and data-gathering requirements have been instituted, without any fundamental changes to our delivery system. Results for the early stages of federal efforts to encourage accountable care organizations have been, to be honest, underwhelming.

...This administration and this President are not interested in incremental steps. We are unafraid of disrupting existing arrangements simply because they’re backed by powerful special interests.

Here is the four step plan of action:

1. Give consumers greater control over health information through interoperable and accessible health information technology
   
2. Encourage transparency from providers and payers
   
3. Use experimental models in Medicare and Medicaid to drive value and quality throughout the entire system
   
4. Remove government burdens that impede this value-based transformation.
   

At this point I am wondering if perhaps someone has shown him the papers that President Obama wrote in JAMA and in The New England Journal of Medicine in 2015 and 2016 suggesting how the ACA could be improved based on the experience of the first few years.

The next statement definitely is a business twist on Ideas going back to Crossing the Quality Chasm. I am convinced that this guy is a reader and understands how to use the PDCA cycle.

The key theme uniting these four priorities is the recognition that value is not accurately determined by arbitrary authorities or central planners. It is best determined by a marketplace of many players — in the case of healthcare, patients and, where necessary, their third-party payers. Each piece of our plan for value-based transformation recognizes this, and it’s the main reason I am optimistic that we may have more success, and sooner, than past efforts.

But I want to emphasize that this will not necessarily make the process easier, and certainly not more painless. Putting the healthcare consumer in charge, letting them determine value, is a radical reorientation from the way that American healthcare has worked for the past century.

That last sentence is a restatement of the IHI concept of asking patients “what matters to them” as the next step up from “patient centered.”

Like a good clinician he tells us it will hurt a little and will not be easy. It will even be “disruptive.”

In fact, it will require some degree of federal intervention — perhaps even an uncomfortable degree. That may sound surprising coming from an administration that deeply believes in the power of markets and competition. But the status quo is far from a competitive free market in the economic sense of the term, and healthcare is such a complex system, that facilitating a competitive, value-based marketplace is going to be disruptive to existing actors.

Simply put, our current system may be working for many. But it’s not working for patients and it’s not working for the taxpayer. Today is an opportunity to let everyone know that we take these shifts seriously, and they’re going to happen — one way or another.

He proceeds by announcing that changes in health IT will be foundational. Interoperability and the patient’s control of all the medical data is a priority.

—unless we put this technology in the hands of patients themselves, the real benefits will never arrive.

He wants the patient record to be used as easily as Open Table.

Patients ought to have control of their records in a useful format, period. When they arrive at a new provider, they should have a way of bringing their records, period. That’s interoperability. The what, not the how....Putting patients in charge of this information is a key priority. But if we’re talking about trying to drive not just better outcomes, but lower costs, we also have to do a better job of informing patients about those costs.

He tells a story about how his doctor ordered a test to be done in the hospital. It was going to cost $5,500. He worked through all of the issues and found that as an outpatient the test was available at $550. He then asks the key question that raised my hopes and won me over until he does something to prove that he was just “faking it.” I am gullible, but I am desperate for him to be the real deal.

Now, there I was, the former deputy secretary of Health and Human Services, and that is the kind of effort it took to find out how much I would owe for a procedure. What if I had been a grandmother? Or a 20-something with a high-deductible plan?

So this administration is calling on not just doctors and hospitals, but also drug companies and pharmacies, to become more transparent about pricing and outcomes of their services and products. And if that doesn’t happen, we have plenty of levers to pull that would help drive this change.

Listening to him I said, “ That is a threat! He is throwing down the gauntlet. He is serving notice. This may be real. He must think that he holds the cards to make things happen.”

He then got into the “how.” HHS will use their control of Medicare and Medicaid to drive changes in the commercial market.

The third piece we’re looking at is using Medicare and Medicaid to drive the value-based transformation of our entire health system.

In addition, as we all know, commercial payers mimic the fee-for-service payment systems that come out of Medicare. If we don’t change those, nothing will change.

Since MACRA was passed I have been saying to anyone who will listen, and you have read it in these notes, fee for service will end. He now has his hands on the steering wheel and his foot on the accelerator. He plans to maximally use the gears he has to pull the load of healthcare along to where it must go.

We already have a range of tools for using these programs to pay for value, many created by 2015’s MACRA legislation. The Center for Medicare and Medicaid Innovation, alongside these tools, vests HHS with tremendous power to experiment with new payment models.

He implied that risk will be demanded of providers. There will apparently be no more shared savings without vulnerability to cost overruns. His plan acknowledges the burden of reporting many metrics and restrictive impediments to innovation that many federal regulations foster. In this part of the talk he does sound “Republican” but perhaps his point are true.

As a matter of principle, we want to move to a system where we can be agnostic about ownership structures, a system that will allow independent providers to group together to drive innovation, quality, and competition.

This brings me to our fourth key engine for transformation: addressing any government burdens that may be getting in the way of integrated, collaborative, and holistic care for the patient, and of structures that may create new value more generally.

He ends with a discussion of “why” that may resonate with the Triple Aim. He even suggests that the program will be driven by the empathy that the president has for “working class Americans.”

I want to end by laying out why I’m so optimistic that we can tackle these long standing priorities under this administration. First, the time has simply come — as costs continue to skyrocket, the current system simply cannot last.

But it is also because this administration is unafraid of disruption in the way many political actors are. President Trump is a man of courage and vision. He has seen and heard how the high cost of healthcare is burdening working-class Americans, and he has given us a mandate to do something about it.

I was a little worried by what was left out of that last statement. Does the president’s purported concern for “working class Americans” spill over to include all Americans? Does Azar read the quote from Hubert Humphrey that is carved on the wall of the looby near the elevator to his office?

It was once said that the moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; and those who are in the shadows of life, the sick, the needy and the handicapped.

I would have loved him to confirm that sentiment, but I am willing to watch open mindedly as he makes his effort. He has an aggressive agenda and he ends with a big dollop of reality balanced by a threat.

This won’t be the most comfortable process for many entrenched players. But those who are interested in working with us to build a value-based system will have the chance to take advantage of a market where consumers and patients will be in charge of healthcare. We believe that is a system that will serve patients first, but it will be fair for providers and payers, too.

Change represents opportunity, and I exhort all of you to take advantage of the opportunities represented by what I’ve discussed today. Because I assure you: Change is possible, change is necessary, and change is coming.

If things are going to change and change quickly, are you ready, or will the switch in direction Secretary Azar describes and says is coming soon leave you, your colleagues, your practice, your hospital, your health system “dazed and confused?” The sudden emergence of a process that has been a long time coming always catches the defenders of the status quo flat footed. Secretary Azar seems to have taken a page from my old coach who loved to say, “Lead, follow, or get out of the way.” Indeed, change may be coming. Should I remind you of how the world changed after Nixon’s trip to China?


Let It Snow! Some More

The “header” for this letter was taken just as the storm began late Wednesday afternoon. It had been great to get my Wednesday walk in on dry roadways. After my walk I was moving enough firewood from the woodshed to my deck to get us through the next forty eight hours. It was a cogent move because by yesterday morning we had more than a foot of new snow and it was still coming down.

The first flakes of our much heralded “nor’easter” were just beginning to fall when I snapped the picture. The weather experts on television had been delivering their pre storm advice for over two days with all the excitement and enthusiasm of “red carpet” interviewers on the runway at the Oscars. I got my picture just in time because thirty minutes later the only thing visible was a wall of white. The distant shore was erased by flakes being dumped from the sky at a rate of two to three inches per hour. The waves of snow over the ice on the lake that you can see in the picture were the residual from previous dumps and had been whipped up into the appearance of surf by the stiff breezes that were the leading edge of the storm that was about to burst onto my scene and block my vision with an opaque white wall. Despite several days in the forties, and one or two in the fifties, my guess is that the ice under those beautiful waves is still over a foot thick, if not more.

We have had a significant snow cover since early December, but it had come in small servings of three to six inches. Surprisingly, this early March treat was the first greater than twelve inch dump. I love big storms. Perhaps my love for the white stuff is because where I lived as a child two inches of snow was a once in five years event. The daddy of all of the “nor’easters” in my experience was the “blizzard of 78.” As that storm began I offered a colleague a ride home to save her a ride on the subway followed by a long walk. I was driving a little rag top TR6. It took us two hours to go the five miles to her house, and another couple of hours for me to cover the final three miles from her house to mine. The roads were like bumper cars in a parking lot. My little British beauty had not been built with that sort of challenge in mind. When I got home I was as elated as I would have been had I summited Everest. But that was an early February blast. I also have a fond memory of two dumps of more than twenty inches a piece that occurred separated by only two days in late March during the winter of ‘69. I remember walking up the front walk of a friend where the snow on either side of the walk was as high as my armpits, and I loved it.

I will really enjoy walking in my winter wonderland this weekend while dreaming of Opening Day at Fenway Park which is now less than a month away. Just as much as I enjoyed the curtain call of winter, I am hoping that at 2 PM on April 5th it will be at least 70 with a clear sky as I settle into my seat a few yards from the basepath to first and begin the journey to fall with the Red Sox. I hope that this weekend you will also be out and about getting in shape for the Spring and Summer which may come with just as much rapidity as the storm on Wednesday afternoon.