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Population Health-If Not Now When?

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“The Big Blanket” Published 1991 Baptist Medical System, Little Rock, AR

Population Health- If Not Now, When?

Gordon Hawthorne, JD

SantaFeSabbatical.com

A fatigued US healthcare system and workforce tetter on the brink as they heroically care for citizens infected by this pandemic. The NYT reports “a nation numbed by misery and loss” as we surpass the half-million mark of US deaths from COVID 19. “Black, Hispanic, and Native American COVID-19 cases and deaths exceed their share of our population.” Hospitals continue to be pushed to their limits.  Average life expectancy in the US drops again in 2020. “Gone are the days we applauded healthcare workers outside hospitals and on city streets.” Research predicts the pandemic’s toll on our nation’s healthcare workforce will remain long after we receive our vaccines, and herd immunity slows the spread.  A “mass PTSD on a scale not felt since World War II. This burden should not be ignored.”

 Some view the pandemic as a once-in-a-lifetime black swan event.  Might it have been less catastrophic if population health had taken deeper root in healthcare systems and the populations they serve? More focus on health outcomes and determinants and implementing policies and interventions that link them may have reduced pre-existing conditions and strengthened our collective resilience.

An American Dies from a Death by Despair Every Two and a Half Minutes

Lost in the 2019 Democratic Primary, this sound bite from Marianne Williamson, considered by many a fringe candidate.

“The biggest problem with America’s health care system is that it is not a health care system so much as a sickness care system. It reflects an outdated perspective on health and healing, in which far too little attention is given to the actual cultivation of health and prevention of disease.”

Maybe more of a premonition when considering the pre-pandemic health status of the backbone and the front-line of America- its working-class and working-poor population of 25 to 64-year-olds.

  • Many remain unemployed or underemployed and often underinsured.
  • An increasing number suffer from some form of food insecurity. It is estimated that 17M children are going hungry today.
  • The cheap, convenient, and engineered-to-taste good ultra-processed foods that dominate America’s diet are linked to obesity, heart disease, and Type 2 Diabetes.
  • Nearly half have some form of cardiovascular disease.
  • Close to half of the US population is projected to have obesity by 2030; a quarter will be severe.
  • One-third are estimated to have Metabolic Syndrome or Pre-Metabolic Syndrome.
  • Stress, anxiety disorders, and despair-related illness have risen to an invisible $1 trillion primary care health epidemic impacting over 40 million adults annually.
  • One in seven faces substance abuse disorders, while only 10 percent of those addicted receive treatment.

A Generational Opportunity

I have read many inspirational population health vision statements and goals. Yet, I continue to observe the infrastructure, accountabilities, and funding for actualizing population health often remain siloed at the organization’s edges.  Strikingly, only 20% of our health and wellbeing is related to access to traditional healthcare systems offerings.  The remaining 80% is influenced by a social structure that includes physical environment 10%, socioeconomic factors 40%, and life/behavior choices 30%.  All dimensions are relevant to an integrated population health value chain and ecosystem. 

Healthcare consumes over 17%  of our economy. Our current model relies heavily upon increasing volume and access to advanced medical interventions, polypharmacy, and super specialists. At the same time, our system fails to move us toward enhanced health and greater resilience. Imagine a right to equitable health and wellbeing instead of our current debate on cost and the right to healthcare.

In 2020 the McKinsey Global Institute made a case for improved “health capital” as a post-pandemic growth and economic recovery strategy. It notes that COVID 19 provides a “once-in-a-generation opportunity” to advance broad-based health and prosperity. That said, it outlines that 70 % of this estimated health capital improvement potential requires a broader focus by healthcare providers on environmental, social, behavioral, and preventive interventions. Again, all dimensions of a more intentional population health value chain and ecosystem.

The “Big Blanket”-A Stubborn “Set Point.”

In the late 80′ and early 90’s I served as SVP of Corporate Development for Baptist Medical System, now Baptist Health, a statewide healthcare system in Arkansas.  My title’s irony is not lost on me today, given my advocacy for healthcare as a human endeavor, not a corporate one. That said, in 1991, as part of a comprehensive statewide repositioning strategy, we published an illustrated children’s book called “The Big Blanket.” Today I find its sentiment eerily significant.

“This little book began with a dream, the dream of total, life-long health for every man, woman, and child in Arkansas… we believe that like a quilt, healthcare should wrap around all of us at birth, keep us healthy, happy, safe, and secure for an entire lifetime, and enable each of us to live life to its fullest.”

 I wish that “total health” vision had become more of a reality. I keep the book visible in my studio as I continue to carry that dream still thirty years later.

Apart from more visible providers like Kaiser Permanente, health systems and payors are often stuck at cross purposes. We covet our traditional incentives to generate sickness-related revenue while endorsing, albeit slowly, a movement to value and consumer-centric population health.  I liken this tension to one’s weight loss program.  You hit that stubborn physiological/psychological set point. Even with your extra effort, the body quickly returns to former homeostasis, where it feels most comfortable but maybe not most healthy.  Consider where we find ourselves today:

  • A significant proportion of value-based payment alternatives to physicians and hospitals still rely on some form of fee-for-service chassis.
  • Healthcare leaders, clinicians, boards, and consultants relish adding new programs yet struggle with fundamentally disrupting an industry in which they have invested their careers and community efforts.    
  • Since the70s, we have strategically layered “health” related initiatives considered precursors to a population health value chain. Specifically:  preventative health/wellness; integrated medicine; community health/outcomes; early managed care (PPO’s, MSO’s and IPA’s, medical homes, care coordination, and navigation; home health, occupational health, behavioral health, school-based clinics, retail health; concierge practices; personalized medicine, high-reliability healthcare, combined with today’s ACO’s, CIN’s, value-based care, bundled payments, shared savings, digital health, telehealth, whole person care and narrative medicine.  
  • Significant investments continue to be made in system consolidation, increasing scale, high-end technologies, designer medications, and new bricks and mortar calculated to consolidate and sustain an inherent competitive dimension of today’s healthcare delivery.
  • Innovative value-based, lower cost, consumer-centric health solutions emerge more from outside disruptors or at the edges of our legacy healthcare providers.
  • Traditional hierarchal and centralized operating and compensation models provide line-of-sight P&L management and control of resource allocation while encouraging further disintegration of the patient experience and are counter-intuitive to the localized nature of population health.

Strategic Decluttering, Realigning and Redeploying

Consumers often confront an episode of injury or disease by piecing together and navigating a set of complex provider/payor relationships and imposed options. Such navigation is generally absent of actual health data and devoid of the impact of knowledge of one’s past and current health and life trajectory. Under a Population Health scenario, this same consumer will have an increased awareness of their health trajectory and be guided by a personalized health pathway. A generative algorithm and value chain would integrate lower-cost, high-impact services, diagnostics, technologies, and evidenced-based interventions appropriate to restoring one’s achievable levels of health. Services would be delivered through an intelligent consumer platform and ecosystem of providers and payors dedicated to restoring equitable health and mitigating further decline.

Nothing Changes Until Something Changes

Today’s leaders, clinicians, board members, and changemakers hold the tension of current disruption and despair along with its emerging possibility. On a recent webinar, Peter Senge noted, “we all have been thrown in the river, and now we have to swim.” I suspect we may all need to become health service researchers, designers, and actuaries or recruit some good ones.  Learning to balance this tension between a sickness-based system and a restorative health-based one may take years. Yet, by sifting through the strategic layers of past “health” related efforts, I believe we may find the emerging possibility of improved “health capital.” 

Given our $3 trillion annual expenditure, resources do not appear to be the issue.  I sense it may be what Otto Scharmer, Senior Lecturer in the MIT Management Sloan School and co-founder of the Presencing Institute, describes as action confidence-“the necessary courage and capacity to step into something new and bring it into being.” For starters:

  1. Decluttering, dusting off, and sensemaking of our past and current population health strategies and initiatives.
  2. Welcoming and partnering with the more disruptive forces at the edges and our traditional healthcare systems’ white spaces.
  3. Moving out to our organizations’ edges to re-form, realign and redeploy these resources in an integrated consumer-centric value chain with an end game of restoring health.
  4. Accelerating the implementation of a “value-based” financing and compensation model designed to incent economic recovery and growth whether treating our sickness or restoring our health.

Structural changes alone are insufficient. This effort requires the connection between individual and collective inner wellbeing and the desired system change. Thus, the need for a shift in perspective, inner intent, and courageous action by a community of consumers, providers, payors, social entrepreneurs, regulators, and legislatures.

At times, this shift may begin with our sense of discontent, powerlessness, and burnout. One that requires a painful self-examination of our internal landscape and external habitat and taking greater accountability for restoring its health. This experience liberates within a deeper awareness and motivation to influence health restoration within one’s family, organization, and the broader ecosystem.  As stewards of this $3T annual spend, I believe we owe this to our first responders, front-line workers, and most vulnerable populations. It seems better than thank you posters, applause, and bellringing. Now is the time for Population Health in America-if, not now, when?  

#restoringhealth

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Strategic Silence—(Re)Claiming Your Zone of Privacy

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A recent New York Times article reported that former Exxon Mobile CEO and now Secretary of State Rex Tillerson “keeps a low profile.” The conjecture was that Tillerson’s “cloak of invisibility” indicated being out of 45’s inner circle, or, conversely, it demonstrated a “highly strategic” and consistent element of Tillerson’s leadership style (putting things in place before making a big splash).

During the never-ending run-up to this election and now the first 100 days of public discourse, I’ve found myself reflecting on this notion of “facts and alternative facts,” “noise,” “transparency,” “privilege,” “leaks” and the power of silence. Especially silence as it relates to transparency and privacy in business and among business leaders.

Daily we are assailed with breaking news! News that’s often rehashed through some talking head or thrown at us by media outlets eager to fill the vacuum created by the last sound bite—or tweet. This “noise” becomes deafening when filtered and amplified by 1.8 billion Facebook users, who then disseminate their opinions on the latest noise (along with pictures of whatever it is they most recently ate).

Distressingly, I have experienced these same scenarios and behaviors within the inner workings of top teams and organizations with which I work. This oversharing, lack of boundaries and assaults on privacy and silence have become just as common in these more gated environments as they are on crowded subway cars, in movie lines and in airport lounges, where people engage in what should otherwise be confidential business or intimate personal conversations on their cellphones. I assume they believe they are in a zone of privacy provided by some invisible red phone booth with the door tightly shut.

As an attorney, consultant and leader, I remain exceedingly sensitive to both the privilege and responsibility that emanates from one’s collection and use of confidential disclosures (as well as dialogues with clients, associates, employees and constituents).

Information sharing—or withholding—is power. So when do we disclose authentically, or withhold purposefully, to prevent harm? How do we strike a balance between the need to know, transparency, and our own need for silence, solitude and claiming a personal and professional zone of privacy? The answer is different for each of us, and is based on our nature and circumstance.

1. Consider McKinsey’s perspective on the upside and dark side of leadership transparency in business.

People, employees, constituents often say they want to be involved in every decision. But do they really? Because when it comes down to it, that means they will then be compelled to share in the accountability that that transparency brings.

In the February 2017 McKinsey Quarterly article, “The Dark Side of Transparency,” authors Julian Birkinshaw and Dan Cable note the need among many executives to “get smarter” about when to share versus when to withhold information—to enjoy the benefits of transparency while avoiding the unintended consequences. They also encourage engaging and empowering a company’s front line with information but note that too much information can overload and “legitimize” endless debate and second guessing of executive decision making, and slow or derail the whole process when it comes to execution.

Likewise, too early visibility may stifle innovation and creativity when naysayers begin to weigh in and kill the prototype before it ever has a chance to evolve.

2. Consider Hay Group’s perspective and research on clarity as a primary agent of personal engagement, leading to increased discretionary performance and business performance.

While ambiguity appears to be today’s cultural norm, ambiguity can often signal change and emerging possibilities; and too much ambiguity or unaddressed ambiguity may lead to increasing frustration, mistrust, unnecessary competition, redundancy of work effort and loss of discretionary performance.

The challenge for leaders is to determine what they can be clear about and how best to communicate their message. Hay Group research, conducted through their Organizational Climate Survey, found that of all six climate dimensions, clarity remains the most important dimension of a positive work, yet the most difficult to sustain at a high level.

Clarity helps everyone know where they fit, what is expected of them and how those expectations relate to the overall direction of the organization. But to sustain clarity, employees find there must be consistent high quality discussions and decisiveness (not shifting priorities) about what the direction of the company is—and just as importantly, what it is not. This clarity must also be relayed in meaningful ways that connect people with appropriate and reliable information.

Lack of clarity creates a vacuum, one that’s soon filled with misinformation—or what’s now come to be defined as “alternative facts.” These alternative facts, if not clarified with appropriate information and evidence-based facts, with the help of social media, can be swiftly mainstreamed, normalized and part of your organizational story line. Likewise, it is as crucial to truthfully acknowledge when simply given the reality of the situation is “it is what it is” and not possible or appropriate to give all the people the clarity they desire.

3. Consider that authentic temperament and truth telling requires intentional periods of solitude and mindful reflection.

So here comes the tough, more personal part of this issue. In meetings when everyone feels compelled to weigh in and express an opinion (informed or not), I am reminded of the wisdom of Mahatma Gandhi, someone known for speaking truth to power, who advised people to “speak only if it improves the silence.”

The ability to manage one’s ego and hold one’s power while remaining fully present (yet silent) at times of discord comes from a deeper, more authentic inner space. It is a space cultivated through solitude and mindful discerning of one’s own deeper intent and truth. Weighing in from this place often carries a greater impact, too, one devoid of self-interest and fear of what others might think. This moment of filtering one’s desire to speak or remain silent is what I call strategic silence. And creating space for solitude means claiming your own personal zone of privacy, whether it’s a year’s sabbatical, a pre-meeting reflective walk or a five-minute reprieve from the noise of the day.

4. Consider John O’Donohue’s perspective found in his Anam Cara on “Ascetic Solitude.”

“Ascetic Solitude is difficult. You withdraw from the world to get a clearer glimpse of who you are, what you are doing and where life is taking you,” writes O’Donohue. “There is an incredibly subtle and powerfully calculating industry of modern dislocation, where that which is deep and lives in the silence within us is completely ignored. The surfaces of our minds continue to be seduced by the power of (outside) images. This outer exile really impoverishes us.”

In concluding, I leave you with a final thought from the late Theologian Henri Nouwen. It is his image of controlling your own drawbridge. He states that, “you must decide to whom and when you give access to your interior life,” and cautions us to “never allow yourself to become public property, where anyone can walk in and out at will.”

Not bad advice when thinking about claiming your own zone of privacy—as well as setting the privacy setting on your Facebook page. Or holding back on that next policy-setting tweet.

Vertical Literacy: Re-imagining the 21st-Century University- Otto Scharmer

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The Fridays For Future (FFF) climate strike by high school students may well be one of the most important, yet hardly covered stories by the US media today. During the week of March 15th alone, 1.6 million strikers were counted across 125 countries. This environmental movement to reduce carbon emissions was started by Swedish teenager Greta Thunberg in late 2018. In the meantime, a discussion has ensued among politicians in Germany about whether it is the right thing for students to take to the streets instead of the classroom on Fridays.

The principles in image above weigh in on this conversation from a bigger picture view: how to “update” the world’s educational system, particularly the university, to tackle the technological, environmental, and social disruptions of the 21st century.

The classical university was based on the unity of research and teaching; the modern university has been based on the unity of research, teaching, and practical application. I believe that the current historical moment, with one civilization ending and dying, and another being born, invites us to reconceive the 21st-century university as a unity of research, teaching, and the praxis of transforming society and self.

Read More (via Medium.com)

The Focused Leader

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A primary task of leadership is to direct attention. To do so, leaders must learn to focus their own attention. When we speak about being focused, we commonly mean thinking about one thing while filtering out distractions. But a wealth of recent research in neuroscience shows that we focus in many ways, for different purposes, drawing on different neural pathways—some of which work in concert, while others tend to stand in opposition.

Grouping these modes of attention into three broad buckets—focusing on yourself, focusing on others, and focusing on the wider world—sheds new light on the practice of many essential leadership skills. Focusing inward and focusing constructively on others helps leaders cultivate the primary elements of emotional intelligence. A fuller understanding of how they focus on the wider world can improve their ability to devise strategy, innovate, and manage organizations.

Every leader needs to cultivate this triad of awareness, in abundance and in the proper balance, because a failure to focus inward leaves you rudderless, a failure to focus on others renders you clueless, and a failure to focus outward may leave you blindsided.

Read More (via hbr.org)

Leadership Run Amok

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The desire to achieve is a major source of strength in business, both for individual managers and for the organizations they lead. It generates passion and energy, which fuel growth and help companies sustain performance over the long term. And the achievement drive is on the rise. We’ve spent 35 years assessing executive motivation, and we’ve seen a steady increase during the past decade in the number of managers for whom achievement is the primary motive. Businesses have benefited from this trend: Productivity has risen, and innovation, as measured by the number of patents issued per year, has soared.

In the short term, through sheer drive and determination, overachieving leaders may be very successful, but there’s a dark side to the achievement motive. By relentlessly focusing on tasks and goals—revenue or sales targets, say—an executive or company can, over time, damage performance. Overachievers tend to command and coerce, rather than coach and collaborate, thus stifling subordinates. They take frequent shortcuts and forget to communicate crucial information, and they may be oblivious to the concerns of others. Their teams’ performance begins to suffer, and they risk missing the very goals that initially triggered the achievement-oriented behavior.

Read More (via hbr.org)