An Open Letter

An Open Letter to Atul Gawande, MD

Dear Atul,

Even though you’ve yet to officially begin your new career at the helm of the yet-to-be-named “Amazon-Berkshire Hathaway-JPMorgan Chase health plan” (which we’ll call “ABC”), several of ABL’s Adaptive (Healthcare) Business Leaders have collaborated on a few suggestions for your consideration as you seek to dramatically improve the quality of care ABC employees receive. Of course, they’re also of mindful of your plan to targetwaste in the current U.S. healthcare system.” So here are their recommendations:

Harry Soza (CEO of CAREMINDr) suggests that you, “Create ‘responsibility feedback loops’ so that care decisions and patient commitments to healthy behavior do not live in isolation” – rather, enable “others in the community to monitor, assist, advise, and encourage.”

Dave Sayen (formerly CMS Region 9 Administrator, SrVP, Gorman Health Group) recommends that you, “Provide comprehensive wellness benefits with a health coach.”

Brad Schmidt (CEO of Inglewood Imaging) would like to see you, “1. Max the billed charge amount to 3x Medicare. 2. Designate a “place of service” to encourage consumerism. 3. Allow an easier payment to MD’s for telemedicine MD-to-patients (for ER admits). 4. Reform HIPAA Language to encourage “a continuation of care.” 5. Mandate HIE connectivity for “participating” providers.

Catherine Dodd, PhD (Health Delivery Strategist, formerly Director of the San Francisco Health Service System) advocates that you “Utilize advance practice nurses (NPs, CNMs, CNSs) as well as RNs to the full extent of their licenses. Require care coordination by an RN who has power and will advocate for real patient/family-centered care.

And, Dwight Wilson (CEO of Mission Hospice), offers: “Provide as much choice as reasonable to the employees and their families.”

Anonymous contributors wrote: [Providers] “could deliver excellent care consistently if they could eliminate most of their administrative responsibilities.” Another: [Provide for] “more time with the doctor in a consultative and educational format surrounding the needs of the patient.” And a third suggests, “Reduce prices of drugs and services in order to lower deductibles which impede access to care.”

And, John Price, a principal and consulting actuary with Axene Health Partners (and formerly the president of KPIC, Kaiser Permanente’s subsidiary insurance company), counsels:

[You have an] “interesting mix of goals. Administrative expenses for [ABC’s current] company sponsored health plans are probably 9% to no more than 12% of their total plan costs. Squeezing that will produce a small reduction to the total cost. Most of the other goals require addressing broad infrastructure issues to be effective on at least a regional basis. These are deeply complex and inter-related issues that will likely need to be targeted one small piece at a time by provider specialty and disease groups. The difficulty level is akin to rearranging a house of cards without causing its collapse (due to our highly fragmented health care system), assuming [ABC] can gain critical mass with highly effective and accepted innovations sufficient to influence broad health care communities and processes. At the very least, it’s a huge multi-tasking challenge.

Here’s a sample list of priority tasks (which may vary by region):
1. [Develop] regional processes to continually monitor and measure health care performance (by complete episodes of care, clinical outcomes, service quality, and cost) from the perspectives of all stakeholders (physicians, patients, health care facilities, ABC plan sponsors, and any third party payers, etc.).
2. [Also develop] ongoing processes to further evolve and gain regional professional recognition and broad acceptance of best medical practices and costs. The focus should be by provider specialty and disease groups (physicians, hospitals, allied health professionals, etc.).
3. Recognize and effectively promote use of regional centers of medical excellence and cost for a broad spectrum of diseases – without violating anti-trust laws.
4. Develop and promote effective and aligned incentives among all stakeholders to continually pursue and implement best medical practices, cost awareness and cost efficiencies.
5. Identify and effectively lobby for needed changes whenever laws and regulations present barriers to achieving medical best practices, outcomes and costs.
6. Continually identify and effectively promote adoption of healthy life styles, wellness programs, disease prevention, and patient awareness and compliance with medical best practices. It’s likely this will yield a small short term pay-off, but potentially much stronger long term results.

Atul, at the June 2009 Good Samaritan Hospital Board meeting, Berkshire Hathaway’s vice-chairman and Good Sam’s chairman, Charlie Munger, mandated that we all read your path-breaking New Yorker feature, “The Cost Conundrum.” I’ve been a huge promoter of yours ever since. In the days to come, I’m confident that thousands of healthcare providers, payers, and suppliers will offer you at least as many recommendations about how to “run” the ABC Health Plan. Yet, a cursory review of your features in The New Yorker alone confirms you already have an excellent handle on healthcare’s problems. More, you have The Vision – and the backing – to start solving them.

We’ll be cheering you on as you do so,
Mimi Grant, President
ABL Organization