“Winning” by Defeating the Triple Aim

by joeflower on November 16, 2015

Successful strategies will be the ones that thrive despite high variance, multiple energy inputs and multiple strategic options.

You follow movies? That is, not just watching them but thinking about how they are built, looking at the structure? In classic movie structure there is a moment near the end of the first act. We’ve established the situation, met our hero, witnessed some good action where he or she can display amazing talents but also what may be a fatal weakness.

Then comes the moment: Some grizzled veteran or stern authority brings the hero up short. GabbyHayesThink of Casino Royale, that scene where Daniel Craig’s Bond (after those brutal opening scenes) is back in London and is confronted by Judy Dench’s M. Or Obi Wan Kenobi challenging Luke: “You must learn the Force.” Or that moment in the classic Westerns when the tired, angry old sheriff rips off his badge and throws it on the desk, leaving the whole problem to the young upstart deputy. But before he stomps out the door he turns and says to the young upstart, “You know what your problem is, kid?”

And then he tells him what the problem is: not just the kid’s problem, but the problem at the core of the whole movie. He just lays it out, plain as day.

In health care, this is that moment. We are near the end of the first act of whatever you want to call out this vast change we are going through.

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Does prevention save money? __ Yes __ No

by joeflower on August 6, 2015

DocWPatientOr…it’s complicated.

The New York Times today published a story titled, “No, Giving More People Health Insurance Doesn’t Save Money.” A piece of the argument is, as the author Margo Sanger-Katz puts it, “Almost all preventive health care costs more than it saves.”

What do you think? What’s the evidence? Leave aside, for the moment, the “big duh” fact that at least in the long term saving people’s lives in any way will cost more, because we are all going to die of something, and will use a lot of healthcare on the way. Leave aside as well the other “big duh” argument: It may cost money, but that money is worth it to save lives and relieve suffering. Leave that argument aside as well. The question here is: Does getting people more preventive care actually lower healthcare costs for whoever is paying them?

My thoughts? #1: No consultant worth his or her salt trying to help people who are actually running healthcare systems would take such a blanket, simple answer as a steering guide. Many people running healthcare systems across the country are seriously trying to drop real costs, and how you do that through preventive care is a live, complex and difficult conversation all across healthcare.

#2 thought: It depends. It needs analysis. It depends on which preventive tests, screens, and prescriptions you’re talking about, and how it is decided whom to help with them. Sanger-Katz’ article only shows that we cannot assume that every preventive screening or test saves money and/or is worth the money spent. Mammograms, for instance, show no benefit (no extra tumors caught, no lives saved) over breast exams alone (Canadian Breast Cancer Study, n=89,000 over 25 years).

This is true of many preventive items, including the annual checkup — it’s hard to show a true benefit from them. So yes, if you assume that every preventive test, screen, or prescription is worth it, and then you give more people access to those, you’ll end up spending more money. Equally important, the assumption is that you screen everyone, and you do it the most expensive way, like giving older people regular colonoscopies as a test for colon cancer. There are far less expensive ways to pre-screen people for that. This one assumption alone costs an estimated $10 billion per year in the U.S..

The problem is that these assumptions mean giving a lot of medical care, much of it not even effective, to people who are well. There are reasonable ways to narrow the focus of expensive, personal, procedural preventive care and maintenance to the 5% or so who really need it. Find that 5%, give them extra care, and you will save money.

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When the pace of change is accelerating, you need a flexible process and a paradoxical mind.

How do you plan? Obviously, you have to. Obviously, you can’t.

For your organization, and for you as a health care leader, the rapid and at times chaotic changes in the payment systems, the purchasers’ strategies, your population base, new technological possibilities, and the competitive landscape mean that you must plan for the future and act vigorously to make that future happen — or you fail. At the same time, those very same factors render traditional planning methods irrelevant, impossible, even deadly.

The movie line that comes to mind is “Forget it, Jake. It’s Chinatown.” But we can’t just forget it. We must figure this out.

Let’s step through it: the shape of the complexity we are dealing with, how the process must change to deal with it. Then we get to a core issue that often gets overlooked: What kind of mind do we need for this new thinking, and how do we cultivate it?


Today, not only is the environment far more complex, not only is the rate of change higher, but the very nature of the change is far more complex, as each changing vector influences others in ways that rapidly lead us beyond any simple prediction or trend lines.

In the past, each strategic decision (say, to go big on a cath lab, or to pour capital into the cancer program) operated in parallel with whatever else you were doing. Each had its own revenue streams and outputs, often even its own sources of capital in bond programs and charitable funds. They were additive. They influenced one another only marginally.

Today, in the movement from volume to value and the roiling of purchaser markets, the output of any one strategy becomes the input of other strategies. For instance, if you are really successful at a program of marketing segmentation that targets “super users” for extra help, your emergency department and acute admissions will drop, as will income from procedures. And the inputs and outputs shift in time: A population health management program keyed to an accountable care arrangement will require significant resources now, to produce an unknown amount of savings or revenue in two years or more.

A set of vectors in which the output of one process is the input of another in overlapping and iterative feedback loops: This is the definition of a complex adaptive system, an irreducible complexity whose outputs are by nature unpredictable. This is health care today, with multiple new inputs and constraints, and multiple new interconnections.

Sneaker Waves

This complexity means that many of the strategy choices health care organizations are taking today are seat-of-the-pants guesses, operating on a wing and a prayer, in structures held together with chewing gum, duct tape and baling wire. They give good PowerPoint, but you only have to lift up a corner to see the patches and gaps and that one tire that won’t even make it to the county line. Will it work? We can’t tell because we haven’t done it. It’s prototypes all the way down.

Experiments are great. Ad-hocery is necessary. Prototypes are part of the process. But you can’t build your organization on prototypes and pilots.

You know what a sneaker wave is? If you’re a sailor, you do. All mariners know about sneaker waves or rogue waves, massive things two or three times the size of the waves around them that can arise without warning to swamp and even sink ships. A sneaker wave is an expectable artifact of any sufficiently complex system. Such overpowering anomalies arise from a combination of unknown, insufficiently known, rapidly changing inputs, interacting in a complex adaptive system.

Where are these sneaker waves hiding? They are hiding in your assumptions, in your unasked questions, in your lack of information, in the narrowness of your search.

How Is It Different?

Strategy planning today must be vividly different from what we used in the Ye Gud Olde Days:

  • Broad: The scan of your environment, populations and possibilities must be much broader than we are used to.
  • Assumption-free: It’s not enough to simply declare the planning effort an assumption-free zone. The planning effort has to incorporate processes designed to ferret out the organization’s shared assumptions, examine them and overturn them.
  • Seek experience elsewhere: Your organization may not have much experience with these new strategic possibilities, but somebody does. For somebody, this is not a prototype but a proven model. You must gather those experiences and examine them to see how their environment and resources are like and not like your own. This is one of the major values of using consultants who have worked broadly with other organizations.
  • Experiment: In a changing environment, you will never have what feels like enough information to act. You must be willing to try things before you can prove that they will work. Then you must be rigorous about what each experiment teaches you, and act on that information early.
  • Constant process: Producing a five-year strategic plan, then implementing it is a suicide pill. Strategic planning must be a constant dynamic process, ready to start, change or kill initiatives as new experience and inputs come to light.

Taken together, this means we have to learn to think differently, even perceive differently, both as an organization and as health care leaders. So it’s about the process, but it’s also about the mind — your mind and the group’s mind.

The Process

Let’s take a look at the process first.

What’s the process?

We’re going to take your bog standard strategic planning process and add three important new elements to it.

In Standard Land, the world the way it was, we would start with scanning your environment, your internal environment and your intelligence resources. You know the drill: The environment is mostly your three Ps: payers, purchasers and politics. The internal asset scan is much more complex, ranging from physician relations to physical assets, capital capacity, present and potential revenue streams, cash flow versus budget, and present organizational culture and politics. Then your intelligence and resources, the database of experiences elsewhere in health care that you have constructed or your consultant has brought you, strategies that have been tried elsewhere, the elements and results of those strategies.

Standard, but necessary. You must know this stuff in a way that can be written down. And because in this new era the process will be constant, all of this has to be brought into a database that is coded, tagged and easily accessible for your staff, all for the next iteration.

The three added elements the new era demands are roots, assumptions and loops.

Roots. It’s easy to get lost in all this change unless you are firmly anchored in the answers to two questions: Who are you, what are you here for? And: What kind of institution are you?

The first is a question of DNA and heritage. What is your mission (in plain English, not that wispy stuff most people use for mission statements)? Are you a for-profit? Are you out to help the poor and disadvantaged? Nurture the health of the whole community? Are you out to make health care really work better for a defined portion of the population (say, employees of major firms) by bringing them health care in a better business model?

The second is similar, but more nuts-and-bolts: Are you a major teaching and research center? A community hospital in an upscale area? A city general hospital with a level-one trauma center? A rural hospital? Part of an integrated delivery network?

You must also work through these two questions for yourself as a health care leader: What are you really here for? And: What kind of person are you, really?

A clear understanding of these two questions is key. You can set any aspirational stretch goals you like, but if there is visible variance between that goal and what you are really here to do, and what you are made of, then the goal is useless or, worse, a distraction.

This is best done at the beginning of the process.

Assumptions. Before moving onto solutions and strategies, take a side step: It’s time to root out assumptions and falsify them wherever possible. This is not easy. It calls for a process that is rigorous, written, thoughtful and direct.

You can use any number of specific processes. But the details of the process matter less than that you have one, and use it rigorously. You don’t think differently just by wanting to.

Loops. As you move forward to evaluating strategies, you must remain aware of the complex feedback loops that they will all participate in. For example: How are these new revenue streams likely to affect each of the others? Will your venture into neighborhood urgent care cut your acute and emergency income? You must attempt to ferret them out and try to predict their size and the nature of their influences.

From Intelligence to Action

Possible strategies will suggest themselves directly out of the process of intelligence gathering, internal and external scanning, and challenging assumptions. Gather them. Do not judge them prematurely.

Make a list, then process the list. If something is mandatory, set it aside. It’s not a strategy, it’s a task. A strategy is a separable set of tasks and tactics that solves a problem. Make vague strategies specific. “Go lean” isn’t actionable. “Institute lean manufacturing processes in each department” is closer. Make sure it is a separable strategy, one that can be followed independently of other strategies. If not, find the knot that it is part of — that’s a strategy.

That done, take your list of possible strategies and rate them by answering a series of questions, such as:

  • Solution: Does it solve a problem? Which? Whose? Yours or someone else’s?
  • Size: Is the problem big, measured by revenue, by impact on the populations you serve, or by laying the foundation for other large changes? Or is it interesting but small-scale?
  • Alignment: Does this problem and this solution align with your roots questions, who you really are and what you are trying to do?
  • Allies: If the problem it solves is partly someone else’s, can you make that someone else your partner, ally, supplier or buyer?
  • Urgency: How urgent is this problem?
  • Immediacy: Is the solution something you can act on now? Take a first step toward? Launch a prototype?
  • Workability: How workable is it? If it is not very workable, it may be the wrong size. Can you slim it down? Can you carve off a chunk that is workable? Alternatively, can you go big, enlarging the strategy in a way that might bring in new resources, new partners, new revenue streams?
  • Prototyping: How can you prototype it? Far too many health care strategies go big on the prototype without sufficient testing. This is exactly what happened to Healthcare.gov in the fall of 2013.
  • Resources: What resources does it take — capital, personnel, physical plant, management? Can you gather or deploy them in a reasonable time frame?
  • Options: Does this option foreclose other possibilities? Or can it be run in parallel?

Honest and rigorous answers to these questions will give you a strong basis on which to eliminate possibilities and prioritize others. This is your strategy.

The Mind

To do this right, what kind of mind do you need, does your organization need, to foster?

What company will you keep?

So we not only need different thoughts, we need in many ways a different mind, a paradoxical mind that can think in different ways, broader, with more suspension of disbelief, readily combining imaginative leaps with stepwise analysis, able to spin up scenarios and to break down the project and its inputs and outcomes over time, combining depth of experience with a freshness of thought.

In your organization, you do your best to put the right people in the right spots, implementers for implementation, team-builders for team-building, analysts for analysis, engineers for engineering. For your continual future-proofing you will use consultants and executive coaches. In doing this, you have to ask yourself not only whether they are technically competent. You have to ask yourself whose company you want to keep — because this will greatly influence the kind of mind you wish to foster in yourself and in your organization.

In my trajectory as a health care futurist, I was greatly shaped by the 60 classic masters of change and leadership from Peter Drucker to Jim Collins, Peter Schwartz to John Seely Brown, Warren Bennis to John Gardner to Ronald Heifetz, whom I interviewed over an intense period of 15 years. I was immersed with them in what works, what doesn’t and why. They are on the team of voices in my head who profoundly shape my thinking, even today. Who do you want on your team?

As you move forward into new territory, who would you choose to sit on your shoulder and advise you, whether you’re in a meeting at a long table, or alone at your desk, staring out the window? What must those angels be like? When you’re pushing forward to new horizons, it’s not just the external conversations that matter, it’s the internal ones.


First published in Hospitals and Health Networks Daily, a publication of the American Hospital Association, on July 14, 2015.


How We Build Healthy Cities: Talking with Dr. Len Duhl, Pioneer of Population Health Management

June 18, 2015
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The Change-Master Series: Deep Dives Into the Essence of Change-Making and Leadership by Joe Flower Twenty years ago we talked in his cramped, book-lined, ex-carport study with the laden plum tree bowing its fruit over the garden gate outside. What Dr. Len Duhl had to say then is, if anything, more true today than it […]

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Obamacare Rates Set To Spike? Um…

June 11, 2015
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So it’s all over the news space and the shrieking blogosphere, with headlines like, “Obamacare Rates To Spike Up To 51%,” “Obamacare Hell…” and “Obamacare Inflationary Deluge…” And online friends are commenting about “Obamacare premiums set to rise next year as much as 51% in some states…” Hey, hey, hey. No need to panic. “Set […]

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Productivity? In Healthcare?

June 3, 2015

Obamacare is built on the assumption that healthcare can be more productive, that we can squeeze more health per dollar out to the system that is built to give it to us. Practically everything I write is based on the same idea — big time. I believe we could do healthcare better for half the […]

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GOP has The Fear: King v. Burwell

May 26, 2015

Republicans have raged against Obamacare for six years now. But do they really want to see it crash? We are rapidly approaching the day when the Supreme Court announces its decision in King v. Burwell. The case found a four-word phrase in the 900-page law that says that the tax subsidies are available to people […]

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The Smoking Gun: How U.S. Health Care Came to Cost Insanely More

May 19, 2015

A historic chart of health care spending exposes the culprit in rising costs: code-based fee-for-service medicine. To Be Notified When the Book Is Available for Purchase Go Here Cost is the big factor. Cost is why we can’t have nice things. The overwhelmingly vast pile of money we siphon into health care in the United […]

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Getting Paid to do Better Medicine for Less

May 13, 2015

Atul Gawande’s new New Yorker article, “Overkill: America’s Epidemic of Unnecessary Care,”  brilliantly lays out why and how we are getting so much overtesting, overdiagnosis, and overtreatment — testing that is inappropriate, not helpful, and often harmful; diagnosis of problems and abnormalities that are real but actually won’t hurt us; treatment that misses the mark, is […]

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Des Moines, the Heart of the Revolution

April 29, 2015

In Des Moines, brides are posing in the spring sun under the profusion of flowering trees in the Arboretum and families are strolling the path around Gray’s Lake. Up in the cavernous Veterans Memorial Convention Center, UnityPoint is wrapping up its Leadership Symposium celebrating its 20th anniversary as an integrated system. An outsider might be […]

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