In the opening pages of Leading the Revolution, Gary Hamil invites readers to conduct a thought experiment on business innovation.  “Which group has taken best advantages of all the changes that have taken place over the last decade or so: political, economic, social or technical”, he asks; “traditional players or newcomers”?  Most instinctively realize that the evidence suggests “newcomers”.  He then asks if these newcomers prevailed by “executing better on traditional rules of engagement or creating new ones”?  You see where this is going, I’m sure.  Industries change from the outside; health care is not exempt.

Several months ago I posted on healthcare’s changing ecosystem.  The precipitating event was the chance to get up close and personal with the hundreds of mobility devices coming into health care from outside the industry: smart band-aids, smart pill bottles, fashion forward monitors, etc.  The big news was not just the devices, but the analytics they made possible.

Now we’ve gotten a peek at an even more revolutionary incursion from retail as Wal-Mart sent out a nationwide request for partners to help it “dramatically … lower the cost of healthcare … by becoming the largest provider of primary healthcare services in the nation.”  In a 14 page RFP, the company asks firms as diverse as Kaiser and DaVita to spell out their expertise and to provide information on how they would oversee patients with complicated chronic conditions like asthma, HIV, arthritis, depression and sleep apnea. Partners are to be selected in January.  The company declined to elaborate on specifics, calling it simply an effort to determine “strategic next steps.”

I’ve seen this play.  I was involved in pharmaceutical distribution strategy when Wal-Mart set this Big Hairy Audacious Goal of providing retail pharmacy services at mail-order costs.  Think of all the traditional retailer expenses that would have to go away to accomplish that.  Try to imagine the value chain that might make that possible.   Yet within three years, the company was offering generic drugs at $4 for a month’s supply.  Its low-cost pharmacy has become hugely popular with employers and seniors.  It’s not a far stretch to see Wal-Mart exercising its massive purchasing power to medical supplies, diabetes test strips or even durable medical equipment.  Whatever shape the move takes, it will capitalize on the growing demand for primary care likely to surge beyond 2014.

As you might expect, there was no shortage of detractors.  Analysts suggested that this RFP amounts to conceding defeat and rooting around proposals for answers.  Wal-Mart was the nation’s leader in opening clinics, but with a footprint of 140 has dropped to third place, well behind CVS Caremark’s 550 Minute Clinics and Walgreens’ 355 Take Care clinics.

Physicians have been critics of in-store clinics, arguing that patients need a regular source of care from someone who knows their medical history.  They would argue that retail health care takes “care” in the wrong direction through further fragmentation.  Health policy mavens concede that Wal-Mart can deliver “stuff” more cheaply but caution that health care is not a widget. They also argue that primary care isn’t really the main driver of costs, so doubt any retail move can “bend the trend”.

Hmmmm.  Anybody remember what the Swiss watch makers thought about the Timex?

My guess is that Wal-Mart is discovering its way toward a new business model.  They can’t look at their 3,500 US stores along the 17% of GDP committed to health care and sit this one out.  Only a fool would bet on traditional players with traditional rules of engagement.  Expect the 5.1 upgrade on the “doc-in-the-box”.  More to come

For all those who’ve wondered “where was the board” since the crash of 2008, the swift actions of the Penn State directors stands as a profile in courage carrying three important lessons:

To the University community…that doing the right thing should always trump saving face regardless of apparent reputational risks;

To the governance community…that separating executive from governing authority is an essential component of fiduciary and ethical oversight, and;

To the predatory community…that destructive self-indulgence and those who enable it will not be tolerated

I think it was Gary Wendt who remarked that “most of the good and all the bad things in organizations began in the board room.” Anyone associated with Penn State should take pride in the fact that this one ended there.   Others take note

This poem was animated by a tale shared by a captain while working at a shipyard:

Half a mile from the dry dock

over fries and grouper

he shared his defining moment…

Headed home, he’d dumped his catch,

navigating through billows

to net the bewildered

He and the rest…

Ferries, barges and tugs

frigates and fishermen like himself,

many never having plied those waters

But pilot they did into

what grandfathers faced at Dunkirk:

no harbor master, no rules

only sobbing and the smell of terror

unspeakable chaos…

By night, half-a-million

from Bridgeport to Bayonne

saw home through fresh, wet eyes

Good fortune in the face of bad

on a scale hard to dismiss as coincidence

the response, perhaps, to a prayer

sent up in silence

as real prayers have always been

Leadership has the capacity to test, reveal, shape, and evenbreak the spirit in powerfully unique ways.  This article examines five recurring leadership crises that accompany all good-faith effort to take personal responsibility for collective action. It’s based on a talk I gave in 2003 at the Oxford University Conference on Social Values in Leadership and was recently accepted for publication in the forthcoming anthology for the Southern Festival of Books.

As followers of this blog know, most entries have dealt with the triple aim of providing better health and better care at lower cost.  It has been directed primarily toward the policy makers, directors and general managers who create, govern and run the context in which caregivers work.  This post takes a broader look at leading itself…not from the context back, but from the inside-out.

My first lesson in leadership took place as a follower; and it happened at the hands of my first best friend.  Remember your first best friend?

In the fall of 1951, my family moved from the little apartment they had during the Second World War to a rented house in a neighborhood not ten blocks away.  For me, though, it might as well have been the other side of the moon.  The place we’d lived had been quiet… older people who used to think it was neat to have little kids around.  Our new neighborhood was teeming with kids…mostly boys, and mostly older.  This was great for my big sister but scared the crap out of me.  Working class, tiny houses all bunched together, horse barn across the street…  These guys slapped the horses on the rump and made them kick at you.  They punched each other for fun and threw each other into headlocks.  They carried packs of cigarettes rolled up in the sleeves of their T shirts; and they called each other by their last names.  When they did it to me, it sounded like a dirty word.  “What are you looking at, Kipp?”

Richie, though, was a little more my speed…and a lot more my idol. He wasn’t big and tough, but he just seemed, well…at home; and everybody liked him.  I wanted to feel at home; and I wanted people to like me. Truth is, I wanted to be just like him.  So whatever he was into, I was there.

We spent the winter playing with our Lionel Trains and spying on our older sisters, trying to discover the secrets of life.  As the spring came, though, the whole neighborhood got psyched about baseball; and I learned that Richie was a terrific pitcher.  This was well before the age of political correctness, so the way it worked, the fathers could stack the team they coached with the best players and could kick everybody else’s butt.  For two years running, the gang to beat had been the Ford-O-Matics sponsored by Parsons Ford.  And hey, since I was Richie’s friend, I got to play with the Ford-Os!

We had cool uniforms…stirrup socks and everything.  My father thought I looked like a first baseman.  He started calling me “stretch”.  Inside, I knew that I was afraid of the ball; I also thought I probably looked like a dork. But since it seemed to go over at home I told myself that maybe I could pull it off.

As we got into practices my true colors started to show.  Richie had this chatter that coach Springer liked to hear…”no batter, no batter, chuck one, chuck one; he can’t hit; no batter, no batter”.   I wasn’t like that.  Richie could spit between his teeth and just have this nice little dollop come out in a perfect arc.  So I tried it…and ended up with Popsicle drool on my shirt.  I was one of these kids you’d see out in the field with the glove on his head.

In the first game, I got everybody’s attention by letting a grounder roll between my legs.  When I got my first “ups”, I struck out without taking the bat off my shoulder.  I sat down on the bench not too far from the coach and saw him make a note on his clipboard…”Kipp to Cardinals”.  I was being demoted; kicked out; sent to the farm team; down with the weenie kids!

“Do I get a uniform? No – just come as you are”, he said.  The Cardinals played in the field behind the church… no uniforms, no cheering crowds; only the most dedicated mothers watched.  Within a week, I hated the Cardinals; I hated baseball; most of all, though, I hated that I wasn’t going to get by being Richie.  I was going to have to be me.  Within three week’s I lost my first best friend.

Eight years and a family move later I broke my high school’s record for the quarter mile…and it still stands (small school).  I heard Coach Springer’s comment about the uniform…come as you are…in a new way.

Authenticity

So the first crisis is one of authenticity.  And I wish I could tell you that Little League was the last time I ever needed that lesson; but I have to confess that every time I step into an unfamiliar role I get a big “am I enough” attack. There’s always a Richie.  And it’s so tempting to live a borrowed life rather than to discover my own “game”.

Joseph Campbell said  “if you see your path laid out before you, step by step by step, then you know it’s not your path”.  But what’s so bad about “fake it till you make it?”  For one thing, leadership itself can be a compensatory response to feelings of inadequacy.  Hey…with all this responsibility I must be OK.  Leaders who are shaky about their own identity and self worth often end up depriving other people of theirs.

Then too, leaders are subject to so many projections that they sometimes find it difficult to stay in touch with who they really are.  They’re either all-powerful so they’re bound to let you down, or they couldn’t lead a group in silent prayer.

I got to be Deputy Commissioner for New York State through an accident of circumstances and relationships.  We had an office on the 58^th floor of the newly opened World Trade Center.  I used to go down from Albany fairly frequently and remember staying at the Harriman Estate, playing touch football with a bunch of Doctors from Columbia.  They were all very deferential.  (They didn’t know about my career with the Ford-Os.)  I could still smell the horse shit on my shoes, but had talked myself into believing that they couldn’t.

One of the things I’ve learned from peers over time is that most leaders fear being held in contempt by those they lead.  In the movie version of Glengarry Glennross, there’s a wonderful scene where Al Pacino roars at Kevin Spacey, “You’re not fit to work with men”!  Anyone who has ever taken personal responsibility for collective action shudders at the image of that kind of invective being hurled at them.  “Come as you are”?  Not a chance!

In the storytelling tradition, there’s a sentiment that at any given moment a man is seeking either his fortune or his identity; the best stories happen at the crossroads.  Who do you think you are, Kipp; what are you going to do about it? What’s most authentic about me…right here; right now?

Authenticity always travels with vulnerability.  As early as the Diaries of Cicero we read, “Had he never been called upon to exercise authority, no one would ever have doubted his capacity for it.” If you’re visible you’re vulnerable.  Leaders often shrink from authenticity to make themselves less vulnerable.

Whether she used the words or not, my mother gave me the sense that someday I would be called to greatness…and I’d better be ready.  Now we were a working class family with a very imperfect idea of what greatness looked like. Most calls to “greatness” come by chance…or from headhunters.  Having answered the call, you try to be heroic or tough-minded or humble or whatever you think the role calls for.  Parker Palmer suggests that the very way in which people become leaders tends to screen out their inner consciousness.  So you wear the face you think you’re supposed to wear.  After all…you’re just there on a pass.  I love the way the poet Alden Nowlan puts it:

What happened when he went to the store for bread

Because I went to the store for bread one afternoon when I was sixteen and arrived just in time to meet a man who had stopped for a coke, and because this man invited me to visit a place where I met another man who gave me the address of yet another, this one in a distant city, and because I wrote a letter and got an answer which took me away from the place where I was born, I am who I am instead of being somebody else.

What would I have been if I hadn’t left there when I did?  I would almost certainly have gone mad.  I might have killed someone.  But even if something else had saved me from madness, I would not be the same person.  I’d have come to look at things in such a different way that even my memories of childhood and youth would be different; it might even seem to me now that there was never anything to escape from.

Then too, there are those who are other than they would have been because of some small act of mine; I played a record once because I liked it, and because he liked it too, a stranger became my friend and as such, met the woman he married, and now they have two children who would not have been born except for my taste in music.

Carrying the thought further still, there must be people in cities I’ve never visited whose lives have changed, perhaps not because of what I’ve written but because I wrote at all.  It might be they didn’t like my play and so left early, and because they left early something happened that would not have happened if they’d stayed – I put it that way so as not to sound immodest.  God knows, there’s not a lot to boast about when so much seems to depend upon the time of day a boy goes out to buy a loaf of bread.

This squares with every meaningful conversation I’ve had with people trying to lead anything.  Regardless of the context, the most common underlying theme is the surprise at how “far” they’ve gotten with its accompanying fear that they’ll be “found out” for how profoundly ordinary they are.   Under the veneer of certainty they wonder: “How did I get here…?  Can I keep this together; is this as good as it gets; Is this what I want to do with my life?” Having to confront my own authenticity or retreat one’s own authenticity is an unexpected spiritual crisis, opening the door to those that follow.

Vocation

Vocation comes from the Latin, “voice”…literally, a calling.  As Frederic Buechner puts it, vocation is the place where your deep gladness meets the world’s deep need.  People want to attach to something larger than themselves: a noble calling or important event.   The pull to do so is often strong enough to make them deny or falsify their personal history.

The leader’s job is to find and evangelize the noble calling in the humdrum of daily life at the putty knife factory; and to give people a way to become part of it themselves.  I was at a meeting for a Pharmaceutical company in the process of mapping out a new initiative.  At the closing dinner, my host asked the group if they recalled the last time they’d raised a glass together.  Some suggested it was the record-breaking quarter; others thought it might be the day the stock hit $50 a share.  What he had in mind he said, was the day they’d gotten FDA approval for the drug that would so profoundly change the lives of thousands of patients.  He was reminding people, and himself, of what it’s all about.   In the banking business I was a part of, our passion was “helping people afford, acquire and enjoy the home of their dreams.”  Aventis speaks of “vaccinating a world at risk.”  And National Geographic’s mission is”to celebrate what is right with the world”.  That’s why we save them.  We want to join the celebration.  Unless they’re just spray paint, such sentiments drive behavior to the point where they really are worth personal sacrifices; maybe even changes in personal direction.

Kay Koplovitz, Chair of the National Women’s Business Council, describes a defining moment she experienced as a college student in the 60s.  A pre-med senior, she heard Arthur C. Clark speak to an assembly about geocentric orbiting satellites.  She instantly saw their potential to inform, educate and entertain anywhere within and beyond the free world; and the course of her life was changed.  She switched to mass communications, later founding USA Networks…the first female network President in the history of television.  Her network developed into the largest provider of original programming among basic cable alternatives with, among other offerings, the Sci-Fi Channel, documentaries like the Emmy award winning Erase the Hate and a long list of made-for-television movies such as Melville’s Moby Dick.  No one ever wondered what her vocation was.  Most of us are never blessed with such clarity.  In the car or on vacations we wonder is this what I should be doing with my life? Unresolved, it shows…and takes its toll.

The management books would have us cap off this crisis in the form of mission statements as if this particular form of energy could be bounded by word choice.  The problem with such statements is that unless they reflect something you see rather than something you say they’re just a wallet card.  Leaders have to take people there to bring the music to life.

A buddy of mine and I love to sing.  He found this church in New York where every month a group gathers to do some choral piece; and whoever comes is the right group.  Occasionally they have a guest conductor.  This particular night they were doing Kodaly’s Missa Brevis and the conductor, like Kodaly, was Hungarian.  The group sight read a couple times through and it sounded like a bunch of Hungarians at an Irish Pub.  Then he took a few minutes to describe the context for this piece.  In the 1930’s Kodaly and Bartok had traveled with a tape recorder capturing folk music to build into a unique classical expression of their culture.  The Missa Brevis was part of that body of work, written in the early 50’s.  By 1958, the Hungarian revolution was underway and the country was bathed in blood.  Anyone who could get out did so.  Kodaly and a few close friends escaped over the Carpathian Alps…one of the most treacherous routes, with whatever they could carry; Kodaly with a copy of the music taped to his chest.  As they neared the top, they stopped to look back, knowing they might never see it again, and they sang this piece.

Can you imagine how the next run-through sounded?

The counterweight on the spirit of vocation is that you have to enroll people on their own terms.  Everybody’s not going to get all dewy about the mission.  My dad worked for Scott Paper Company back when you could tell a papermaker by the short pants and the missing fingers.  I never heard him talk about Scott’s earnings per share and I doubt he carried a wallet card with the corporate creed.  But he and his crew set up the first continuous winding press for the company, proud to be picked to stress-test the new equipment.  Nobility doesn’t have to be grandiose to be grand.

Half a century later one of our sons worked a few hours a week in a day care center at the University of Massachusetts.  He tells the story about trying to teach this little girl about perspective.  She’d colored a picture with some green on the bottom and blue up toward the top with a lot of white space in between.  When he took her to the window and said “do you notice how when you look out there, the sky comes down and the ground comes up and they meet?”  “No it doesn’t” she said…“I’ve been over there…and it doesn’t”.  While it’s true that the first task of leadership is to define reality, the folks you want to go to the future spend a lot of time in it.

Struggle

In the pursuit of any calling there are struggles.  These are the defining moments that shape, test and reveal us for what we really are.  Joe Badaraco wrote a book on such moments, showcasing the supremely difficult task of deciding between right and right; situations where mission, strategy and corporate creed won’t let you off the hook.  The “right vs. wrong” choices are easy.  The true dilemmas, though, are times where you’ve got collateral damage no matter what you do.  Alden Nowlan once again captures this reality in his

Rites of Manhood

It’s snowing hard enough that the taxis aren’t running.  I’m walking home long after midnight with the whole city to myself when across the street I see a very young sailor standing over a girl who is kneeling on the sidewalk and refuses to get up although he’s yelling at her to tell him where she lives so he can take her there before they freeze.  The pair of them are drunk, and my guess is he picked her up in a bar and later they got separated from his buddies and at first it was great fun playing the old salt at port in a city full of women with hinges on their heels, but by now he wants only to find a solution to the infinitely complex problem of what to do about her before they fall into the hands of the shore patrol – and what keeps this from being squalid is what’s happening to him inside: if there were other sailors here it would be possible for him to abandon her where she is and joke about it later, but he’s alone, and the guilt can’t be divided into small forgettable pieces; he’s finding out what it means to be a man and how different it is from the way that only hours ago he imagined it.

Dilemmas…a forced choice between two equally unattractive alternatives…are at the heart one of the hero’s journey archetype, never failing to induce a kind of spiritual crisis.  That’s what makes plays like Les Miz and Fiddler on the Roof so great.  Their plot lines are struggles with universal dilemmas.  We’ve all experienced variations on these dilemmas, each unique and uniquely challenging.

That’s what makes plays like Les Miz and Fiddler so great.  Their plot lines are struggles with universal dilemmas.  You’ve seen hundreds of examples, I’m sure, but I’ll share one that is particularly memorable for me.

Years ago, I inherited a staff member when I joined a company in one of my first supervisory roles.  In the shifting responsibilities that accompany high growth, this employee had been passed along from role to role, never performed well and had become a bit of a joke around the office.  We got along well, though.  We knew some of the same people and enjoyed many of the same things.  We had a job to do, though; a noble purpose, and this was one of the folks I had to rely on.  I tried all the standard stuff…goal setting, feedback, and training…but in a few months it was clear that we weren’t going to enjoy success.  I really agonized over what to do: let it go, deal with it?  I decided that I needed to clean it up.  Several months later I learned of the suicide…a response, I was assured, to a long history of difficulties.  It’s still with me, though…a part of finding myself at the top.

Anyone who agrees to lead agrees to struggle; and as they do, they sign on for those situations in which there’s no guarantee of a good outcome no matter what they do.   I commented earlier that leadership had the capacity to test and even break the spirit…a dangerous, debilitating circumstance for leader and follower alike.  The dispirited leader is one who is stunned at the heavy toll taken by some defining moment.  So we need to be intentional about seeking and extending redemption.

Renewal

My first job after the paper route was bussing tables at Howard Johnson’s.   By mid-summer I’d gotten pretty good at handling the big oval trays.  I could weave through the crowd like a dancer, pretending  I didn’t care who noticed my style and grace.  One afternoon we’d been slammed…two or three tour busses in a row.  The restaurant was a mess until about 3.  This was one of those old HoJo’s where you come in the front, counter to the right, booths to the left and then an open dining room toward the back.  Things had pretty much cleared out except for one old couple in a booth finishing up their vanilla ice cream.  I looked out and said to myself “I’m gonna clean this whole restaurant on one tray”.   So I started to do my thing. I had ketchup bottles and hamburger plates and milk shake glasses all laced in for the ride.  I got to the last booth, wheeled around and caught the edge of the tray on the coat rack; the one just before the old couple with the ice cream.  KKKKKKKKKKKKKKKKK!  Plate hit this guy right in the middle of the head.  Broken glass on the table; leftover burger bits; the woman cut her hand on the glass.  Out came the head waitress and pulled me in the back.    Out came two other waitresses with wet towels.  Out came the manager with the insurance forms.  I shook, I cried, I was white as a sheet.  The manager was a little turd of a guy who took the place a lot more serious than any of us summer kids did.  He looked at every plate on the way out the door and would say things like “no more than six potato chips on a sandwich…it’s a garnish…not part of the meal.  He came back in the kitchen.  I thought I was gonna get fired.  He handed me a tray and said “Mike I think there’s one more table out there.  Do it today or you’ll never be able to do it tomorrow.”   And I loved him.

When I was at HCA in the early 80’s, Forbes put us on the cover as “One of the Five Best Managed Companies in America.”  Pretty heady stuff if you were inclined to believe your own bullshit.  We met the morning after and flipped through the article to see who’d been quoted.  We thought about how life was good; and how appropriate it was that we were at the center of it.  Don McNaughton, our Chairman and former Chairman of Prudential stilled the small talk with his reminder that International Harvester had been on that only a few short years before.  “They give the trophies out when it’s over” he said.  That started a lively discussion of shifts in the market in which we’d made our reputation. This was the platform used to reframe the way the company did business because McNaughton had “redeemed” us from our complacency.

Teens making their first consequential mistakes or adults who’ve let themselves get too comfortable for their own good are able to transform themselves because somebody finds a way to renew their spirit.  In that sense, the dispirited leader is a danger to self and others.

Integrity

So how can those who lead remain open to each of these predictable and recurring crises of spirit: authenticity, vocation, struggle, redemption and integrity?  For me, at least part of the answer lies in leading with integrity; not the dour, earnest, Tom Trublood sense of the word, but by integrating the three primary dimensions of leadership:

The Personal: summoning the courage to really “come as you are”.    The greatest power we have is the power of our personal presence.

The Contextual: discerning what’s really happening and what the highest leverage intervention might be in this specific context.

And the Behavioral: …struggling over what to do about it.  McNaughton led us away from complacency by driving us into reflection.  My friend at the pharmaceutical company, promoted and made an officer because of his achievements, later elected to retreat to his former charter…not because he was right or they were wrong about anything, but because he had no wish to integrate his role into the person he really was.  He could do the job but he couldn’t be the job.

This is the real meaning of integrity.  It’s not just the apple-cheeked resolve to be fair, but the struggle to get it together without becoming flaccid or disempoweringly charismatic; and with no guarantees on the outcome.

Those who lead with spirit stand on the razor’s edge between action and reflection…between an appropriate internal and external focus…because that’s where the best prospect for integrity resides.  Robert Bly’s Things to Think captures that fusion well:

Things to Think

Think in ways you’ve never thought before

When the phone rings, think of it as carrying a message

Larger than anything you’ve ever heard…

Vaster than a hundred lines of Yates

Think that someone may bring a bear to your door,

Maybe wounded and deranged; or think that a moose

Has risen out of the lake and he’s carrying on his antlers

A child of your own whom you’ve never seen

When someone knocks on the door, think that he’s about

To give you something large; tell you you’re forgiven,

Or that it’s not necessary to work all the time,

Or that it’s been decided that if you lie down, no one will die.

Taken together, these five crises of spirit constitute something of a hero’s journey.  En route, an ordinary person is “called to greatness”, summons the courage to try and, with the aid of unexpected helpmates, overcomes a series of obstacles until facing a supreme challenge in which all is apparently lost.  Then suddenly, victory, and with it, a new wisdom with which the hero returns home with a renewed sense of self and the world around him.  Our favorites are the ones where the hero lives.  Even where we are disappointed, though, as in the Gladiator, the wisdom survives as a gift to the rest of us.

My aspiration in sharing this framework has been to map what I believe to be a universal journey toward this deeper sense of integrity and to equip fellow travelers to better navigate the predictable crises along the way.  Oh, and as for this hero business, don’t believe it for a minute.  For most leaders,  it usually means one who is informed by life rather than revered in it.

“Ever step you take is forever. You can’t make it go away. None of it. You understand what I’m sayin?”

When Cormac McCarthy wrote this line he wasn’t referring to the American lifestyle…but he could have been.  Chronic Disease represents almost 75% of US health care costs, affecting 45% of the population or just over 110 million people.  Seven disease states account for most of this, nearly 80 cents on the Medicare dollar going to treat cancers, heart disease, pulmonary disorders, mental disorders, diabetes, hypertension and stroke.  And how much, I wonder, comes from the steps we take that are forever.

Take food.  10% of the country is now a food desert…an area where residents have little or no access to a healthy diet…endless fast food restaurants and convenience stores selling fatty, sugary junk food to overweight customers.  This partially accounts for a tripling of childhood obesity since 1980.  The paradox: open a full-service supermarket in a food desert and people tend to buy the same artery-clogging crap they did down the street…just at better prices by dint of the purchasing power of the supermarket.  Even in food gardens, count the number of people who shop the outer walls of the store vs. how many penetrate the aisles where the trans-fats and glory-Os await.

We’ve got at least three dynamics working against us on this front:

• Consumer preference seems to favor the unhealthy over the Healthy Choice
• Supplier economics, supported by public policy, seem to favor the unhealthiest lines as well, and
• Over the last four years, the price of healthier foods has increased at twice the rate of junk food

So roughly one in three adults is obese…close to 25 million of them diabetic with all the attendant consequences, including shorter lives along with it.  In 2007, the average life expectancy at birth was 78 years.  Obesity may very well change that.  For American women, a rise in life expectancy of 3.3 years from 1980 to 2007 represented just 60% of the gains made by other developed countries…countries that spend 4 to 7 fewer percentage points of their GDP on health care, I might add.  For men: stay tuned.  The prospects aren’t good when the staples are red meat, alcohol and fried food.

The three dynamics above are impossible to shift from the trenches and can’t even be altered from the command posts of the health care industry.  Bending them has to be Job 1 for directors, general managers and policy makers who have more than a casualty management view of the system; people who take seriously the challenge of better health and better care at lower cost.

Reform requires we shift from provider-centric, disease focused, transaction based notions of care to patient centered, person focused and episode based notions

A few posts back, I recalled my Army ’201 File’, lamented the fact that we couldn’t all carry our personal health records with us and gave a nickle’s worth on I-denti-fied, a start-up that’s using personalized RFID technology to do essentially that.  Steve Wise, I-denti-fied’s president, just shared a mock disaster trial they just ran with FEMA in which the company’s solution streamlined processing and facilitated in the response to an actual medical emergency.                                                                      

For context, I-denti-fied is a secure system to positively identify individuals, provide access to a Personal Health Record on-demand and improve patient care through real-time patient intelligence.  The I-denti-fied system provides members with a passive RFID transponder that’s the gateway to a folder of cloud-based facts on their treatment preferences, medications, allergies, clinical condition, diagnostic findings, emergency contacts, and other vital information.  First responders and care-givers are provided with an RFID reader that accesses a member-specific 16-digit ID, unlocking access to the PHR.

This May, the Indiana Department of Homeland Security (IDHS) participated in a multi-state exercise that simulated a 7.7 magnitude earthquake at the New Madrid Fault, followed closely by a 6.0 magnitude aftershock in Southern Indiana’s Wabash Valley Seismic Zone.  Local first responders, county emergency management officials, state and federal personnel, and private sector partners from across Indiana’s 92 counties took part in Indiana’s largest disaster exercise ever.

A key component was the boots-on-the-ground element involving more than 1,200 emergency responders from local, State and Federal levels.   Dozens of units mobilized and deployed in the interest of assessing and refining the response capabilities of law enforcement, search and rescue, disaster relief, animal shelter, civil support, and fire suppression under comparable circumstances.

As it happens, Health Information Management exerts a tremendous gating influence on response time within the first responder community.  Information is typically hand written, usually dated and generally unavailable when needed most.  An inordinate draw-down on time occurs at deployment simply collecting medical history and emergency contacts for the response team.  The utility of the information depends upon the accuracy and availability of the responder’s last physical, inviting downstream problems if the information needs to be used for decision-making.   This challenge is mirrored and magnified many times among the folks for whom mobilization has occurred.

Officials recognized the need to streamline their mobilization efforts and simultaneously provide everybody credentials at each stage of the exercise.

Recalling an earlier exercise, Russ Shirley, District One Task Force Commander noted that “with our old method, we spent over 3 hours checking-in about 65 people…and we really didn’t gather much useable information.”

To meet the needs for both this exercise and business as usual, I-denti-fied worked with District Director Don Hess to integrate a flexible Health Information Management System with their current credentialing process.  The existing system produces a Photo ID Card with a bar code for tracking personnel during mobilization and at the scene.  The I-denti-fied System embeds RFID technology in the card to serve as a unique identifier and a gateway to the responder’s Health Record.  This gateway is agnostic on the record itself; it could be the one provided by an employer, a carrier or a care-giver or can be provided by I-denti-fied and completed during registration or in the field.  This solution supplies the missing link in the provision of intelligence-based health care and supports the evolving credentialing requirements being developed across the country.

“With the use of the I-denti-fied System” said Shirley,” we were able to substantially streamline a cumbersome check-in process.  We registered 125 people…twice what we usually deploy…in less than 30 minutes.  The 2 ½ hours we saved could prove tremendously valuable in a real emergency.   Beyond that, we now have the added benefit of having every responder’s medical information immediately accessible when needed.”

The online PHR eliminates handwritten forms and makes it easy for responders to collect, store and update their health history as it evolves; the secure and confidential access management features provide the medical team with easy access to clinical history from any location.

As an unintended outcome, one of the volunteers did, in fact become ill, disoriented and temporarily lost in the course of the trial. When found, he was quickly identified, his medical record popped on the screen in the ambulance and he was appropriately treated in a matter of minutes.

The I-denti-fied System has proven itself as a valuable tool for both first responders and the Hospitals that support their work.  Over and above the obvious efficiency gains, though, harnessing a reliable and secure Health Information Management System provides immeasurable benefits for those who put themselves in harm’s way.

Wise says that the I-denti-fied solution is currently at work in adult living communities, within select fire departments and among two of the Olympic Teams representing the US in China today.  This is one to watch

We used to make the distinction between a global and a multiple-domestic business…a useful differentiation as we think about the pursuit of “the triple aim”.

Global businesses can be essentially “stateless”, relying as they do upon global supply chains, global research pipelines and capital whose origin is immaterial to the sustainability of the enterprise. Multiple-domestic businesses may seem global because they have common characteristics and can be found everywhere, but they draw on local supply chains, attract local capital and cater to distinctly local tastes.  Although they are similar anyplace they operate, their are few economies of scale, they don’t aggregate well and they need to be replicated end to end wherever they do business.

The treatment end of healthcare has many stateless attributes.  Talent, equipment and knowledge travels easily…as do patients themselves.  Medical tourism is one of the faster growing segments of the industry and virtual healthcare will grow even faster once they get the reimbursement worked out. (I wonder how many doctors take and respond to email from their patients, by the way.  Mine doesn’t; and most of the providers I talk to are afraid it would draw down too much time without compensation: so make an appointment.)

Wellness, on the other hand, is a multi-domestic or even local matter.  People who are into staying well tend to shop locally, prepare foods with local ingredients and exercise with locally available resources…even if its just the stairs at the office.  Some gyms are chains, but they depend upon the vibe created by the local staff for their vitality.  Carlo Petrini’s slow food movement launched in the late 1980s gave rise to a whole generation of counter-fast foodies.  There are even initiatives like the 30 Mile Meal Project and publications like the 100 Mile Diet, evangelized by J. B. McKinnon.

The other sense in which wellness is local is that it originates with a decidedly localized motive. Whereas caregiving interventions are delivered by casualty management systems arising from an emergent or enduring need, wellness interventions are chosen by the individual, absent an emergency. Said another way, you may consent to be treated but you’ve got to want to stay well.  I personally like this implication of local because it enriches the rhetoric about entitlement with a healthy dose of personal accountability.

My dad used to sagely declare that if this is true, its very important. I’ve contended throughout this blog that the problem in health care is not the caregivers, but the system and tried to direct my musings to policy makers, governing board members and general managers since they are the architects and stewards of the system…such as it is.  The implications of seeing wellness as a local rather than a national or even phenomena seem important for this audience as it tries to shape the appropriate response to the mess we’re in.

Several years ago, my friend Clifton Meador, MD wrote a tongue in cheek essay in the New England Journal of Medicine. Cliff is kind of the Will Rogers of health care.  He warned that well people are disappearing.  I should have known it was coming when the invalids became extinct after the advent of Medicare, which demanded specific diagnostic labels even though none applied.

Like Margaret Meade, he reported on the rise of conversations in which everyone has something: high cholesterol, borderline anemia, sleep apnia, lactose intolerance, suspicious Pap smear, attention deficit disorder and codependency.  Cliff noted that the demands for definitive wellness collide with the belief in a diagnostic system that can find only disease.   This pursuit of the unobtainable, combined with clinical tools powerful enough to find the smallest lesion is a setup for diagnostic excess…false positives being the arithmetically certain result of applying  a disease-defining system to a population that is mostly well.

Cliff was underscoring the paradox of a world in which we have no test to distinguish a will person from a sick one….wellness cannot be measured…yet continue to seek it with analytic methods.  This was in the early 90s, nearly 20 years before health reform any rally around a triple aim.  Health Costs were a mere 13% of the GDP.

I thought of this from time to time when I was running the diagnostic accuracy business.  The premise was that subspecialists with “tipping point” experience (10,000 or more similar studies) were most likely to bend the curve in which nearly a third of all cases were misdiagnosed.  And they were…with remarkable results.  But I worried that a diagnostic fellowship so highly refined in detecting disease might not discern its absence.

The more provocative paradox foreshadowed by Cliff’s essay is the pursuit of that triple aim of better health and better care at lower

Dr Clifton K Meador

cost from an increasingly refined and well financed (17% of GDP and rising at twice its rate) care-giving community.  While there may be a science to it, wellness is decidedly non-diagnostic, and non-disease-based.  Are we placing too much weight on one side of a step-ladder?  And what would a re-balancing look like?  More to come…

Clifton K Meador, MD is professor of Medicine at both Vanderbilt and Meharry and director of the Meharry-Vanderbilt Alliance. He has published extensively in the medical literature and is perhaps best known for The Art and Science of Nondisease and The Last Well Person.  He is also author of six other books, including the best-selling A Little Book of Doctors’ Rules

Congressman Ryan’s proposal to privatize Medicare might be worth saving as the platform for an adult conversation worth having.

Ryan is a Profile in Courage for pumping up the volume on the sustainability of our social safety net to the point where almost everyone hears it.  The facts strongly suggest we can’t go on like this. While the AARP and Nancy Pelosi warn seniors (like me) that the mean-spirited Republicans are taking their pills away, John Boehner keep pointing to the undeniable fact that Medicare is the budget problem and the key driver of the deficit. Reality bites, denying us the simple answers we love to hear.

So in thinking about saving private Ryan I found myself helicoptering up to the big questions behind the plan: What do we know about privatization and what do we believe is driving up the cost of care?

Ryan is basically proposing a voucher system, subsidized at lower levels, to activate the free market on behalf of seniors.  It’s worth thinking about what’s salvageable and what might be tweaked in that idea.   So here are two thoughts:

Experience says that if you can harness private capitol in the service of public challenges you can accelerate their solution. Microfinance grew dramatically after its leaders learned how to access capital markets.  Cities, counties and states that have privatized public services are more efficient while their citizens continue to be well served.  Delta Dental and Blue Cross plans that have employed private equity have made dramatic strides on behalf of their stakeholders while preserving their public trust.  I’ve been personally involved with all of these.  I understand full well that greed has to be held in check.  Each environment including the nonprofit and governmental sectors is subject to excess, but the record suggests that each is equally governable .

And Medicare costs, like Cyrano’s nose, march on ahead of us for many reasons.  Chief among them is that no matter who buys, we pay for transactions while people get sick in episodes.  A transaction is a unit of service: a doctors visit, an MRI, a lab test or a prescription, each a profit center all its own.  Its purpose is to complete and repeat.  An episode, on the other hand, is a series of transactions on behalf of a specific individual.  It’s purpose is to restore health.  This is especially important for a Medicare population in which the well visit…a single transaction…constitutes about 10% of the traffic.  Most Medicare recipients with medical conditions encounter 7 or more care-givers across 5 treatment setting in the course of an episode. And 75% of all Medicare is spent on patients with eight chronic conditions.   The essence of the ACO initiative, another idea worth saving but under heavy assault, is to tag the locus of accountability for the care of an individual over the full cycle of care and to pay for that episode by the case rather than buying random transactions by the drink.  And if we coupled that with measuring outcomes (extent of renewed health) we’d have made a sea-state change for the better.

In a system built to produce and pay for transactions, the discontinuity of care creates waste and compromises lives.  The constructive tweak in the battle plan for saving private Ryan, then would be a shift to paying for episodes instead of transactions.

So why not consider the Ryan plan as the wind-sock for episode-based or bundled reimbursement in all but clearly transactional instances.  Altering the payment premise rather than the source would alter the business model for the industry as a whole, using the scale of Medicare as the lever.

Details, I know; but let’s move the rhetoric from Republican vs. Democrat and see if that starts the right conversation.

A shout out to Ron Lennox, my high school track coach for that bit of enduring wisdom.  I was a quarter-miler, one of the guys who are loosing it (and sometimes their lunch as well) as they finish.  As we trained for the State meet, coach Lennox put together a mile relay team made up of myself and three sprinters who ran the 220.  I had the last leg, and we trained for days on passing that baton.  You were done as you approached the hand-off.  You could drop a second or two trying to get it done; the guy grabbing it could take off too fast, or could shuffle out of stride with the guy trying to get it to him; and three chances to screw it up.

Well, we got it down, we prevailed and its all ancient history now; but I thought of coach Lennox the other day as I accompanied someone I know very well on a medical appointment.  (I’ll avoid names so as not to be guilty of a HIPPA violation.)    She’d had some unusual chest pains so arranged to meet with her doctor (of ten years) in her office at the MOB adjacent to the hospital where she practices.  Following the preliminary workup, she sent what was now the patient up one floor for some blood work and a few other tests.  She also sent her across the driveway for a stress test.  So three check-ins; three clip boards…each of which asked for much the same information…and three copies of the insurance card.  One of the tests completed in the doctors office was repeated by the lab (and presumably paid for by the health plan).  The stress test was delayed because the patient had hand carried the pink copy rather than the white one needed by the desk.  And when the patient used her cell phone to call back asking her doctor’s office to fax over the form (the attendant at the desk couldn’t call a referring physician) she was asked to step away from the desk so she couldn’t see the PHI on the screen.   As with my high school track team, we prevailed and its all ancient history now…or is it?

This vignette unfolded in a well funded, allegedly integrated multi-hospital system with a fully deployed electronic medical record platform.  So why the clip boards?  Suspenders and a belt, maybe?  But this scene is repeated with such frequency that the real question is “what can be done to change it“?  To the best of our knowledge, my friend’s problem was relatively benign.  This was not the state meet.  Had it been, we all would have lost it in the hand-offs.