In his first two months as chief of Beth Israel Deaconess Medical Center, Dr. Kevin Tabb has gotten to know the hospital but he has also gone on a Massachusetts health care walkabout. He has circulated through virtually every hospital in Boston as well as some 20 community hospitals, talking to allies and rivals alike.
Nothing like fresh eyes — fresh, informed eyes. (Dr. Tabb made the unusual migration eastward after many years at Stanford.) Here, in a lightly edited chat, he shares his perspective on the state’s health care scene, including his impression that many of us fail to appreciate just how exceptionally rich in excellence we are: “If you take any one of these great institutions alone and put them in any other city, they would be the medical center,” he said, “and we’ve got many.”
Californian colleagues questioned his decision to move to the difficult, competitive health care landscape of Boston, he said — not to mention the nasty weather he would face. His response:
If you really care about effecting change, there has never been a more interesting time, at least in modern history…And Massachusetts is the epicenter of change. We here in Massachusetts are at least five years ahead of the rest of the country in terms of what is going on around experimenting with new models for delivery and health care reform. And the rest of the country will get there but they’re not there yet. I don’t know if people here in the Commonwealth and in Boston understand just how closely the rest of the country is looking at what is going on here as a view of what the future will look like.
Well, certainly, we’re aware that Massachusetts health care has great political resonance, both because of Mitt Romney’s involvement in the state’s health reform and because the federal health overhaul made use of the Massachusetts model.
I’m talking about more than that. Some of what I’m talking about is legislation, but it’s not just legislation. If there were a magic wand and the legislation were to go away tomorrow, hypothetically, you would still see forces here that are forcing really pretty rapid change in health care delivery models that have nothing to do with any single piece of legislation. So it’s a combination of the legislation and regulators, but also of economic forces and, I think, the forces of innovation that exist at this time. Nobody has a monopoly over that.
One problem with past approaches was dividing care into silos: ambulatory vs. hospital; treatment of the sick vs. keeping people healthy. But it was also siloed in terms of thinking of problems and solutions as hospitals separate from payers separate from pharmaceutical companies separate from patient. First of all, we all bear some responsibility for the current situation, although none of us, including hospitals, bear all of the responsibility. And I wouldn’t want to see solutions solely attempted on the backs of a single sector. But we all are only going to be able to solve this together because siloed approaches siloed haven’t worked in the past. The economic forces are aligning here to require us to work together.
Which economic forces?
Clearly the trend of spending on health care nationally and here in Massachusetts is not sustainable. It’s got to change. We feel it, and our patients feel it perhaps more acutely here than in many places. So we’re willing to talk about other models of care that make a lot of sense from a policy perspective, a patient perspective, but have never aligned with the economic incentives before, that all of a sudden do.
I think many physicians and clinicians and patients knew intuitively that it makes sense to take care of people before they get sick, to take care of people in their own communities, to coordinate care. But the system has been geared in a different way, towards, ‘We will incentivize you to do more of whatever it is you do.’ Well, again for the first time, that’s changing. There is no question.
Here’s a concrete example. A significant portion of BIDPO, our physician organization’s population and contracts with payers are now ‘at-risk.’ [Editorial note: 'At-risk' means the doctors aim for an annual budget along with quality benchmarks, and can gain or lose money depending on whether they meet it.] This is not just talking about things, this has actually happened. I think we’ve passed the tipping point here in Massachusetts. The rest of the country has not. I think you’d hear similar things from my colleagues here and throughout the state.
I’ve been here exactly 60 days. I’ve spend most of my time outside the walls of this institution for two reasons. One is, I think w’ere in very good shape. We’re very well run. This is not a turnaround situation. We’ve got a good team in place and I’m very comfortable with where we’re at at this moment.
Also, I spent time outside the four walls of this hospital because the really important changes are going to happen externally as well. So I’ve been to almost every hospital in Boston, which in any other city you could do in a day. And that means going to see people who are collaborators and friends but also people who are competitors. I’ve also been to close to 20 community hospitals outside of Boston, which has been fascinating.
At your initiative?
Absolutely. It’s really important because that’s where much of the care of the future will be delivered, in those community hospitals. It’s not new that Academic Medical Centers want to partner with physician groups and community hospitals, but the type of partnership we’re talking about is very different from the types of partnerships we talked about in the past. In the past we thought about, ‘How do we get more referrals here downtown?’ That’s not the model for the future.
The model for the future is that there will always be a place for good academic medical centers to do the very complex things that can’t and shouldn’t be done elsewhere, to do the incredible research and the outstanding education we do. But if we’re honest with ourselves, there are many things that we do here downtown that don’t have to be done here, that can be done at a level of high quality and at a different cost structure, and in people’s own communities. We need to learn to partner with others in a variety of different models. It’s going to require huge change, and I wouldn’t underestimate the difficulty of that. This is something we’ll all go through. Those of us that understand and change quickly will thrive.
It’s going to require something else on our parts — it may require a level of humility that academic medical centers in general have not always been known for, and an understanding that there is knowledge that resides here but there’s a wealth of knowledge that resides out there too.
How do you keep your revenue flow up if you’re reducing referrals to your mother-ship hospital?
We need to be part of a larger ecosystem so that we can do the things that are really appropriate to do here. And there’s a lot of it, there is, and if you’re part of a large enough ecosystem, there’s that. And we need to share in risk models so when there’s benefit, we share in that as well. I think it’s a combination of models, and this is finally an alignment around good policy, what’s good for the patient, what patients want, and the way things are structured. And that hasn’t been aligned before.
A combination of legislation and economic pressure and a realization from many of us that the model is broken.
But to be clear, we’re just at the beginning of that change and I wouldn’t want to make the claim that it’s all done, or it will all be easy, or by next year this will be done. This will be a lengthy process and painful in nature. Painful because change can be hard and it’s very different from the way we’ve done things before. But there are a lot of people who are really ready to do it.
There are a variety of opinions and I think there’s not going to be a single path forward. There will be a number of different paths, which I think will work and make sense.
But we’re expecting just one payment reform bill to come out of the legislature in the coming months…
I think it will accelerate the things we’re hearing about. Without specifics, the concern with a single bill is as much about unintended consequences as it is about intended consequences. I don’t have a specific issue because you don’t know what will happen, but it’s well known that when changes are imposed with a large single stroke — you sometimes get consequences you don’t intend. That said, I think it will accelerate change.
So what will the health care scene here look like in five years or so?
We’re going to see much more focus on wellness. I think you’re going to see all of us heavily taking on risk. I think you’ll see us partnered in new and different ways, with more of an emphasis on care provided in the community.
What else have you seen on your travels?
I think there’s an understandable combination of some optimism about the fact that forces are aligning with a fair amount of anxiety by a lot of parties trying to understand their own place in an ecosystem that hasn’t yet formed. I think that’s maybe the overarching theme.
And it really doesn’t matter who you talk to, everybody’s still trying to figure out where are they going to be in all of this, and there aren’t clear-cut answers. This is a sort of naturally anxiety-inducing time. But again, I think those institutions that are forward-thinking and don’t wait for it to happen to them, but start to make those changes now, will do just fine.