Consequential Impact

I have been contemplating what it means to have a consequential impact in my work.  “Consequential impact” is what Eisenhower Fellowships asks of its Fellows in return for the substantial investment that the organization makes in them.

This contemplation has at times overwhelmed me.  I completed my trips to Germany and Mexico three months ago.  What has changed?  What have I been able to accomplish?

I dread that I will be that one Fellow who doesn’t deliver the goods.

If it were just that I failed to live up to EF’s expectations, that would be bad enough.  What makes it worse is that I dearly want to make a difference in people’s lives.  I want to leverage the Eisenhower experience into impact for the people I serve at Casa de Salud and through various other organizations that I contribute time and effort.  To fail at that, that’s the thought that truly sends a tremor through me.

Last week, I sat down and talked with one of our patients, something that, regrettably, doesn’t happen very often.  He told me how he tells people that he wasn’t born in Mexico, but at Casa de Salud, because that’s where he was “born again.”  He’d had a heart attack, and my staff was able to correctly diagnose it and get him the emergency attention he needed.  Then post-recovery, we have been providing on-going follow up treatment for him.

It occurred to me that this was a pretty consequential impact.  A man’s life had been saved. A family had been preserved.  And no, it wasn’t a direct result of my Fellowship – it was, in fact, a testament to the skills of my staff – but this is what I signed up for when I took the job at Casa, and it’s what I want to enhance through EF. 

My wife reminds me that it’s ego and ambition that I have to worry about.  Consequential impacts take many forms, and can take much time.  If I am hell-bent on hitting a home run right now, I might miss the opportunity to do important but long-term and perhaps low-visibility work. That made me think again of my blog post about the talents, and that my job is to do the best I can with what I have, and help others to do the same.  So I continue to use the EF experience to inspire my work now, and position myself to do whatever tasks are placed before me in the future.

The Comprehensive Primary Care Initiative

I was reading about a provision of the Affordable Care Act (ACA) called the Comprehensive Primary Care Initiative that, among other things, provides funding for Care Coordinators and other incentives to do team-based approaches to delivering healthcare.  One of the main goals is to free the physician from a fee-for-service model to enable them to do a better job of chronic disease management.

Needless to say, I’m very pleased that the ACA is trying to impact a very difficult and costly area of patient care.  I’m also proud to say that Casa de Salud has already been taking this approach for almost two years.  We have an RN Care Coordinator in place who can reach out to patients before, during and after appointments, which improves show rates and compliance.  Her work also affects outcomes, because she can track how a patient is doing over the course of our interventions (whether in our clinic, at a partner organization, through our Home Visits Program, or a combination of the three).  If a particular indicator (maybe an A1C level for a diabetic patient) is going in the wrong direction, the Care Coordinator can reach out to speak with the patient, try to understand what is going on, and take the appropriate action.  We also offer diabetes education free of charge to all of our patients, another aspect of care promoted by the ACA.

We have seen the impact generated by this form of care.  Patients who had highly elevated A1C levels are now at or near normal. Many who were struggling to make lifestyle changes are now implementing them and seeing reduced weight and blood pressure.  Most importantly, our intervention is supporting the patients’ own desire to control their illness and get better.  And all of this achieves significant cost reduction, both for the patient and for the healthcare system itself, which means savings for all of us as the expense of uncompensated care is reduced.

 
That is what Casa has been able to achieve through the vision of our Board of Directors, the collaboration of many partners, and the generosity of our funders. I’m glad to see that the ACA is working to mainstream this type of approach.

A Wedding or a Funeral

I had the good fortune of spending the last weekend of September in Florida for my cousin Bernadette's wedding. The whole family was assembled for the occasion. There was a lot to celebrate.

My cousin has lupus, and that disease has made life very difficult for her. But Bernadette is a fighter with a very supportive fiancée (now husband). So it was that, after countless times in the hospital, myriad medications, and finally a kidney transplant, Bernadette arrived at her wedding day.

That day would not have been possible if she hadn't had access to the best our healthcare system can provide.  We can and will debate about how the costs of care are shared and distributed, and how we manage finite resources in the face of large demands. But that debate should take place in the context of the lives that are at stake.  It's too easy to lose sight of the fact that our political decisions and our policy making are not abstract discussions. They affect real human beings.  For my family, accessible care was the difference between celebrating a wedding and attending a funeral. 

That, I think, is what should ground all our discussions about healthcare. 

Trump-etilla

I was unexpectedly interviewed by a local news channel after Donald Trump threw Univision anchor Jorge Ramos out of his press conference and said that illegal immigrants were partly responsible for the events in Ferguson.  I granted the interview because I thought it was important that we all, in any way we can, push back against Trump's xenophobia and the tacit legitimacy he is giving to the worst elements in our country.  Here is the interview (very short).

Talent

I rarely write publicly about spirituality or religion, especially my own.  But last week I went to an event where the gentleman who was speaking reinterpreted the Parable of the Talents. 

For those who are unfamiliar, the usual take from the pulpit when this passage takes its turn in the Lectionary at Sunday Mass is that God has entrusted each of us with certain gifts.  Some may have more than others, but all are called - actually, obligated - to put what gifts we have to use for world around us. And if you don't, well...in the passage, the Master expels the servant who buried his Talent "into darkness" where he will weep and gnash his teeth.

This parable more than any other has occupied my mind in adulthood. Am I using my talents to the best of my ability?  Am I using them as God intended?  What about when I get cynical and discouraged (easy to do in the non-profit world, I'm afraid) and just want to chuck it and get a corporate job and make money?  More pointedly, am I the guy in the story with the one talent, and what is the Master going to think of me when I face him with my meager return on his investment (or heaven forbid a loss)?

So I was quite taken when, listening to a speech at an awards ceremony, the speaker said he had a different take on this parable.  What if, he said, the other two servants, instead of just doing their thing in an "every man for himself" fashion, helped each other?  What if they recognized that the servant with one talent didn't know what to do, was afraid, was disoriented to point that he couldn't think of anything else but to bury the talent?  What if they had partnered with him?  They might not only have spared him from the Master's punishment, they perhaps would even have brought out the talent in him that the Master first recognized and, in so doing, increase their own return from 10 fold to 20 fold.

That really resonated with me.  None of us should have to be the guy blowing in the wind.  At some point, depending on the circumstances, we will each be the person with five talents, two talents, and one talent.  It is incumbent on us to reach out and work together for a collective impact that even the person with five talents would not be able to accomplish on her own.

I left that session inspired.  But there was still something gnawing at me. Regardless of the results, why would the Master - God - react with such anger and hostility?  He is supposed to be a compassionate ruler, and after all, the servant didn't steal his money or spend it illicitly. He did nothing worse than return what he was given.

In the past week, I have thought about this a lot, and came to the conclusion that we must still need to reinterpret some more, because it is inconceivable the God that Jesus constantly describes as loving and merciful and who he addresses as "Daddy" should act like the Master in that parable. 

That led me to borrow from psychology. As Freud and many others have shown, the ego is a powerful force within us.  I started, then, to wonder if the Master in the story is actually us.  I am all too aware of my flaws and personal insecurities, and the very real sense of failure that these can engender. Extrapolating from this to the telling of the parable, it's not a big stretch to think that the humans who wrote the Gospels from an oral tradition would have painted the Master in the way they would have expected him to act and reflecting their own deeply seated fears. The Master, then, is not a benevolent God, but our own fear of failure and separation from others.

This is a lesson I'm trying to hang on to.  When I go it alone, when I treat my organizational or personal success as a zero sum game, at best I diminish my returns and at worst I subject myself to feelings of resentment and unworthiness that are bad for me and for the ability of my organization to accomplish its mission of serving people.

Adios México

Today I concluded my trip to Mexico with a visit to a maternal health clinic that focuses on pregnancies with no-to-low complications and, through coaching and education, tries to help lower Mexico's enormous rate of cesarean procedures (almost half of all children here are delivered via c-section). I also visited a government agency that helps repatriate Mexicans who are deported from the United States. They have a dozen offices at the border, and one at the airport in Mexico City where every Tuesday and Thursday at 11:00 am a plane arrives with 135 deportees. It's always 135, the maximum number the plane can transport.  The authorities expect two additional weekly flights will be added.

My 18 days here were well spent. I return to the United States with a much deeper appreciation of a nation that is and will continue to be an important partner for our future in America.  I have new colleagues with whom I can collaborate on ways and means to serve the immigrant population.  And I feel even more deeply embedded in a community of people who are committed to providing the best possible healthcare to all human beings, regardless of their circumstances.  

I cannot begin to say how happy I am to be even a tiny part of this effort on behalf of others.  It gives my life tremendous meaning, great joy, and - I hope - serves as an exemplar for my daughter on what it means to be fully alive.

My Week in Mexico

It was a full week here in Mexico.  Highlights:

* A tour of the Clínica Amistad on the Santa Fe campus of Hospital ABC, a clinic totally devoted to preventative services.

                                               With Dr. Lourdes Rivas of Clínica Amistad

* An overview of how some private hospitals have incorporated the Toyota Production System and the philosophy of Just Culture into their operations.

* An in-depth discussion about Seguro Popular with Mexico's National Commissioner of Social Protection in Health, Dr. Gabriel O'Shea.

                                                           With Dr. Gabriel O'Shea

* A presentation on the complexity of the myriad issues surrounding immigrants and health with Haydeé Pérez and José Knippen of Fundar.

                                               With Haydeé Pérez (left) and José Knippen

* A visit to the Office of Intercultural Development to better understand the roles that traditional and alternative medicines play in the modern Mexican healthcare system.

* The education and training of doctors at the University of Anáhuac.

* A deep dive into data about socioeconomics and international migration at CONAPO.

                                                      With staff members of CONAPO


* Impact measurement and data evaluation at the Office of Evaluation and Performance.

                                                          With Dr. Rubén López Molina

And these are just the highlights, not even mentioning other interesting parts of the week (like Teletón, Mexico's equivalent of the Jerry Lewis Telethon).

                                                 With Tania Karasik of Fundación Teletón

It is very difficult to distill all I saw, heard and learned over the course of the past week into this post, so I will constrain myself to some impressions.

My initial sense that Mexico puts an immense amount of effort into prevention was reinforced.  It was amazing to visit a clinic the size of Casa de Salud that was 100% about promoting and enabling the prevention of disease; to see multiple programs aimed at reducing teenage pregnancy (including movie-quality PSAs aimed squarely at pre-adolescents and teens with explicit messaging - "it's not about preventing sex, it's about preventing pregnancy and disease"); and the government-sponsored bike riding classes to get young children active as soon as possible.

Although Seguro Popular has theoretically led to universal access, to a certain extent this is true only on paper.  As I mentioned previously, coverage does not necessarily equal access, and that is certainly true here. As just one example, Seguro Popular may cover your costs for treatment, but if you live in the state of Chihuahua, which, despite being the largest of Mexico's 31 states, has only two hospitals, then you're going to have a difficult time having your healthcare needs met despite no out-of-pocket costs.

Medical students in Mexico must serve one year in a Level One clinic (basic non-urgent care, similar to community clinics in the U.S.) before being granted their official MD. Not only does this enhance Mexico’s prevention efforts, which locally are often centered at these clinics, it also inculcates a sense of service into the providers.  How I would love to have Casa de Salud and the more than 1,000 other community clinics in the U.S. benefit from this type of mandate.

By the admission of many of the people I've spoken with, Mexico lags in metrics and measurements and their evaluation.  Still, they are not ignorant of the importance of these issues and people like Dr. Rubén López, who I met at Office of Evaluation and Performance, are working diligently to bring the country up to speed (I am grateful that he took the time to review my information about Casa de Salud's operations and make some excellent suggestions about how my clinic can do better in its own impact evaluation).

So what am I left with?  I am in a country with constrained resources (spending just above 6% of GDP on healthcare when the average in Latin America is 8%) and large swaths of territory that are rural and remote, yet has a Constitution that declares healthcare a human right guaranteed to every Mexican and is trying (especially through Seguro Popular) to live up to that ideal.  Its system is complex, fragmented, and siloed, leading to different levels of access and outcomes.  Given this set of facts, it is making an enormous effort to push and prod the population to adopt healthier lifestyles that will unburden the system and free up resources to deal with existing chronic illnesses and an aging population.

In short, though the particular circumstances are unique to Mexico, the country shares the challenges of most other nations of scale:  how to best use finite resources that are always inadequate to the overall need; how to improve outcomes without untenable cost increases; and how to engage the entire citizenry in being responsible for its collective health.  And where there are similar challenges, there is an opportunity to find solutions from cooperation.

This is what I find particularly satisfying about the Eisenhower Fellowships experience. One of the main ideas behind the program is that there is mutual prosperity to be had when nations learn from each other. This premise has been affirmed by my visits to Mexico and Germany, combined with my native understanding of the United States. Each country does certain things very well, while other aspects are lacking.  Each has a different philosophy, but all are trying to achieve the same general result: a healthy population.  To the extent that we are willing to examine what other peoples are doing and have the humility to, when it makes sense, adopt or adapt their strategies that are working, it can only help us. And given the ever-growing global nature of health (can you say Ebola?) it is in all our best interests to do so.

Of Costs and Benefits

I had a really excellent discussion with Alejandro Alfonso, CEO of the Hospital ABC.  I was so impressed that I now think of him as my personal bar setter, the administrator I hope I can evolve to be.

                                                                     Alejandro Alfonso

Some of the highlights of our conversation revolved around the cost/benefit equation of service delivery and the role of technology.  But it started with his assertion that the pillars of a prosperous (with all the things that word encompasses) society are education and healthcare.  The two form a feedback loop.  Education leads to self agency and economic self sufficiency, both of which have a direct impact on health status.  In the same vein, a lack of access to quality care (and Alejandro noted that insurance coverage does not by itself equal access) can negate the advantages of a quality education.

This is also why, Alejandro asserted, healthcare cannot be treated as just another market (a sentiment that I and many others share who critique those who believe that healthcare is a commodity).  If you have a tumor, Alejandro said, you can't go to the surgeon and say, "Take a third of the tumor out now, and I'll come back to you for the rest of it after I've saved up some money."   Thinking of healthcare as just another thing that consumers purchase is misguided.

Of course, providing those services is expensive, which is why Alejandro places a premium on a cost/benefit analysis based on hard data.  Just because you can provide a service doesn't necessarily mean you should. He referenced my earlier conversation about the robot assistant in Zacatecas.  That robot, he noted, costs $140,000 per year in maintenance costs. It might still be a good investment, but you have to show that the investment in this particular item produced results that could not have been obtained otherwise or that were more impactful than another area where you could have spent the money. If not, you might end up with marginal improvements at immense costs.

Alejandro went on to provide a personal example.  Years ago, a certain medical center had lobbied to purchase a very expensive diagnostic machine, the next generation of the equipment the center currently had.  As it happens, Alejandro had to have back surgery, and they told him that now he would see how good this piece of equipment was when it was used on him pre-op. When Alejandro came for his appointment, though, the machine was inoperative.  So they used the first generation machine, which had not yet been discarded. Alejandro made an inquiry from the tech, who said that the next generation machine was faster, but that was about it.

Alejandro thinks of this as a cautionary tale. If you're not careful, he said, you can find yourself in the conundrum of "el cómo sin el qué."  Which is to say, you should first know what you want to achieve before you start talking about how you're going to achieve it.