Category Archives: Leadership Flexibility
The lost art of compromise
In nearly every facet of our lives, all of us are routinely put in the position of trying to settle disputes or disagreements, whether it be with our spouses or significant others, our children, our siblings, co-workers, neighbors, contractors — you name it. It’s part of everyday life. Conflicts arise and we figure out how to resolve them.
Unfortunately, in the politically toxic environment in which we now live, compromise is now perceived as a sign of weakness. Elected leaders are routinely criticized and attacked by fellow party members and their constituents for trying to find middle ground on any issue, particularly those rooted in ideology. The bipartisan agreement reached in Congress last week on gun safety was a rare and welcome exception.
While they hold starkly different positions and come from states that are thousands of miles apart geographically and politically, Senators Chris Murphy, D-Conn., an outspoken proponent of stronger gun safety laws, and John Cornyn, R-Texas, a staunch Second Amendment advocate, found a way to set aside their differences and reach compromise on the so-called Bipartisan Safer Communities Act that was approved by the Senate 65-33 and the House by a margin of 234-193. President Joe Biden signed the legislation into law June 25.
While the new law does not go nearly as far as Senator Murphy and most of his fellow Democrats wanted by, for instance, banning the sale of assault rifles or at least increasing the age to buy them, the willingness to finally get something done after 30 years of Congressional gridlock was a long-overdue victory for common sense.
Bipartisanship has also been evident in Congressional support for military funding for Ukraine and the 2021 Infrastructure Investment and Jobs Act, but little else.
Despite the glimmer of progress in our nation’s legislative branch of government, it appears that polarization now has a firm grip on our nation’s top court. In trying to find middle ground in deliberations on Roe v. Wade, U.S. Supreme Court Chief Justice John Roberts sought this compromise with his five fellow conservatives and three liberals on the bench: support Mississippi’s prohibition against abortion after 15 weeks, but preserve some semblance of reproductive rights for women by not overturning Roe v. Wade or the court’s 1992 ruling in Planned Parenthood v. Casey.
“The Court’s decision to overrule Roe and Casey is a serious jolt to the legal system — regardless of how you view those cases,” Roberts wrote. His incremental approach found no takers among his entrenched colleagues on either the right or the left. Hence, constitutional protections for abortions that had stood for nearly 50 years — and are supported by the vast majority of Americans — were stripped away in a 5-4 vote, leaving the power to individual states.
Unfortunately, bipartisanship can be equally elusive in state capitals around the country, which does not bode well for reproductive rights advocates in 21 states where abortion is now illegal or have “trigger bans” that will take effect within 30 days of the Supreme Court’s June 24 ruling.
Regardless of whether the issue is abortion or other divisive topics such as immigration, gun safety, voting rights, bail reform or LGBTQ rights, governors and state legislators of one controlling party or another routinely dig in and take intractable positions, leaving little or no room for negotiation.
We would all be well served to reintroduce ourselves to the art of compromise, for the good of our family relationships, for the good of our respective professions, for the good of our country and society in general, and even for the good of our own personal health as we consider whether to consume that extra helping of food or another cocktail.
Moderation is key in our lifestyle choices and it could also go a long way in trying to find middle ground with those who have differing opinions. If adversaries are truly motivated to do the right thing, not political gamesmanship, they should always choose their words carefully, listen with an open mind and always be open to making concessions. In short, we should all start by embracing civility.
Patton’s Principles of Leadership
BORN in San Gabriel, California, in 1885, George S. Patton, Jr. was the general deemed most dangerous by the German High Command in World War II. Known for his bombastic style, it was mostly done to show confidence in himself and his troops, says author Owen Connelly.
On December 21, 1945, Patton died in Heidelberg, Germany. The following day the New York Times wrote the following editorial:
History has reached out and embraced General George Patton. His place is secure. He will be ranked in the forefront of America’s great military leaders.
Long before the war ended, Patton was a legend. Spectacular, swaggering, pistol-packing, deeply religious, and violently profane, easily moved to anger because he was first of all a fighting man, easily moved to tears because, underneath all his mannered irascibility, he had a kind heart, he was a strange combination of fire and ice. Hot in battle and ruthless, too. He was icy in his inflexibility of purpose. He was no mere hell-for-leather tank commander but a profound and thoughtful military student.
Everyone is to lead in person.
Commanders and staff members are to visit the front daily to observe, not to meddle. Praise is more valuable than blame. Your primary mission as a leader is to see with your own eyes and be seen by your troops while engaged in personal reconnaissance.
Issuing an order is worth only about 10 percent. The remaining 90 percent consists in assuring proper and vigorous execution of the order.
Plans should be simple and flexible. They should be made by the people who are going to execute them.
Information is like eggs. The fresher the better.
Every means must be used before and after combats to tell the troops what they are going to do and what they have done.
Fatigue makes cowards of us all. Men in condition do not tire.
Courage. Do not take counsel of your fears.
A diffident manner will never inspire confidence. A cold reserve cannot beget enthusiasm. There must be an outward and visible sign of the inward and spiritual grace.
Discipline is based on pride in the profession of arms, on meticulous attention to details, and on mutual respect and confidence. Discipline must be a habit so ingrained that it is stronger than the excitement of battle or the fear of death.
A good solution applied with vigor now is better than a perfect solution ten minutes later.
Cartoon – Need More Leadership
Can we take the long view on physician strategy?
It feels like a precarious moment in health systems’ relationships with their doctors. The pandemic has accelerated market forces already at play: mounting burnout, the retirement of Baby Boomer doctors, pressure to grow virtual care, and competition from well-funded insurers, investors and disruptors looking to build their own clinical workforces.
Many health systems have focused system strategy around deepening consumer relationships and loyalty, and quite often we’re told that physicians are roadblocks to consumer-centric offerings (problematic since doctors hold the deepest relationships with a health system’s patients).
When debriefing with a CEO after a health system board meeting, we pointed out the contrast between the strategic level of discussion of most of the meeting with the more granular dialogue around physicians, which focused on the response to a private equity overture to a local, nine-doctor orthopedics practice. It struck us that if this level of scrutiny was applied to other areas, the board would be weighing in on menu changes in food services or selecting throughput metrics for hospital operating rooms.
The CEO acknowledged that while he and a small group of physician leaders have tried to focus on a long-term physician network strategy, “it has been impossible to move beyond putting out the ‘fire of the week’—when it comes to doctors, things that should be small decisions rise to crisis level, and that makes it impossible to play the long game.”
It’s obvious why this happens: decisions involving a small number of doctors can have big implications for short-term, fee-for-service profits, and for the personal incomes of the physicians involved. But if health systems are to achieve ambitious goals, they must find a way to play the long game with their doctors, enfranchising them as partners in creating strategy, and making (and following through on) tough decisions. If physician and system leaders don’t have the fortitude to do this, they’ll continue to find that doctors are a roadblock to transformation.
Cartoon – Setting Realistic Expectation
Healthcare executives fear for their organizations’ viability without a COVID-19 vaccine
A complete financial recovery for many organizations is still far away, findings from Kaufman Hall indicate.
For the past three years, Kaufman Hall has released annual healthcare performance reports illustrating how hospitals and health systems are managing, both financially and operationally.
This year, however, with the pandemic altering the industry so broadly, the report took a different approach: to see how COVID-19 impacted hospitals and health systems across the country. The report’s findings deal with finances, patient volumes and recovery.
The report includes survey answers from respondents almost entirely (96%) from hospitals or health systems. Most of the respondents were in executive leadership (55%) or financial roles (39%). Survey responses were collected in August 2020.
Findings from the report indicate that a complete financial recovery for many organizations is still far away. Almost three-quarters of the respondents said they were either moderately or extremely concerned about their organization’s financial viability in 2021 without an effective vaccine or treatment.
Looking back on the operating margins for the second quarter of the year, 33% of respondents saw their operating margins decline by more than 100% compared to the same time last year.
Revenue cycles have taken a hit from COVID-19, according to the report. Survey respondents said they are seeing increases in bad debt and uncompensated care (48%), higher percentages of uninsured or self-pay patients (44%), more Medicaid patients (41%) and lower percentages of commercially insured patients (38%).
Organizations also noted that increases in expenses, especially for personal protective equipment and labor, have impacted their finances. For 22% of respondents, their expenses increased by more than 50%.
IMPACT ON PATIENT VOLUMES
Although volumes did increase over the summer, most of the improvement occurred in areas where it is difficult to delay care, such as oncology and cardiology. For example, oncology was the only field where more than half of respondents (60%) saw their volumes recover to more than 90% of pre-pandemic levels.
More than 40% of respondents said that cardiology volumes are operating at more than 90% of pre-pandemic levels. Only 37% of respondents can say the same for orthopedics, neurology and radiology, and 22% for pediatrics.
Emergency department usage is also down as a result of the pandemic, according to the report. The respondents expect that this trend will persist beyond COVID-19 and that systems may need to reshape their business model to account for a drop in emergency department utilization.
Most respondents also said they expect to see overall volumes remain low through the summer of 2021, with some planning for suppressed volumes for the next three years.
Hospitals and health systems have taken a number of approaches to reduce costs and mitigate future revenue declines. The most common practices implemented are supply reprocessing, furloughs and salary reductions, according to the report.
Executives are considering other tactics such as restructuring physician contracts, making permanent labor reductions, changing employee health plan benefits and retirement plan contributions, or merging with another health system as additional cost reduction measures.
THE LARGER TREND
Kaufman Hall has been documenting the impact of COVID-19 hospitals since the beginning of the pandemic. In its July report, hospital operating margins were down 96% since the start of the year.
As a result of these losses, hospitals, health systems and advocacy groups continue to push Congress to deliver another round of relief measures.
Earlier this month, the House passed a $2.2 trillion stimulus bill called the HEROES Act, 2.0. The bill has yet to pass the Senate, and the chances of that happening are slim, with Republicans in favor of a much smaller, $500 billion package. Nothing is expected to happen prior to the presidential election.
The Department of Health and Human Services also recently announced the third phase of general distribution for the Provider Relief Fund. Applications are currently open and will close on Friday, November 6.
Cartoon – Importance of Change
U.S. says it won’t join WHO-linked effort to develop, distribute coronavirus vaccine
The plan, which is co-led by the WHO, the Coalition for Epidemic Preparedness Innovations and Gavi, the vaccine alliance, was of interest to some members of the Trump administration and is backed by traditional U.S. allies, including Japan, Germany and the European Commission, the executive arm of the European Union.
But the United States will not participate, in part because the White House does not want to work with the WHO, which President Trump has criticized over what he characterized as its “China-centric” response to the pandemic.
“The United States will continue to engage our international partners to ensure we defeat this virus, but we will not be constrained by multilateral organizations influenced by the corrupt World Health Organization and China,” said Judd Deere, a spokesman for the White House.
The Covax decision, which has not been previously reported, is effectively a doubling down by the administration on its bet that the United States will win the vaccine race. It eliminates the chance to secure doses from a pool of promising vaccine candidates — a potentially risky strategy.
“America is taking a huge gamble by taking a go-it-alone strategy,” said Lawrence Gostin, a professor of global health law at Georgetown University.
Kendall Hoyt, an assistant professor at Dartmouth’s Geisel School of Medicine, said it was akin to opting out of an insurance policy.
The United States could be pursuing bilateral deals with drug companies and simultaneously participating in Covax, she said, increasing its odds of getting some doses of the first safe vaccine. “Just from a simple risk management perspective, this [Covax decision] is shortsighted, she said.
The U.S. move will also shape what happens elsewhere. The idea behind Covax is to discourage hoarding and focus on vaccinating high-risk people in every country first, a strategy that could lead to better health outcomes and lower costs, experts said.
U.S. nonparticipation makes that harder. “When the U.S. says it is not going to participate in any sort of multilateral effort to secure vaccines, it’s a real blow,” said Suerie Moon, co-director of the Global Health Center at the Graduate Institute of International and Development Studies in Geneva.
“The behavior of countries when it comes to vaccines in this pandemic will have political repercussions beyond public health,” she added. “It’s about, are you a reliable partner, or, at the end of the day, are you going to keep all your toys for yourself?”
Some members of the Trump administration were interested in a more cooperative approach but were ultimately overruled.
Health and Human Services Secretary Alex Azar and Deputy Secretary of State Stephen Biegun had interest in exploring some type of role in Covax, a senior administration official said, speaking on the condition of anonymity because they were not authorized to discuss the decision-making.
But there was resistance in some corners of the government and a belief that the United States has enough coronavirus vaccine candidates in advanced clinical trials that it can go it alone, according to the official and a former senior administration official who learned about it in private discussions.
The question of who wins the race for a safe vaccine will largely influence how the administration’s “America first” approach to the issue plays out.
An unlikely worst-case scenario, experts said, is that none of the U.S. vaccine candidates are viable, leaving the United States with no option since it has shunned the Covax effort.
Another possibility is that a U.S. vaccine does pan out, but the country hoards doses, vaccinating a large number of Americans, including those at low risk, while leaving other countries without.
Experts in health security see at least two problems with this strategy: The first is that a new vaccine is unlikely to offer complete protection to all people, meaning that a portion of the U.S. population will still be vulnerable to imported cases — especially as tourism and trade resume.
The second, related problem is that a U.S. recovery depends on economic recovery elsewhere. If large parts of the world are still in lockdown, the global economy is smarting and supply chains are disrupted, the United States will not be able to bounce back.
“We will continue to suffer the economic consequences — lost U.S. jobs — if the pandemic rages unabated in allies and trading partners,” said Thomas J. Bollyky, a senior fellow at the Council on Foreign Relations and the director of its global health program.
Proponents of a multilateral approach to global public health would like to see all countries coordinate through Covax. Perhaps unsurprisingly, interest is strongest from poor countries, while some larger economies are cutting deals directly with drugmakers.
WHO officials have argued that countries need not choose — they can pursue both strategies by signing bilateral deals and also joining Covax.
“By joining the facility at the same time that you do bilateral deals, you’re actually betting on a larger number of vaccine candidates,” Mariângela Simao, a WHO assistant director for drug and vaccine access, said at an Aug. 17 briefing.
If nothing else, the United States could pledge surplus vaccine doses to Covax to ensure they are distributed in a rational and equitable way, experts said.
Some cautioned against a focus on “winning” the race. Given the complexity of supply chains, vaccine development will necessarily be a global effort, regardless of whether countries want to cooperate.
The decision to steer clear of Covax comes at a time of tremendous change for health diplomacy.
The United States has long been the biggest donor to the WHO and a major funder of vaccine initiatives.
In the early days of the coronavirus pandemic, Trump praised both China and the WHO for their handling of the outbreak. But as the crisis intensified in the United States, he turned on the U.N. health agency.
In April, he announced a freeze on new U.S. funding. Not long after, the State Department started stripping references to the WHO from fact sheets and rerouting funds to other programs.
By July, the administration had sent a letter signaling its intent to withdraw from the WHO.
But untangling the United States from the agency it helped found and shape is not simple — and the terms of the separation are still being assessed.
It is not yet clear, for instance, whether a U.S. withdrawal means the United States will just stop its contributions to the WHO or whether it will stop funding any initiative linked to the agency in any way.
For instance, the White House no longer wants to work with the WHO, but the United States is a major supporter of Gavi, which co-leads the Covax project.
Asked to comment on the Covax decision, a State Department spokeswoman pointed to U.S. funding for Gavi, as well as money for such programs as UNICEF and the Global Fund to Fight AIDS, Tuberculosis and Malaria.
J. Stephen Morrison, director of the Global Health Policy Center at the Center for Strategic and International Studies, said the White House could still reverse course and join Covax, or at least let the Senate fund through Gavi — a political workaround.
“This just shows how awkward, contradictory and self-defeating all of this,” he said. “For the U.S. to terminate its relationship with the WHO in the middle of a pandemic is going to create an endless stream of self-defeating moments.”
Cartoon – Big First Step toward Bi-Partisanship