Leeba Ruth Lessin was a giant in the healthcare industry prior to her untimely death in January ... [+]
Last January, healthcare lost of one its most original thinkers in Leeba Lessin. From 2006 to 2015, Leeba led CareMore, the pre-eminent integrated health plan and provider organization focused on addressing the needs of high-cost, high-need patients. For years, CareMore has been regarded as a model for the future of healthcare. Many of the current crop of startups focused on improving care for the elderly (Devoted, Oak Street, Landmark, Alignment, and others) drew inspiration (and talent) from CareMore (now part of Anthem, Inc).
I met Leeba in 2014, when she was looking for someone to succeed her when she retired from CareMore. I had heard of CareMore, but I hadn’t heard of Leeba. When I first met her, it was clear to me that I was in the presence of someone special—someone who saw the world with uncommon clarity, who operated with an unshakeable moral compass, and whose big intellect was only eclipsed by her massive heart. When I was offered the opportunity to work with her, I left behind an established life on the East Coast and moved to California to learn from her. And learn from her I did.
Over the course of the next several years, Leeba became one of my best friends and closest mentors. I’ve had the privilege to work with many notable healthcare leaders—but none have been more influential in my life.
When Leeba told me that she’d been diagnosed with the cancer that eventually took her life, one of my first thoughts was that she needed to write a book. I wanted her thinking to outlive her.
Unfortunately, she never had a chance to write that book. But before she passed away, I promised her that I would share the lessons she’d taught me with others. “Carry it all forward,” she told me in the days preceding her death.
And so I am. Here are some of the lessons she taught me.
In fee-for-service healthcare, everyone profits when patients are sicker.
Leeba was frustrated by the notion that the US healthcare system’s profit pools are based upon people being sick. When a patient is sick, doctors bill for visits. Hospitals bill for procedures. Home-health vendors bill for in-home visits. Pharmaceutical companies bill for drugs. Durable medical equipment suppliers bill for their goods.
Whereas some think the way to change profit motives in healthcare is to nationalize the system, Leeba instead thought the solution lay in long-term global capitation arrangements, where every party at every point along the healthcare delivery pipeline has an incentive to keep patients healthier. On this front Leeba was no hypocrite; she implemented global capitation arrangements at CareMore and demanded a cost-consciousness among her team members. For Leeba, saving even pennies was part of the mission.
Capitation is freedom, not risk
Global capitation is the payment model by which healthcare organizations are paid a per-person fee to manage all of a patient’s healthcare expenses. Many healthcare organizations refer to accepting global capitation as “taking risk,” because the organization is “at risk” for all of the medical expenses incurred in order to provide care to the patient. The truth is many physicians and hospital systems are uneasy about capitation because they don’t want the pressure of assuming financial risk for patient care.
In Leeba’s view, this framing was all wrong. “Capitation is freedom, not risk” she used to say. Capitation enables physicians and health systems to make necessary investments in order to manage costs. At CareMore, when we learned a patient didn’t have a refrigerator in which to store insulin, we bought her a fridge. When patients missed medical appointments because they couldn’t find rides to their doctors’ offices, we paid for rides. Refrigerators and Lyfts are much cheaper than untreated diabetes and missed doctors’ appointments.
Leeba believed that far too many organizations avoid capitation out of fear of “risk.” Instead, she insisted they should view it instead as the freedom—finally!—to do what’s right for patients.
Healthcare should be outbound, not inbound
The US healthcare system’s chassis primarily relies on patients making appointments and visiting their doctors as needed. Leeba believed that this orientation was mostly backward. Instead, she said that healthcare organizations should be constantly surveilling data—and should be proactively reaching out to patients, not waiting for them to show up. Diabetics don’t need their hemoglobin A1C checked every six months during primary care appointments; they need proactive, regular support to ensure that they are eating right, exercising regularly, and taking medicines as directed. Frail, home-bound patients should not have to make heroic efforts to come into the office for a check-up; teams of physicians and nurse practitioners should visit them in their homes.
Outbound care should be the default, said Leeba—a position she thought would be obvious to any healthcare organization that pursued global capitation.
All patients shouldn’t be treated equally
Healthcare is increasingly focused on standardization. Plan benefits. Clinical programs. Clinical protocols. For Leeba, at the root of this standardization was a well-intentioned, if somewhat misguided belief that “all patients should be treated equally.”
Leeba rejected this idea and believed patients who had more intensive healthcare needs should have access to more intensive interventions. Some patients might require daily follow-ups. Others weekly, others monthly, and, still others, annually. Healthcare too frequently fails to titrate interventions to the needs of the individual and Leeba believed incorporating this kind of variability was a key design principle for the healthcare system of the future.
Jargon is the enemy
Leeba hated jargon. Her most hated phrase was “value-based care.” She was a fan of plain speak and believed that jargon, as much as anything else, gets in the way of our ability to move towards healthcare that is high in quality and low in cost. “Population health” and “social determinants of health,” two common darlings of the healthcare reform set, should just be referred to as “doing the right thing for patients.” “Top of license” should just be “making the best use of the team.” The invention of terminology might serve academics and industry pundits—but it does little to serve patients. Full disclosure: I had to thoroughly deprogram myself when I went to work with Leeba.
You can only manage what you can measure
Another reason Leeba disdained what is frequently referred to as “value-based care” is that so much of what passes for it is disconnected from clinicians’ daily reality. It’s not just a meaningless piece of jargon; it’s also an abstraction.
Leeba insisted on creating metrics that could be evaluated on a daily basis, and that enabled clinicians to measure whether they were successful in keeping patients healthy. For instance, at CareMore, we operated with the daily discipline of measuring our inpatient “bed-days,” meaning the number of patients who were in the hospital on any given day. If we were successful at managing patients’ chronic diseases, we were successful in keeping them out of the hospital and their bed-days were low. If we weren’t—then the bed-days were high and so, too, were healthcare costs. “The numbers don’t lie,” Leeba would say, adding, characteristically, “only expect what you plan to inspect.”
You can’t change without changing
Leeba was frustrated by how many healthcare leaders and organizations wanted to drive change, innovation and transformation, but then got stuck in the usual cycles of incrementalism and consensus-building. To Leeba, many who were in positions to drive change were not leaders, but instead corporate politicians who were less interested in doing the right thing than they were in going along to get along.
People at other health systems whose reform efforts often were bogged down in pilot programs would ask Leeba how CareMore was able to continuously innovate to improve care. “You can’t change without changing,” Leeba would tell them. Which is to say: real change requires real trade-offs and not just talk. Too many healthcare organizations are stuck because, while they say they want to change, they don’t want to make the sacrifices that are necessary to bring about true reform.
You can’t change something until you know something
When I first started at CareMore, Leeba advised me to “get to know this organization before you try to change this organization.” It is a lesson I repeat almost daily to new recruits. Too often, in the rush to “make a difference,” new leaders opine on things without a full appreciation of the complexities of what is happening or an understanding of why things are structured the way they are. To Leeba, “Shoot first, aim later” leadership was incredibly common—and also at the root of how ineffective many leaders are in their roles. Take the time and invest in understanding, she’d counsel, and make change that is informed by an understanding of people and history, as opposed to thoughtlessly implementing change for change’s sake.
Most employees at healthcare companies don’t care about the stock price
Too many leaders at healthcare organizations lead conversations with employees with references to the stock price without realizing that most employees are not concerned with it. Most employees of private companies don’t have any material amount of stock and could care less about whether it went up or down yesterday. Mostly, they are concerned about whether the company is doing well enough that they will continue to be employed and whether the company supports them in helping patients.
I will always remember Leeba’s last trip to a CareMore care center when she was CEO. A receptionist asked if they could have a fish tank for the waiting room of the care center. Without thinking much, she said yes. When we walked out of the care center, she told me that the fish tank was a modest investment that would make employees feel visible, valued and heard. The fish tank was installed a week later.
There are some things you only learn how to do once you do them
When I asked Leeba why she was willing the hand the reigns of CareMore, the company into which she’d poured so much of her time and energy, to me—a 35-year old first-time CEO, she told me that there are “some things you can only learn how to do once you do them.”
When Leeba was 20 years old and just out of college (she was the first in her family to attend), she was hired to be the secretary of a local medical society in Santa Barbara, California. When the CEO of the group was fired eight weeks later, the physicians made Leeba the leader of the group. She had so quickly grasped the nature of the work and impressed the doctors with whom she worked that they committed to supporting her despite her inexperience. Leeba made a career of giving people (like me) a shot before others did—because she herself had been given an opportunity early and made the most of it. She made unconventional personnel choices like this throughout her career and was rewarded richly for them. It’s an example I’ve followed with similar results.
Leeba taught me and many others important lessons about healthcare, leadership, and life. Those of us who knew her miss her every day—but every single one of us is better for having known her.
As we near the one-year anniversary of her death, I’m working with others to honor her memory in a way that seems fitting, considering how much she taught me and others. We are sponsoring an internship in Leeba’s honor at the National Academy of Social Insurance, so that young people with a passion for improving the lives of others can begin their own journey toward learning, understanding and driving change.
