Sunday, February 23, 2014

Hope is on its way

As we consider the imperatives for a health care system that Gene Lindsey espouses, we have to wonder who will get us there.  Clearly it will not be the government, for the government is paralyzed by the conflicting interests of those who seek to extract their share (or more) from the 18% of GDP represented by the health care system.  Legislators and presidents are not very good at resolving what they view as zero sum game.  In that world view, any changes are viewed as what we negotiators call value claiming:  "If I get more you get less." It's hard to build a coalition for change if you view the world in that manner.

While value claiming is part of any set of transactions, the more satisfying part of negotiation is value creation.  Here, we focus on the underlying interests of the parties and satisfy them by engaging in packages of trades that are of low cost to one party and high value to another.  Instead of zero sum, both parties gain.  A coalition for change is created, and blocking coalitions are held off.

Gene's marvelous list is rife with opportunities for value creation.  Look at it again:

1) Care based on continuous healing relationships: Care should be given in many forms not just face-to-face encounters. The system should be responsive 24 hours a day. 
2) Customization based on patient’s needs and values. 
3) The patient as the source of control. Encourage shared decision-making. 
4) Shared knowledge and the free flow of information: Unfettered access to medical records with effective communication between patients and clinicians. 
5) Practice should not vary illogically from clinician to clinician.
6) Safety as a system property.
7) The need for transparency. 
8) Anticipation of need. 
9) Continuous decrease in waste. 
10) Cooperation among clinicians. 

As I have noted:

My view is that inspiration comes from within and is tied to those ethical standards and good intentions that caused people to enter the health care professions in the first place. The leader’s job, then, is not to inspire. It is to use his or her influence to help create a supportive environment that permits the waiting reservoir of such intentions to be tapped.

This kind of leadership has been demonstrated in a number of progressive parts of the industry to date. Who's going to do this on a broader scale?  I'm not sure, but I am carefully watching the growth of several cadres of doctors who believe in the elements in Gene's list and are acting on them.  As one example, I refer to a number of young doctors in CIR (the Committee of Interns and Residents.)  This union, in addition to focusing on the regular economic issues of its members, has placed an emphasis on quality and safety, process improvement, sharing what has been learned, and patient partnership for its members and their hospital workplaces.  These doctors understand that these imperatives are not part of a zero sum transaction, but instead add value to all parties.  I've had a chance to interact with many of them at the Telluride program, but I've also now see many of them in action in their localities.  If this group is indicative of the classes coming up through residency training, we'll be heading the right way.

Indeed, these young doctors go well beyond their workplace in acting to make the world reflect Gene's list.  Here's one example, Kate McCalmont, who wanted New Mexicans to have a better chance of getting health care coverage under the Affordable Care Act. She invented a way to help them. You can see the TV news report here.


Anonymous said...

I totally agree that it will not be government that creates value. I also do not believe that it will be our wonderful academic medical centers. It is going to be the young professionals who create the new world. Older leaders and managers have too much to lose in transition and do not have the energy for the learning curve of value creation.

C Johnston said...

Nice piece. I generally agree with you that the critical component of changing health care for the better is strong leadership and culture. But I also agree with Ashish Jha (here and here that it is not satisfactory to wait for good leaders to show up all over the country. I see government playing a key role in changing incentives slightly so that it is easier for better leaders to emerge (e.g., paying for quality or safety in a meaningful way). There are always unforeseen risks and unintended consequences that arise from any government intervention. Fixing problems legislatively should perhaps be a last resort. Given the nature of the government involvement in our system, however, it is hard to imagine any solution where it doesn't play some role. Additionally, perverse incentive structures often stand in the way of effective leadership instead of facilitating it. I am cautiously optimistic that the government can be a positive force by reorienting the system so that it is at least more rewarding to be an effective leader.

The last point I'd like to make is that I see that list as necessary, but insufficient. It is patient-centered, but it doesn't focus specifically on how to reduce costs. The few points that do touch on cost abstractly (e.g. evidence based decision making, continuous decrease in waste) are not big enough to make health care dramatically cheaper, in my opinion. There is a missing component of new, disruptive, and innovative approaches to providing care that have the potential to make a larger impact.

Thanks for the thought-provoking posts as always!