A tale of one city

Two illustrative stories about health care in today's Boston Globe, with stories by Kay Lazar and Jeff Krasner. While various interest groups squabble about the perceived zero-sum game of who is going to pay for the costs of the health care in Massachusetts, new entrants to the region find a way to gain market share in a small segment of the sector by delivering services at a lower cost.

The problem with the health care "marketplace" is that it is not a real market. There are so many intermediaries that the usual connection between buyer and seller that we see in other fields does not exist. Thus, the incentives for suppliers (doctors and hospitals) to engage in efficiency improvements and value enhancement are extremely slow to emerge. Also, the incentives for consumers to seek greater quality and lower costs likewise are very weak in this field. (This is aggravated, of course, by the lack of transparency about relative quality of providers.)

Then, we overlay on that the fact that government sponsored programs, Medicare and Medicaid and other state subsidized insurance plans, are ruled by administrative fiat and competing political agendas, and we see that over 40% of the delivery of health care is not subject to market influences at all. One result there is the focus on quick fixes that have headline value (not allowing payment for "never" events, for example) that only cover an infinitesimally small portion of the problem but do not address underlying structural problems. Another result is political battles focused on splitting the pie differently but not making the pie the right size or more tasty.

For those of us in academic medical centers, the result will be a gradual whittling away of financial support for the type of clinical care, research, and education for which we were created. We have already seen it on the research side, with cuts at NIH. I predict the next focus in Congress will be on Medicare funding for graduate medical education (residency training).

I have tried to make the point here and in my public appearances that unless academic medical centers prove their value to society as centers for quality and safety improvement and enhancement of operating efficiency in hospitals, the inevitable political response to our pleas will be, "What have you done for me lately? You are the highest cost portion of the health care system, and yet you display no leadership in modeling the kinds of changes we need for it to be sustainable over time."

Ditto, by the way, for the medical schools. When will the thoughtful deans of our medical schools take on the concept of introducing the science of care delivery as a major focus of the curriculum, so that their faculty and new generations of doctors come to believe that field to be as interesting as the study of disease, diagnosis, and therapies? The opportunity exists for leadership opportunities for those universities that pave the way in this arena.

Then, imagine hospitals and medical schools doing this together! As Arlo Guthrie suggests, "Friends, they may thinks it's a movement."

Absent that commitment, the health care agenda will be set by interest groups who will self-interestedly squabble over the distribution of the pie and/or seek commercial advantage by cream-skimming profitable sectors of the health delivery system. Political officials, meanwhile, will follow the votes in setting legislative and administrative agendas. The major institutions that are the crown jewels of the American medical system and were created solely to serve the public good will be, at best, participants in the squabble, and, at worst, passive observers whose assets and programs and influence are slowly but inevitably diminished.