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Health Care Reform
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December 31, 2007

For Health Care to Transform, Must the Status Quo Be Viewed As A Disaster?

"Our only mistake would be to give up and accept defeat"


By Mike Magee, MD

A recent article by Richard MacLean, Executive Director of the Center for Environmental Innovation, titled "Ignoring Impending Disasters: Why Do the Warning Signs Go Unheaded?" finishes with these summary remarks:
 
 "Human nature and organizational dynamics are what they are. You will never change these forces. What you can do is factor these dimensions into your planning. For example, building strong teams and interdepartmental allies, breaking down information barriers, and encouraging contrary views are obvious positive steps to overcoming inertia.

Groups should actively seek input from others who can challenge their assumptions. Groups also can be broken into sub-groups and can work on the same problem using different assumptions. One group may even play the role of devil's advocate for the other. Decision-making at the point closest to the expertise should be encouraged.

For the really big elephants in the room, sometimes it helps to bring in outside experts who can raise issues that would be far too controversial for the EH&S staff to broach themselves. Top executives almost always perceive outsiders as more competent and knowledgeable than insiders. It's sad, but true.

Last, do not underestimate the forces you are up against. Our profession's attention to building "better business cases" and "demonstrating value" conveys a subtle message that we are ineffective and unconvincing. In actuality, the challenges we face are enormous. Our only mistake would be to give up and admit defeat."
 
MacLean is speaking to his peers in the EH&S (Environment, Health and Safety) community from the backdrop of tragedies in our lifetime like Hurricane Katrina, the Columbia Space Shuttle breakup, the BP Texas Blast, and the Minnesota Bridge collapse. His last sentence above reflects on the status quo as a definable force that resists change.
 
What is striking to me is that the argument that addressing future threats requires planning and collaboration within the context of disaster mitigation sounds so main stream. And yet the arguments he advances are strikingly similar to those I, and others, have advanced for some years, to support fundamental health care transformation. Listen to these words from July, 2003:
 
"Today's challenges in healthcare - both globally and locally - require strong cross-sector partnerships to ensure successful outcomes. Health remains deeply siloed on both a macro and a micro level. The segregation is reinforced by different cultures, by language, by tradition, and by the power elite in each sector. On macro and micro levels in health, we have developed and developing nations. We have government, industry, academics and non-governmental organizations. We have hospitals, doctors, nurses, insurers and suppliers. We have generalists, specialists, home-based caregivers, pharmacists and health educators. We have silos with governance and financing often strictly constrained within traditional and rigidly-defined boundaries.
 
But over the past two decades, we have seen emerge and collide two extraordinarily powerful external forces. The first is health consumerism, moving from emancipation, to empowerment, and on to active engagement. Coincident with this has been the explosion of the internet, disregarding boundaries of geography, class, religion, race and politics, and carrying empowering health language and knowledge to a global population increasingly at risk for the health decisions of themselves and their families.
 
While these two forces have created demand for progress and new opportunities, they have also revealed glaring inequities in healthcare at home, the uninsured, safety in hospitals, or health disparities in minority populations. They have also created a globally connected population, reinforced by rapid air travel and overnight delivery, which is less tolerant of health disasters (like HIV or SARS) that were previously ignored, as they were perceived to occur in someone else's backyard.
 
Health consumers worldwide are quietly coalescing on an island of their own. They see around them the traditional health sectors, and acknowledge the validity and importance of historic checks and balances. But they believe as well that these can be preserved while, at the same time, cooperatively addressing a variety of significant health issues that reside on this "island of common stewardship."
 
The major sectors in health care have well-defined historic purposes, roles and strategies for success. Governments have focused on governance and purpose, defined roles and responsibilities, invested in system redesign and re-engineering to advance efficiencies, and developed skills as bridgers and collaborators in an effort to share responsibility for the creation and execution of sound policy.
 
Academics have traditionally focused on a mission of service, education and research. Today, they confront diminishing resources and increasing demands for service and social action. In response, they have emphasized reengineering of patient-care processes to accomplish operational efficiencies, and constructive approaches to partnering, emphasizing trust and transparency, with a constant eye on institutional integrity.
 
Industry has focused on business performance, the delivery of customer service, the creation of wealth, the discovery of new markets, and the expansion and alignment of philanthropy as part of its social mission.
 
Non-governmental organizations, or NGOs, have focused on shaping attitudes and behaviors of government, industry and academics. This new mission has been layered upon traditional missions of service and activism. The enormous growth of NGOs over the past three decades is witness to a focus on and growing expertise in virtual communications, organization building and campaign execution, utilizing and synergizing internet capability and high credibility within traditional media communities.
 
Beyond the desire for collaboration, there must be environmental readiness to ensure success. Desire to truly collaborate is reflected in the various sector's willingness to mutually plan, to align goals and objectives, to share risk, and to exhibit a good understanding of each other's strengths, weaknesses and capabilities. True readiness is evidenced by an appreciation that healthcare is a local phenomenon reflected in concrete and realistic planning, and the design and management of the realities of time, place, people, institutions and target geography. Readiness also implies proactive involvement of all four sectors, right-sizing the effort or program to the challenges."
 
Now, nearly 5 years later, it occurs to me that, in order for health care to transform, we must view our current status quo as a disaster, and have a strong vision to build out as a preferable future. Until we do, nothing will change. That's frustrating, but it is the truth. And as MacLean cautions, "Our only mistake (now) would be to give up and accept defeat."

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by Health Commentary
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Comments
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January 03, 2008

Don't Count On Entrenched Special Interests To Compromise, Even In The Face Of Disaster

History Has Shown Time and Again That It Doesn't Often Happen
Mike,

If you haven't read it already, I'd urge you to at least glance through Collapse by Jared Diamond, the sequel to his Pulitzer-winning Guns, Germs and Steel. Collapse excruciatingly details how society after society KNOWINGLY undermined their own survival, but couldn't stop because the rulers benefitted from the corrosive practices.

This explanation was formative to my own approach to reform, and helped me redirect my energies from bringing all players to the table (including the major HC organizations) to only working on reform with non-health care business leaders.

Another good example is the federal budget process that I talked about in today's post. In June, Peter Orszag, the Director of the Congressional Budget Office testified to the Senate Finance Committee. He said,

"If [Medicare and Medicaid’s] costs continue growing at the same rate over the next four decades [as they have over the last four decades, at 2.5%/year higher than per capita GDP], federal spending on those two programs alone would rise from 4.5% of GDP today to about 20% by 2050. That amount would represent roughly the same share of the economy as the entire federal budget does today.”

Even with that, Congress caved into the HC lobby utterly a few days ago, with no good solutions in sight.

Unfortunately, asking the HC industry to participate in reforms that reduce their earnings is likely to be as fruitful as asking the oil companies to stop promoting fossil fuels, or the junk food companies to start promoting healthful foods. It won't happen. So the trick, then, is to find ways to galvanize the larger groups that are not involved in those sectors around the idea that the health care, fast food and energy industries are engaged in practices that will negatively impact their economic stability and viability.

In the case of HC, it is important to remember that, in 2006, our industry's lobby represented more than 15% of all contributions to Congress. Each industry tends to stick to its knitting, so while Microsoft, for example, mostly focuses on IT issues, it pays only nominal attention to health care policy. This gives each industry open-field running, and makes it very difficult to pass policy that is in the common rather than the special interest.

Even so, health care is the largest economic sector, representing about 1/7 of the US economy and 1/11 of its jobs. So as the mismatch between resources and demands continues to grow (as coverage becomes more costly, skinnier and more inaccessible), the industry's increasing financial instability could ultimately cascade to and disrupt other economic sectors.

This threat of financial instabilty - not the growth of uninsurance, or social injustice - is ultimately the reason why the nation's non-HC business leaders might choose to come together, overwhelm the health industry's lobbying dominance, and push through reforms that can rationalize the massive waste in health care that is drowning the system.

This action plan, of course, requires access to the highest levels of industry, and requires supportive scenarios that are compelling.
by Brian Klepper
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January 04, 2008

Readiness

Taking Risk for Success
Thanks, Brian.  Over the years my more optimistic side has left
hope that strong leaders with great timing and an accessible and
funded platform could coalesce major players. More recently, I've felt
a missing link was a well articulated and compelling vision of what
needed to and could be built together. My more pragmatic side however
has been simultaneously saying that new visions must be built out in
parallel accessing the assets, IT expertise and "home-insider
positioning" of sectors that have purposefully been excluded from the
health care arena including Financial, Entertainment and Home
Technology. Extending an invitation to all to the table is one way of determining readiness. Absent readiness, generally more resources, different tactics and powerful partners and vision are all required (along with a willingness to take risk) to achieve breakthrough success.
by mike magee
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