Will More Really Be Better?

As an integral component of most of the leadership development programs that the Center for the Health Professions runs we usually try to sharpen skills around visioning. Over the past fifteen years I have been awed and humbled by the understanding, breadth, compassion, and wisdom of the visions developed by my clinical colleagues. A part of one of the exercises we use to stretch these skills is to ask participants to think about and record the barriers to achieving these passionate visions for a better health care world. Invariably the first barrier named is resources, not enough budget, to do the things that seem so right and are so needed.

But how can this be? The nation already spends more on health care than any other nation in the world. While adding the extra dollars to each individual’s vision seems only right, in the aggregate such additions only mask the real problem of health care which leaves the nation and individuals paying so much and deriving what is perceived to be of decreasing value. The real problem is the lack of integration and misaligned incentives and feeding more dollars and other resources into such a misconstrued system will not make it better.

For the past thirty years the Center for Evaluative Clinical Sciences at Dartmouth Medical School under the direction of John Wennberg has assembled a vast array of compelling data that points to the conclusion that expanding resources of such as working physicians or hospital beds has little to do with improvements in quality, outcomes, or satisfaction. Even at a gross level, without this detailed research a similar conclusion might have been drawn. There are about twice as many physicians in Connecticut as there are in Iowa, but any look at the health status of the populations of the two states will reveal few, if any, differences.

We are poised to begin what promises to be a decade long expansion of programs to produce more health professionals. The shortage of nurses is well documented and there is an even bigger gap growing within virtually every allied health profession. As the nation ages the demands for pharmacist will also grow beyond the current capacity to produce new ones. In many rural and inner city areas children are experiencing a tragic epidemic of dental caries and lack access to dental professionals. Primary care physicians are difficult to find and spot shortages of different medical sub-specialties are increasingly frequent. New schools and programs are under construction or currently planned in all regions of the nation. But will more professionals produce the outcomes we desire higher quality, greater access sustainable costs?

I believe that more professionals will only extend the life of a system that cannot long stand. Before we go head long into a frenzy of funding new programs it is time to pause and ask how we might get more value from the professionals we have. At its very heart this will require that we carry out four careful examinations. First, what are the models of professional practice and how do they limit the ability to achieve a different sort of health care system. Do these models serve the professionals are have they aligned themselves with the creation of the greatest public value. Second, how does the regulation of practice limit the capacity of professionals to work toward a different reality for the delivery of service? These laws were created to protect the public, but in many cases, perhaps most, they protect the status quo of a system that will only survive if can become far more innovative and responsive. Third, how does the professional payment part of the financing of health care keep the dysfunctional pattern alive? The payment system may not create the innovation, but it keeps the innovation from emerging. Finally, what are the small steps that we might take or the innovations already in the system that we might adapt to begin the process of releasing the nation’s health professionals to the visions of a reformed system of health.

If we only expand the number of health professionals without fostering these questions we may find that we have fed the beast, but not tamed it to our purpose.