In all of the leadership development programs that the Center for the Health Professions runs, there’s an ongoing discussion about the difference between the realm of management and leadership. Inevitably someone offers the old saying, “managers do things right and leaders do the right thing.” True enough; the skills of the manager are more attentive to the tasks that make an existing system run more efficiently and those of the leader are more centered on new initiatives or systems that may require a change to be managed. The line between the two domains is permeable and I know few managers that don’t have a lot of leadership abilities and, vice versa, even the most charismatic of leaders must at least know enough to outsource the management when needed. One new twist to this idea is the observation that the U.S. health care system today is over-managed and under-led.
By this I mean that the institutions that provide inputs to the system to produce health care – hospitals, clinics, health plans, school, pharmaceutical companies, even regulators – all know how to manage in their environments. The pattern is familiar; following well constructed plans for success, physicians build new ambulatory diagnostic and surgery centers, hospitals open new exotic service lines in cardiac or cancer care, pharmaceutical companies offer new products that offer the same outcome with fewer side effects, schools graduate more professionals, health plans rearrange the benefits to make them more responsive to a particular customer. These and ten thousand other operations take place every day as each part of the overall complex system attempts to maximize its relative position. While each of these activities is likely to serve the interests of some part of the system, when combined they generate what seems to be the inexorable increases in the cost of care. What we sometimes forget is that cost in and of itself is the biggest limitation on access to care, a limitation that reaches up into many middle class families.
Because there is no global health care system, there isn’t a set of overarching goals for each of the parts to work toward. Every institution and professional has the patient’s interest at heart, but they only have a limited way to understand and respond to the needs of the patients as they are presented. Lacking integration, highly trained professionals work in institutions at cross purposes to one another. The examples abound: specialist conflicting with generalist, physician treating a patient with a nurse managing the needs of patients across episodes of need, the in-patient setting with the need for ambulatory care, the needs of prevention conflicting with the enormous investment of treatment, and the growing need to manage chronic diseases and disability in non-medical settings with a system of service that is fundamentally tied to the hospital and clinic. The old saw about having a hammer and the whole world looking like a nail plays out tens of thousands of times daily in the U.S. health care system. It begins in training, is reinforced in the ways practices and institutions are structured, is further encoded in practice acts and malpractice insurance and finally, as if that was not enough to fracture service, the reimbursement scheme is often at cross purposes to the desired outcomes. Institutions and professionals being rational economic beings go where the money is and too often it is not in the direction to leverage the best outcome.
Many promote a single payer approach as the answer to the problems that beset the health system. This remedy might work if the only problem was wasted dollars on administrative oversight, but the real problem is the lack of alignment and integration of the providers to create a safe, cost effective set of services that can produce the outcomes that consumers need. Having a single payer system would not necessarily move the nation to this outcome. It would simplify the administrative process and if additional resources were added it could provide coverage to all, but the question would still remain as to how the professionals would change to provide a different type of service. If such an override of the current system of finance was attempted at the national level it would face significant political obstacles.
In part objections would be raised because health care in the U.S. remains a local concern, but the governing structures and tools to bring effective leadership at this regional level do not exist. Payment and financing systems are set by federal and state authorities and insurance carriers, practice acts are state-based legislation, hospitals cannot cooperate because of restrictions on anti-competitive behavior and there are few if any local or sub-state regional health authorities. Or, if they do exist, they only have a small part of the action with little or no responsibility or authority to address or create a more integrated approach. On the other end of the spectrum, some hope that a freer market and more individual responsibility and action will lead to a more rationalized system as patients as consumers express their preferences for quality, service and price in a better performing market. While some gains by such actions are likely to be made, the ability of the traditional providers to resist reform seem likely.
What is needed is the ability at the local level – this might be state-wide for those with small populations or sub-state regions that create a natural health care market – to bring together consumers, purchasers, providers, and public officials to create an assessment of the current situation, a framework of expectations, specific and measurable goals and new ways of both making decisions and working together. This is not a call to return the health planning councils of the past or for more government intervention, but for the creation of a Health Commons which can recognize private and public needs and actions, but do so in a common framework of expectation and accountability.
The notion of a Commons is an old idea that many discount as viable in our modern market-driven world. It recognizes the value of private and public input, participation by those who produce and consume and promotes the shared understanding of outcomes that are desired by all. In heath care we have demonstrated a reluctance to turn over everything to the invisible hand and many are hesitant to have government intervene in something which is seen as essentially private. Without something like a Health Commons we seem destined to continue to transfer hundreds of billions of dollars to the health system we have which is exquisitely managed yet tragically incapable of leading us to the place where the world’s best health care professionals and institutions can provide an efficient and consumer-responsive set of services that is sustainable in the overall economy.