I had a large number of responses to last month’s essay on how we will execute the health care reform. Not “execute” as in do away with, I had more of “bring to life form” of executing in mind. My basic premise here is that reducing access to care as a way of controlling cost or reducing the payment for specific inputs is not a sustainable pathway for reform. It will be difficult if not impossible to do and moreover, will not bring the level of reductions in cost and improvements in service that are needed. This is a strange alchemy I realize, reducing cost and improving quality, but we do it on other parts of our economy: think Southwest Airlines here.
To get to this place we cannot pursue marginal improvements in quality or savings on the existing practice models, rather we need to reconfigure, sometimes radically, how we organize, structure, finance and consume health care services.To get this outcome, some desire a single overarching solution that would create a system that has all of the needed elements. Only the government is large enough to carry out such a plan and politically in the US such an approach is a non-starter. There has been dissension enough over what is essentially a plan designed by Republicans and passed by Democrats. If politics was not enough, there is just the shear size of the task. Health care in the US is about the size of the seventh largest country in the world by the size of its “GDP”. No one would go about trying to change the entire economy of such a large enterprise with a single stroke. Finally, while there are many evidence based solutions in operation in our current approach to care, there is no single proven solution to every issue and problem, nor is there likely to be.
What we are left with is a great American tradition of experimentalism and diversity. Here are a few of the things to keep in mind as we work toward new arrangements for health and health care services.
Health care is essentially a knowledge business. In the past, the vehicle for storing and transmitting this specialized knowledge was the health professional. Just as information and communication technology has changed every other aspect of our life and economy, we need to let this powerful tool assist in changing health care for the better. This undertaking is not the limited step of using these powerful tools to automate existing practice models, rather it is the much more revolutionary act of allowing the specialized knowledge to be used by as broad a range of professionals, paraprofessionals, family members and patients as possible. Specialized knowledge is the coin of the professional’s realm and this essential step will not come easily, but professionals and those that educate them should reconsider their relationship to the information and the end customer. The reality is that the knowledge has already escaped from the dungeon of the professional’s tower; we just need to inform the turnkey that it is on the lam.
But even before we go about moving the knowledge around, it is essential that every reform keep the patient as customer in mind. The first lesson here is that patients differ, and we could use a better understanding of the market segments that are out there for health care. Key questions such as, what services do they need and desire, what are their health and care seeking behaviors, what resources do they have from technology to education to community and family, what are they willing to spend toward health and care, need to be a part of how these segments are understood. Combining more sophisticated market information and more advanced use of information technology will allow new types of health care organizations to truly deliver the a set of products and services that have the quality of mass customization. Such a pathway is one of the only proven routes to developing a service that appeals to individual preferences and the purse.
Releasing knowledge and empowering the customer are intimately related and call the traditional prerogatives and position of the professional into question. Health professionals of every stripe need to be at the vanguard of these changes, but the impulse is almost universally to preserve the practice patterns of the past because they are comfortable, profitable, familiar and seem to be how the maker wanted this service or that service to be delivered. Breaking free of this psychological attachment to what has been is perhaps the biggest challenge to significant change; greater than regulation, finance, or the lack of an “evidence base”. This will always be an individual struggle. No one can tell someone about the benefits of the new approach, by and large this will need to be one revelation at a time from primary care to bedside nursing to specialty care to oral health service to the delivery of pharmaceutical products. If you are leading the change, it is essential to build in the time and resources for this type of discovery conversion. It is the only way to meaningful change.
It cannot be the case that we don’t have all of the stuff we need for a better health care approach. We buy and pay for too many things, people, buildings and insurance policies for this to be the case. It simply is that what we have is misaligned or not connected properly to the system or just seen in the wrong light. My favorite example of this is outside of health care in education, where across the country we are building new town libraries down the street from the new high school library and neither one of them have adequate information resources. In health care for instance, emergent care is a critically missing part of primary care, even for the well insured with a primary care doctor in a patient centered medical home. How do we change the access point of the hospital to deliver this service in a less costly manner? How could we use first responders to fill in this gap? Could a rebuilt, nurse-led primary care effort in our schools that opens its doors to the community for such services fill in a large portion of this need? There are very few communities that do not have an abundance of pharmacies of the various stripes. Could they play a much more active role in the provision of these services? If we are to have a hope of building something that works for less, we will have to do a much better job of using what we have.
To get to such a place, we will need to think of the whole enterprise. Perhaps ACOs will create such a context, if one is ever spotted. But short of a formal relationship, there are ways to begin building more integrated services. At the practice level this begins with a reconsideration of teams, their roles, their value and their performance. There is much rhetoric around teamwork, but less action on the ground. Anyone wanting to start working on health care reform today can take a careful look at how the team they are a part of both functions and performs. From the micro level up the work becomes very complex, but is going to be essential if we are to move ahead with change that saves money and improves care. A first step in this process is to simply understand what the “other” does. I am always shocked at how units in the same hospital have such disjointed notions about what the other units do or value. The disconnect between primary care medicine and specialty medicine would be laughable, if so many people did not die each year because of the lack of understanding between the doctors. Does anyone really believe that a fuzzy photocopy of instructions given to an even fuzzier post-op patient still clearing anesthesia have much chance of turning out OK? For all of our great rhetoric about continuity of care, for the most part, continuity is defined by the limits of the sight of the professional or institution; and for the most part, we’ve been looking down.
There are a lot of experiments that everyone will need to begin to try as we all move toward change. It is just important to remember that doing what first comes to mind will be a great way to keep doing what we have always been about, and that is not going to help in the long run. Even well intentioned efforts to improve a process--that is the wrong process--have a debilitating impact. Let’s mix it up, but with an eye to something really different.