How Will We Get There?

How will we get there? The task is pretty daunting, but most of the people I speak with these days about health care are committed to changing things; they just don’t know how to take the first step. Or they see the specific thing to do, but do not have a good grasp on the framework that needs to surround the improvement or reform that is just in front of them. Here is a quick review of the challenge and what leaders need to do to sustain the change process.

First, let’s remember the scale of the undertaking. Health care in the U.S. is a $2.5 trillion undertaking. It is the largest part of the federal budget; it swamps most states’ ability to balance their budgets; it has been growing faster than the rest of the economy for decades; and it is the single most important threat to our nation’s long term economic well being. If our health care costs could be reduced so that we were still the most expensive, but only by one percentage point of GDP over the next most expensive nation, then we could balance the federal budget and begin to lower the national debt. It is big, important and challenging.

In addition to being expensive, the system underperforms the expectations of consumers and producers alike and leads to anger, disappointment and fear. This in turn leads to a great deal of dissatisfaction on both sides of the delivery system.

This situation is very curious. Health care attracts some of the brightest, most dedicated individuals that each generation produces. These professionals, clinicians and non-clinicians alike, are regarded as social and cultural leaders. Over thirty years in this field, I can say with assurance that I have rarely met individuals who are not dedicated to doing their very best to serve patients. The nation has dedicated hundreds of billions of dollars for research and training in health care. And we are rapidly approaching spending one-fifth of our entire productive effort on health care. In some respects the health care infrastructure we have built is bright and sparkling and the envy of the world. Yet, it seems to not be working for most of us.

At this point we have three options as we go forward. First, we can limit access to the system that is. We can ration the care services that we have produced, because at the individual and social levels, these resources can no longer be afforded. We have been at this for a few years with schemes of utilization review and management. The efforts have annoyed producers and consumers alike and have not seemed to hold cost increases. The villagers are on to us here and are armed with pitchforks and torches, demanding access to the glittery things that they are accustomed to. It is a form of entitlement that sparks much of the tea-party-like resentment to changes in the status quo, in which no one wants change or is the least bit willing to actually pay the costs. It is a very explosive political tension.

Second, we could go to the incumbents in the system – the nurses, doctors, big pharmaceutical firms, hospitals, medical practices, durable medical equipment companies, long term care facilities, and the myriad other individuals, institutions and businesses that make up health care –and ask for a cut in reimbursement, salary and payment. If our peculiar form of health and health care is about thirty percent more expensive than other nations’, and it is, then we might start with a twenty percent roll back. We could get $500 billion back into other sectors of the economy or even back into individual pockets. But every effort to hold back increases, much less rollback payment, is met by an enormous reaction by the “system” that too much mischief would be done, and in reality, it would be – because just cutting payments without changing how we actually do health work would only demoralize those within and poorly serve the consumer.

Finally, we might entertain that there are other and better ways for us to organize and deliver primary care, specialty care, long term care and most importantly, care for chronic disease and disability. If we could tap into that great American penchant for creativity and entrepreneurial action, the stuff that is supposed to make up our vaunted exceptionalism, then we might be able to not only save some money, but channel all of the professional and institutional commitment to the patient and service in the right direction. We would actually use our technological, human, community, and economic resources to reframe the challenge and deliver novel solutions.

Taking this third option will require several things. First, we need a radical focus on the patient or better, even though some find it offensive, the customer. How can we serve them exceptionally well with an aggressive focus on defining and meeting the outcomes that are needed? How can we do this at a point that can begin to bend the curve of ever increasing prices and actually create meaningful services that people and society can afford? How can we make the consumer smile?

Second, we need to think and see beyond the institutional prerogatives and professional blinders that so limit what we do today. There are certainly payment and regulatory barriers to making these accommodations, but the real barriers lie in the lack of imagination, parochial and self interest, and just the heavy hand of ‘that is how it has always been done.’

Third, we need to borrow, steal and adapt with abandon. Much has already been done in every dimension of needed change. We do not have time for every clinic, practice, hospital, school and professional to experiment with every change. Identify the need and find out quickly who has addressed something similar. How successful have they been? What needs to be changed to fit your problem? What could be easily improved? Get at this information quickly and get it into play. And, importantly, once you have done something share what you did and what the measured impact was with others that need the innovation.

Fourth, if you are still reading this, then you are a leader challenged by this reality. Leading the changes that are needed will require new skills that are continuously developed, outside assistance to help understand and promote the change, and the courage to be truly responsible for addressing the problems over a long period of time. Leaders will need to grasp and continue to evolve an understanding of the problems and challenges we face, translate these to others within their leadership sphere of influence, bring effective transactions to the work to be done and work effectively through others that are out, down and up in our organizations of care.

There are no tricks, gimmicks or fast passes. We need to remake the way we do health. The effort needs leadership, access to ideas that work, better skills and a brand of team work that cuts across professions and institutions.