Sunday, January 5, 2014

I'd like to make a number of subtle and not-so-subtle points today, and I hope you'll stick with me.

A friend and I have ongoing debates about whether Obamacare will make a difference in the practice of medicine in the US and whether that difference will be, for the most part, good or bad.  Interestingly enough, we often find ourselves taking the opposite viewpoints from what we each argued a month or two earlier!  Here's where I have come out after a nice winter break and having now viewed many health care institutions and societal arrangements around the world.

You cannot bolt on a communitarian solution to a health care system that is inherently impersonal and inhumane and expect that the resulting framework will have humanitarian characteristics.  That, for all the commentary, is what Obamacare is trying to do and what its advocates proclaim is the future.  They argue that changes in payment methodologies, an emphasis on preventative care and so-called "wellness,"* and integrated health care delivery systems will inexorably move us down the path to the Triple Aim:  Improving the experience of care, improving the health of populations, and reducing per capita costs of health care.

I would like to think that these folks (many of whom are close friends and distinguished experts) are right, but I think they are fundamentally wrong in their expectation that any externally imposed institutional framework will achieve those results.  Please recognize that I am not in any way arguing against the tenets of Obamacare--universal access to health insurance and removal of nasty rules about pre-existing conditions and lifetime coverage limits.  Nor am I making this argument because the President misrepresented the potential of the law when he promised access, choice, and lower costs.  Indeed, I accept (reluctantly) that his set of promises was a necessary political precondition for getting anything through Congress and changing the shameful situation of millions of uninsured Americans.

Rather the issue is this: As we see from examples around the world, even where there is universal access to health care and where there is coordination across the spectrum of care from birth to hospice, the actual delivery of care as felt and seen by patients and families is simply substandard.  By substandard, I mean that it seldom meets what I would call the gold standard: "The kind of care you would want for members of your own family."  What does that standard imply?  It implies a partnership between caregivers and patients and families of the sort so eloquently outlined by e-Patient Dave deBronkart and his medical partner-in-arms, Danny Sands and by Ted Eytan, Jim Conway, and Pat Sodomka.  It implies a change in the way work is carried out in hospitals and other health care facilities, one that is respectful of front-line staff and empowers and encourages them to identify process improvement opportunities. It implies a full integration of human factors measures designed to offset the physical and neurological cognitive errors that human beings make, as MedStar's Terry Fairbanks has persuasively described.  It implies a full integration of the principles of crew resource management into the hierarchical environment that has to exist in procedural settings, as practiced by Marck Haerkens and others. It implies an expanded view of health care system responsibilities in the community, of the sort practiced by Jeff Thompson and his engaged staff at Gundersen Lutheran.**

As you look at that list, you see that such changes are seldom if ever brought about by government fiat, whether legislative or regulatory.  Likewise, they are virtually never the result of pricing designs or other actions by private or public payers.  Neither are they dependent on such government rules or payer actions. Instead, they rise from within when the leadership of health care organizations--i.e., senior administrative and clinical leaders, supported by their governing bodies--have the desire, guts, and commitment to make them happen.

I've decided that it is distracting to expect the kind of global changes envisioned by the Obamacare advocates.*** The nature of change is that there will be industry leaders and industry laggards.  In other fields, the "disruptive" organizations eventually overcome the incumbents and drive industry-wide structural change.  In health care, this is less likely because of the geographical constraints on care delivery.  While technology might mitigate some of those geographic factors, much of care will always require physical accessibility between patients and caregivers.

In light of this dispersed industry structure, I view my personal advocacy role as one quite different from many of my friends and colleagues.  You see it in the masthead of this blog: I am an advocate for patient-driven care, eliminating preventable harm, transparency of clinical outcomes, and front-line driven process improvement.  I do not believe in global change, though, nor do I expect it to arrive or even be helped much by government leaders in Washington, London, Amsterdam, or Jerusalem. I aim not to change the world but to try to help organizations and leaders who are committed to this general direction and are willing to take the personal and professional risk that it is, quite simply, just the right thing to do.  Those brave people, paradoxically, are usually the ones who, like Contra Costa's Anna Roth, are most modest about what they know, about how to accomplish change, and about progress to date.

With luck, publicity about our successes might help create a broader movement in support of the gold standard, but I am not counting on that.  Meanwhile, we'll do our best to make life (and death) better for the patients and families and clinicians in those health systems that care and act like they care. That will be reward enough.

* Stay tuned on this front to a forthcoming book by Al Lewis and Vik Khanna.
** Beneath and around all those elements, the gold standard requires a different kind of training and reward system for physicians and other clinicians.  By this, I do not mean a financial reward system.  Such has been shown to be ineffective in so many settings.  No, we need a reward system that is meaningful to those well-intentioned people who have devoted their lives to eliminating human suffering caused by disease.  I'll return to that in future blog posts.
*** Take it further. As a thought experiment, or Gedankenexperiment, just consider what would have happened if we had simply expanded Medicare to the entire population. As we have seen, even this well-intentioned single payer system has never been able to escape from politically inspired rules and payment regimes that have done little to help us meet the Triple Aim, much less the gold standard outlined above.


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