Sunday, February 23, 2014

As we consider the imperatives for a health care system that Gene Lindsey espouses, we have to wonder who will get us there.  Clearly it will not be the government, for the government is paralyzed by the conflicting interests of those who seek to extract their share (or more) from the 18% of GDP represented by the health care system.  Legislators and presidents are not very good at resolving what they view as zero sum game.  In that world view, any changes are viewed as what we negotiators call value claiming:  "If I get more you get less." It's hard to build a coalition for change if you view the world in that manner.

While value claiming is part of any set of transactions, the more satisfying part of negotiation is value creation.  Here, we focus on the underlying interests of the parties and satisfy them by engaging in packages of trades that are of low cost to one party and high value to another.  Instead of zero sum, both parties gain.  A coalition for change is created, and blocking coalitions are held off.

Gene's marvelous list is rife with opportunities for value creation.  Look at it again:

1) Care based on continuous healing relationships: Care should be given in many forms not just face-to-face encounters. The system should be responsive 24 hours a day. 
2) Customization based on patient’s needs and values. 
3) The patient as the source of control. Encourage shared decision-making. 
4) Shared knowledge and the free flow of information: Unfettered access to medical records with effective communication between patients and clinicians. 
5) Practice should not vary illogically from clinician to clinician.
6) Safety as a system property.
7) The need for transparency. 
8) Anticipation of need. 
9) Continuous decrease in waste. 
10) Cooperation among clinicians. 

As I have noted:

My view is that inspiration comes from within and is tied to those ethical standards and good intentions that caused people to enter the health care professions in the first place. The leader’s job, then, is not to inspire. It is to use his or her influence to help create a supportive environment that permits the waiting reservoir of such intentions to be tapped.

This kind of leadership has been demonstrated in a number of progressive parts of the industry to date. Who's going to do this on a broader scale?  I'm not sure, but I am carefully watching the growth of several cadres of doctors who believe in the elements in Gene's list and are acting on them.  As one example, I refer to a number of young doctors in CIR (the Committee of Interns and Residents.)  This union, in addition to focusing on the regular economic issues of its members, has placed an emphasis on quality and safety, process improvement, sharing what has been learned, and patient partnership for its members and their hospital workplaces.  These doctors understand that these imperatives are not part of a zero sum transaction, but instead add value to all parties.  I've had a chance to interact with many of them at the Telluride program, but I've also now see many of them in action in their localities.  If this group is indicative of the classes coming up through residency training, we'll be heading the right way.

Indeed, these young doctors go well beyond their workplace in acting to make the world reflect Gene's list.  Here's one example, Kate McCalmont, who wanted New Mexicans to have a better chance of getting health care coverage under the Affordable Care Act. She invented a way to help them. You can see the TV news report here.


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