The reform isn’t perfect, but maybe it’ll help us avoid disaster.
The rapidly ramifying crisis in health care may (we can pray) end all delusions. It may at least begin to weaken them by exposing them to the light, to the sobering effects of reality.
The reform act has not brought us to the Promised Land. By bringing us access without capacity, fierce restrictions coupled with vague language and loopholes, mandates coupled with fines low enough to become the cheap way out, strong new ideas that are only pilots, and tough commissions and task forces that have no teeth, the reform act delivers us into a period of maximum melee, in which the needs and desires of hospitals, doctors, citizens, politicians, insurers, drug companies, device manufacturers and hundreds to thousands of niche industries within the sector, get pitted nakedly against one another.
Everyone in this melee will increasingly be driven by the ratcheting drumbeat of cost, cost, cost—which is another word for over-use of resources.
It can seem at times like a kind of existential madness. But in fact we are engaged in a struggle over the very meaning and substance of who we are, what we do and why we do it. We can hope that at last and increasingly, we will be shedding our delusions and engaging in that struggle on the basis of some kind of reality.
You know the facepalm moment. It’s that moment when you smack your hand on your forehead, accompanying the concussive thwap with the expletive of your choice, when confronted by a bit of numbskullery so dense as to tear the space-time continuum.
I get out a lot, all over this industry. This spring found me in 17 cities in two months, speaking for hospitals, hospital associations, professional groups, insurance companies, vendors of all types. I go to the receptions and the dinners, and I walk the booths. I talk to people, I ask questions and I listen.
Everywhere I go I am inspired to meet people who really understand the industry and its problems and are working their butts off to make health care better, faster and cheaper. And everywhere I go I meet facepalm moments.
I’m sure you have heard every one of these, and many more—or at least divined them, since people may or may not actually say the words. But by their actions, you know the attitudes of delusional citizens, politicians, executives and doctors.
Delusional citizen: “Cheetos are health food. They’re organic. That’s why they have that color. And look, the beer I drink says ‘Lite’ right on it. Exercise? Do you have any idea how hard it is to get out of a bean-bag chair? Besides, I watch ESPN.”
“Medicine will fix me. Medicine is magic.”
“More medicine is better. Since it’s all so confusing that it’s hard to know what to choose, we can take ‘more expensive’ as a proper marker for ‘more.’” (Some studies actually show that drugs work better when patients believe they are more expensive.)
“I have a right not only to good, strong, proper, quality health care, I have a right to just plain more health care. No, I’d rather not give up smoking or super-size nachos, thank you very much, but look, I’m into recreational stents. And order me up some new hips, new eyes, heck, give me knees that will let me get into skydiving and tae kwan do. While you’re at it, make me young!”
“Of course, somebody should pay for all this, but it should not be someone of my class, age, BMI, hair color, something, in any case, not me or people like me.”
Delusional state government: “Hospitals and doctors are a bunch of whiners. Look at those huge budgets—in most localities, the biggest employer is the hospital. We can carve out more and more, and they can just adjust.”
“What do they mean, there is no care for the poor? They get it at the ER. Hospitals need to just suck it up.” (To pick one example from a wealth of them, Minnesota’s governor, Tim Pawlentey, recently completely de-funded the state’s general assistance medical care for the poorest of the poor. The legislature relented and put the funding back in—at 7 cents on the dollar. Many hospitals are declining the payment as not even being worth the paperwork.)
Delusional politician: “All those countries that the experts tell us do health care for half our cost and get better results are a bunch of socialists. Nothing to learn there.” (One politician suggested that we go back to a barter system: Bring the doctor some chickens; paint the doctor’s house. I couldn’t make up stuff like this if I tried.)
“Besides, we have the best health care system in the world.”
Delusional hospital: “Dodged that bullet. Whew!”
“We don’t really have to do anything different, do we? A few adjustments around the edges, that’s all we need.” (Hospital exec to me: “Nah, we’re not going to do that digitization stuff. We looked into it, and the stimulus incentives are less than it would cost us. We’re not stupid, you know.”)
Delusional hospital employee: “At least my job is safe. I don’t have to worry. We’ve got a union, there are regulations, this place has plenty of inertia, they need people like me.”
“Management is always coming up with the buzzword of the week—‘lean’ management, quality this and that. We just outlast ’em.”
Delusional doctor: “Hey, I’m a doctor. I’m a good doctor. The country needs doctors. To be specific, it needs my kind of doctor, doing the kind of procedure I’m all set up to do here in my private center. The one that brings me an excellent living, actually.”
“Of course, I send all the ones that can’t pay enough over to the hospital. I’m not a charity, you know, and they are. That’s their business.”
“Don’t give me this stuff about how the hospital has to charge more because they’ve got that emergency department and all the non-pays and all that. They just don’t know how to run their business. Not my problem.”
“No, I never even go over to the hospital anymore. That’s why they have those hospitalists and intensivists.”
“Take call? I don’t think so.”
“No, I don’t have to pay any attention to those studies that claim to show that aspirin, yoga and dropping a few pounds can do the same job as my procedure for one-hundredth the price. This is America, this is a free enterprise system, and no one has the right to tell me that I can’t do whatever procedure that I deem medically necessary, and get paid for it by the government.”
“Guidelines? I don’t have to do it that way; that’s not the way I do it.”
“Don’t give me this checklist stuff. I don’t make basic mistakes like that. Besides, I’m too busy.”
Delusional pharmaceutical company: “Dodged that bullet. Washington knows that there’s blood in the water if they try anything like imposing prices on us.”
“This is a business, and we pay attention to business: The stock price, the ROI, and the quarterly reports. You want charity? Go talk to one.”
Delusional health plan: “We can work this. We’ve got more lawyers working HHS than there are feathers in Vegas.”
“There’s loads of gray area in that reform act. And you can bet we’ll find every hole in it.
“Here’s one: Can’t drop someone’s coverage for having a pre-existing condition anymore, right? But we certainly don’t have to cover someone if they don’t take care of themselves, like if they don’t take their medicine, their statins or whatever that would keep them out of the hospital. Then we tell them that they have to buy their pharmaceuticals online, or by mail, and outsource that part to a company who is world-class at making it insanely difficult to do, especially for the elderly sorts. Bingo! One more excuse to drop people. You didn’t take your medicine, now did you?
“Besides, the bit in the law that says, ‘No rescissions’ also says, ‘except that this section shall not apply to a covered individual who has performed an act or practice that constitutes fraud or makes an intentional misrepresentation of material fact as prohibited by the terms of the plan or coverage.’ Hoo boy, you have no idea how much fraud is out there, and intentional misrepresentations up the wazoo! One guy listed his birthplace as Van Nuys, Calif., when his birth certificate was signed by a doctor at a hospital 2 miles away in Panorama City. Talk about fraud!
“Anyway, we can just stay out of those exchanges until they cry uncle and soften the regulations. We don’t need that market under those conditions. They need us.”
And on and on. I am sure you could come up with plenty more. The file is labeled “Denial.”
Avoiding the Disaster
I think about Joseph Tainter’s Collapse of Complex Societies (1988) and Jared Diamond’s Collapse (2006). I think about how complex systems crash and burn, how the collapse comes quickly, after years of struggling with increasing complexity and increasingly rapacious use of resources, with the elites in charge never able to ratchet back the complexity and resource use, until finally the system shifts rapidly from over-complexity to massive simplicity, the houses and temples left to rain and geckos and weeds.
It doesn’t seem like that is possible in health care, does it? But something like it is possible, some concatenation of rapid, drastic, cascading, unintended changes that leave us floundering, devastated and impotent, a disaster of implosion.
The irony is that we actually know how to avoid this disaster. There are many examples of how to manage health care better, in other countries, in other industries, and in multiple local examples across this country, if we have the will, if we have the spine to push changes through everywhere we have influence.
Health care has not been fixed, not by a long shot. But the reform legislation has, just maybe, surfaced the tensions, the delusions and the denial that are driving us toward an uncreative destruction, a bonfire of complexities. And that surfacing provides a chance that maybe this time we can finally do the right thing, we can pull back from the myopic concerns of our individual niches, we can find a way to make health care work for everyone—better, faster, cheaper.
With nearly 30 years’ experience, Joe Flower has emerged as a premier observer on the deep forces changing healthcare in the United States and around the world. As a healthcare speaker, writer, and consultant, he has explored the future of healthcare with clients ranging from the World Health Organization, the Global Business Network, and the U.K. National Health Service, to the majority of state hospital associations in the U.S. He has written for a number of healthcare publications including, the Healthcare Forum Journal, Physician Executive, and Wired Magazine. You can find more of Joe’s work at his website, www.imaginewhatif.com, where this post first appeared.