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Facepalming Our Way into the Future

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.

Stupidity Everywhere

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.

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11 replies »

  1. You left out one “delusion citizen” saying”:
    “Hey, I’m an American! Give me a pill. I don’t want to change my diet.”
    As far as social networking delusion is concerned, I am waiting for TwitterFace before I go on the web.

  2. “….until finally the system shifts rapidly from over-complexity to massive simplicity….”
    And that massive simplicity shall be named “Single Payer Universal Health Care”, with one simple basket of services, one simple fee schedule and one simple tax to pay for it.
    Optional complexity will be available for purchase on the much diminished private market.
    — Margalit Gur-Arie

    I disagree. Your assumptions are predicated on an act of faith concerning how the U.S. Federal Govt. operates. A faith I do not share. There will not be one simple basket of services, nor will there be one simple fee schedule. Most assuredly, there will not be a “simple” tax.Why would the Federal government not use the regulation and provision of health care as an opportunity to “buy votes” once the authority of provision has been taken by the feds? Already, the various parties and representatives have been utilizing the reform measures to maneuver themselves into a better position among their constituents. Similarly, what benefit would there be to the legislative bodies in imposing a tax specifically to pay for healthcare? How would that tax be implemented anyway?Let’s put aside the notion of it being a simple tax, as there is no such thing at the federal level in reality. Assuming the implementation vehicle chosen for generating revenue was a payroll tax, that would immediately exempt the richest among us. (I’m assuming that we would want to make the richest pay for other peoples health care. In an irony not unnoticed by me, it would seem that those whom need healthcare the most, often times cannot afford it. The “rich” and the healthy middle-class have the resources to pay for more than their fair share of healthcare.).The rich do not appear on payrolls, therefore would not be subject to the tax. A payroll tax would affect the business owners (large and small) and their employees. Presumably, you would want to place a filter on the payroll tax lest you have very poor making payments they might not can afford. Besides, using a “filter” means that legislators have more capabilities provided them when it comes time to target their election machines.If you used income tax, that would “net” the rich, as you could now include as revenue a percentage of stock liquidations, estate transfers (death tax), and other earned income that is not sourced via payroll. The problem with income tax, is it is funneled to the “general fund” for the most part. That means that revenue can be used for DOD, DOE, DOT, NASA, and any other budgetary line items that get paid for out of the general funds. Note that the payroll tax could still be constructed to fund the general revenue accounts.Perhaps there would be a V.A.T. or “national sales tax” levied on consumer purchases on all or some types of products. This would include anybody who purchases something in the U.S. Citizen or non-citizen alike purchasing resources for the production of legal and illegal goods. I would imagine that you would allow a non-citizen the option of having their taxes refunded them much as Europe does with the various reimbursement forms available to the visitor of a country. This sort of tax would mean that even the poorest would be included in the assessment of the tax. There isn’t a good way of preventing the taxation of the poor at point of sale. You could “ask” if they were poor, or perhaps piggy-back on the various state assistance programs, so that someone paying with “food stamps” and their modern equivalents didn’t need to pay the tax. Of course this would mean that those who use cash to purchase the resource would be assessed the tax. Also, this would subject the VAT and national sales tax to the same fraud already pervasive in the various assistance programs.Another option would be to assess a tax only on certain types of products, cigarettes, liquor, junk-food, gasoline, etc… The problem with these taxes is that at least in the instance of cigarettes and liquor, the healthier you become, the less you pay. Presumably because you aren’t smoking and imbibing as much unhealthy materials. In the case of junk-food, you would be striking the poor. Junk-food (McDonalds, Burger King, etc…) are very cheap as a ready made food source and are often frequented by folks with low income. Additionally, as this is a consumer tax, in periods of recession and otherwise reduced consumer spending; revenue falls. Probably during periods when it cannot be afforded to fall. This last effect would affect the VAT or national sales tax as well.Of course, I’m speculating on a great deal. But then again, so are those who pushed the reform. I just don’t think the outcome will be simple or all that effective. I think that in general, taxes are a bad idea, especially consumer and income taxes. That’s probably why the founding fathers did not include an income tax in the Constitution nor provide for the collection of income taxes when establishing the U.S.A to begin with.

  3. “And that massive simplicity shall be named “Single Payer Universal Health Care”, with one simple basket of services, one simple fee schedule and one simple tax to pay for it.”
    Yes, authoritarian opacity is always simple. After the complexity has been moved from the private sector, where you can see some of it, to Federal agencies, where you can’t, it will look to one type of observer like “simplicity”. It will be simple like a cheese line is simple: nothing to read, nothing to figure out, just step forward till they hand you your cheese.
    Everything that is now describable as “complexity” will still exist, except it will be behind the bureaucratic walls of the Beltway, and only accessible by political action.
    Your sentence is the most haunting I will read today. You might as well have pulled a hoodie over your head and intoned “one ring to rule them all.”

  4. This is absolute BS; as more and more Americans get educated on how they are losing their privacy each and every day they will wonder what wonk thought up this great chase. When companies Matt Holt, Health 2.0 and others hold companies like Keas up a models for the future we are in deep trouble. The Keas – Pfizer model is just the newest spin on another way for capturing data and selling it without your consent.

  5. Its not government at fault for the state of Health Care. However,it is the private sector that has caused Costs to soar. Couple that with the demands of investors for large returns. This industry is full of lies and deceptive practices.The absence of Affordability is and does in many cases lead to death. Just because you stabilize someone at the ER,Because its a” law” doesn’t mean that Patient’s don’t die after they are sent Home. If these institutions were really Free MARKETS. Better than Half of them would fold from being non-competitive ,substandard and a Hackery. Throw out Health Insurance contracts for profit and watch this industry seperate those in it for the Money and those who truley Care.

  6. People are dying prematurely now as a result of the problems, both the excesses and the deficiencies. The enemy is the government for its price controls on doctors and hospitals, and the doctors for putting up with it. Prices are high for legal time too, but not affording it does not result in death. Doctors and hospitals alike have altered their behavior in perverted ways to make due with the perverted system that the government has legislated over the past 2 decades.

  7. “….until finally the system shifts rapidly from over-complexity to massive simplicity….”
    And that massive simplicity shall be named “Single Payer Universal Health Care”, with one simple basket of services, one simple fee schedule and one simple tax to pay for it.
    Optional complexity will be available for purchase on the much diminished private market.

  8. Great post – we have met the enemy and he is us. I completely agree with you about the function of the health reform bill passage in forcing all of this to a head. Otherwise we would have just quietly kept floating closer to the giant waterfall at the end of the river – now we know it’s there, at least, and will all eventually wind up rowing upstream – together?

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