Accountability, Accountable Care Organizations, and Human Mindsets

“Great companies have high cultures of accountability, it comes with this culture of criticism I was talking about before, and I think our culture is strong on that.” – Steve Ballmer

“I am responsible. Although I may not be able to prevent the worst from happening, I am responsible for my attitude toward the inevitable misfortunes that darken life. Bad things do happen; how I respond to them defines my character and the quality of my life. I can choose to sit in perpetual sadness, immobilized by the gravity of my loss, or I can choose to rise from the pain and treasure the most precious gift I have – life itself.”
– Walter Anderson

“When it comes to privacy and accountability, people always demand the former for themselves and the latter for everyone else.” – David Brin

Accountable care organizations (ACOs) are all the rage as the perfect tool to achieve our most important goal in present day American health care: decreasing per-capita cost and increasing quality at the same time. Just this week I am presenting on ACOs at a law firm conference co-sponsored by two state hospital associations and the MGMA in Minneapolis and at a hospital system board retreat in Pennsylvania. Everybody wants to know how to implement ACOs.

An essential ingredient in ACOs is accountability, and yet human beings are not always comfortable with being held accountable. The two blog posts  I wrote on physician report cards generated a lot of comments both in favor and opposed to personal accountability. And yet we know that hospitals and physicians are going to have to change the way they utilize medical resources if we are to indeed decrease per-capita cost and increase quality. Hospitals account for 40% of the rise in health care costs. Physicians account for only 20% of total health care expenditures, but when they treat patients they control the use of hospitals, drugs, medical devices, and laboratory tests.

If we are to control health care costs, hospital admissions will have to go down and physicians will have to order fewer and less expensive tests and treatments than they do today.

Why is accountability so hard?

I cannot stop thinking about why it is so difficult for many of us to admit error and receive blunt feedback. How can we help physicians acquire the humility, courage, and existential strength needed to want to receive the kind of feedback on performance that is necessary for continuous improvement and cost control? In my mind this issue is just as important as perfecting the methods by which we measure performance and quality.

Americans have had an ambivalent and changeable attitude toward success and failure that informs the ideological battle between liberals and conservatives. Americans like success and winners. Whether failure is caused by larger socioeconomic forces or lack of effort on the part of the individual depends partly on your political philosophy.

“‘Americans in general don’t like to talk about failure very much,’” said Professor Scott Sandage of Carnegie Mellon. In his book Forgotten Men: Failure in American Culture, Sandage describes how in America where hard work is supposed to equal success failure is blamed on some flaw in the loser’s character. Failure becomes transformed from an action (I failed) to an identity (I am a failure).

While the dominant culture in America has always celebrated success and winners, some like Chris Argyris have noted that failure is a better teacher than success. At times in the start-up culture, failure can become an asset and entrepreneurs whose companies have failed are more attractive to venture capitalists than executives who have never failed at all. Self help books with titles like Failure: The Back Door to Success get published and college graduation speakers like San Francisco mayor Gavin Newsom list famous, accomplished Americans who have failed: Elvis Presley, Michael Jordan, Dr. Seuss, and Henry Ford.

But the predominant American attitude toward failure and success is to avoid talking about the former and celebrate the latter condition. When Michael Lewis wanted to title his book on the 1996 presidential election Losers, the publisher told him there is no market in America for failure.

Recent research in social psychology has identified a fixed mindset and a growth mindset with completely different takes on failure. Carol S. Dweck, PhD, the Lewis and Virginia Eaton Professor of Psychology at Stanford, describes the research behind these two worldviews in her book Mindset: The New Psychology of Success (New York: Ballantine Books, 2006)

People with a fixed mindset believe that intelligence is static and largely determined by genetics; they want to appear smart and so avoid challenging problems; effortless success is desired because it affirms one’s natural endowment and ability; they get defensive and give up easily when faced with obstacles, and they ignore useful negative feedback; these people feel threatened when others are successful and they plateau early and achieve less than their full potential.

People with growth mindsets believe intelligence can be developed which leads to a desire to learn by embracing challenges; they persist when faced with obstacles and see effort as the path to mastery; criticism and feedback is an opportunity to learn and grow, and the success of others offers lessons and inspiration. They reach higher levels of achievement than one might predict from their IQ scores.

A study of University of Hong Kong students took advantage of the fact that instruction is in English and that some entering students are not fluent in English. The investigators measured the mindset of the students who were not skilled in English and divided them into fixed and growth groups by use of a validated questionnaire. They then asked the subjects if they would take a class for students who needed to improve their English skills. The fixed mindset students were not interested in such a class; the growth mindset students were anxious to sign up for the remedial course.

Richard E. Nisbett, a Distinguished University Professor at the University of Michigan, in Intelligence and How to Get It: Why Schools and Culture Count (New York: Norton, 2009) describes a Canadian experiment where Japanese and Canadian college students were studied. Canadians worked longer on a creativity test if they had succeeded on the first part of the study than if they had done badly. Japanese worked longer on a creativity test if they had failed at first than if they had succeeded.

“Persistence in the face of failure is very much part of the Asian tradition of self-improvement. And Asians are accustomed to criticism in the service of self-improvement in situations where Westerners avoid it or resent it. For example, Japanese schoolteachers are observed in their classrooms for at least ten years after they begin teaching.” (Nisbett)

Dweck gives many examples from business and sports to illustrate the difference between the fixed mindset and the growth mindset in action in real life situations. For me the most compelling was the contrast between two highly successful college basketball coaches: Bobby Knight representing the fixed mindset and John Wooden representing the growth mindset. There is no doubt in my mind which approach is superior.

Nisbett’s book clearly refutes the idea that intelligence is biologically fixed (think The Bell Curve and James Watson’s statements on race and religion). He convincingly argues that culture has a lot to do with how smart we become and how much we achieve in this life.

This emerging field of social psychology with its better understanding of intelligence has developed methods to help people switch from a fixed mindset to a growth mindset. The growth mindset would appear to be an excellent way to equip physicians with the humility, courage, and existential strength needed to want to receive report cards that would improve patient care and decrease the cost of American health care.

Kent Bottles, MD, is past-Vice President and Chief Medical Officer of Iowa Health System (a $2 billion health care organization with 23 hospitals). He was responsible for the day-to-day operations of a large education and research organization in Michigan prior to his work with in Iowa with IHS. Kent posts frequently at his new blog, Kent Bottles Private Views.

8 replies »

  1. Sounds like it’s time for payers to align with physicians, especially primary care physicians, and reward them for keeping patients out of the hospital, following evidence-based care and making investments in health IT by sharing savings. Unfortunately, most payers have spent the last decade or more trying to disaggregate physicians, keep their fees flat or drive them lower and “free riding” off the few physicians who could afford to purchase way-too-expensive EHR systems that are not interoperable. As a result, many PCPs feel they have no alternative but to become employees of big hospitals. It is wishful thinking to imagine that such hospitals will be now want to “partner” with physicians and “share savings” resulting from lost hospital revenue. I’ll believe it when I see it. As health refore seeks to lower costs, I predict a nasty game of musical chairs, where all the big players (payers, hospitals, pharma, etc) will use their clout to protect their share of a very bloated pie.

  2. Pay a physician for NOT doing surgery? No. The Feds shouldn’t be paying farmers not to grow, as it truly does KILL other countries. I just don’t want the federal government or any private insurance footing the bill for an unproven surgery by some arrogant orthopedic surgeon. Every single time cost effectiveness research came around, including “accountability”, physicians (many surgeons, not all MDs), PHARMA, and medical device companies soundly reject it because they know they can’t compete in an actual free market with transparency and reports on performance.
    Accountability may lead to increased transparency and actual differentiation among providers in the market. I’m not so sure physicians are prepared to give up any privileging or associated liability, even with the risk of increased accountability. I don’t think I know a physician under 45, especially NY and any state north of it, that is prepared to do that.

  3. There is some evidence that some things could be done more consistently…with less variation and risk, and both hospitals and doctors are gettiing on board with that now that the data, benchmarks and guidelines are becoming more poignant.
    I agree, an ACO is nothing other than a reimbursement mechanism that will be difficult to formulate, another minor detail overlooked by the Obamacare woolen cap.
    Having said that, what all should fear is the belief by some that gatekeepers, medical coaches and care minimizers are the solution to the problem of health inflation. Most would call it rationing.
    Well today the results are in from a randomized clinical trial (NEJM)that shows that the much heralded unwarranted geographic variation (another Obamacare hustle) doesn’t actually bend the curve yet save much money in exchange for introducing gatekeepers to care. But then again if you only spend $2.00 PMPM on a program, you really can’t expect to save much more than $6.00 PMPM. Payers have been effective in shifting risk to the patient, now for $2.00 PMPM they are happy to shift it to professional rationers. What happened to the potential 30% savings promised by the Dart_mouths?
    I think I prefer the alternative… keeping my local Critical Access Hopital a vibrant contributor to my community. The last thing that I want is a call center in India telling me what my health care options are.

  4. I agree that failure can teach us a lot as individuals: I know of many things I have learned due to struggle. However, this idea can be misused in the same way the “succeed at all costs” model can: all failure is not productive. To the contrary, we as a society have certain standards we feel must be met in order for our civiliation to function. I don’t see people rushing to get into “failing” schools, or to invest a lot of money in a failing company (the opposite is normally true.) Certainly, where death is involved, we have little tolerance for failure.
    My point is that failure has the potential to teach individuals about themselves; it is not so easily to extrapolate that attitude to a larger group, business, organization, or practice. Also, it is hard to get people to accept that failure is good for them if they are fired: this of course depends on the person, as some will see it as an opportunity, but I don’t hear a lot of praise right now for the rising unemployment rate. Finally, being able to admit failure may be productive personally, in the long run, but will probably not be so financially or in the macro setting, and not for the short term. These are all factors that have to be taken into the equation. Simply saying “Failure is good” is not likely to generate much enthusiasm.

  5. Agree with both the above posts. No one has explained what will motivate “non-profit” mega-hospital conglomerates to work seriously to reduce the number of procedures and admissions they generate.

  6. “If we are to control health care costs, hospital admissions will have to go down and physicians will have to order fewer and less expensive tests and treatments than they do today.”
    The solution is simple. Pay doctors to be accountable and to practice cost effectively. However, it may force you to close some of your hospitals. If the average doctor ordered $50,000 less medical services per year, assuming about 800,000 doctors, that would be a good start, saving $40 billion per year.
    That number is easily achievable if you think of one “elective” surgery that gets septic with endocarditis whose cost would be $.25 million. If the doctor did not do the case, there you go…but pay the doctor to not operate (just as the Feds paid farmers not to plant certain crops).

  7. This is a wonderful analysis of success/failure and accountability for both. Unfortunately, ACOs have very little to do with either.
    ACOs, seem to me just another fancy capitation scheme with a new layer of gatekeepers in the form of Hospitals (many for profit) to police the traditional gatekeepers (primary care docs), using financial sticks and carrots tied to “performance”.
    I’m pretty sure success will be defined as keeping the Hospital profitable. I wounder how “failure” will be defined in such system.