OP-ED

How to Blow the Big One: A Methodology

[Note to the reader: Anything that is in italics and square brackets (such as this note) is addressed to you, personally. Yes, you. Try it on, see if it fits.]

Healthcare has, right now, the greatest opportunity we have seen in our lifetimes to make a big change, to rebuild itself in a hundred ways to become better for everyone, and cheaper—to get cheaper by getting better. We’re not talking “bending the cost curve,” cutting a few points off the inflation chart. We’re not talking a little cheaper, a little less per capita, a few percentage points off the cut of GDP that healthcare sucks up. We’re talking way cheaper. Half the cost. You know, like in normal countries.

We’re not talking a little better, skipping a few unnecessary tests, cutting the percentage of surgical infections a few points. No. Don’t even think about it. We’re talking way better. Save the children, help the people who should know better, nobody dies before their time, no unnecessary suffering. Seriously.

I don’t know how high you want to aim, but personally, I think we should aim at least as high as the cutting-edge programs and facilities that are already out there, in the system as it exists today, cutting real healthcare expenses of real people, even “frequent fliers,” by 10, 20, even 30 percent, while making them healthier, much healthier. At least. To me, that’s a wimpy goal, just doing as well as some other people are already doing. Because these programs are just getting off the ground. They’re in the first few iterations. The stretch goal, the goal we can take seriously, is to cut real costs by 50 percent, by making people healthier. There is at least that much potential out there.

All the Ways the System Doesn’t Work

You want a little convincing? Here’s an easy little exercise: You know how the system actually works. [Note: Yes, you do. You’ve been around the block, right?] Pull up an empty notes page on the laptop, iPad, Blackberry, iPhone, whatever, and just start writing a list of all the frustrations you can think of, the thousand and one ways that the system does not drive toward the best health at the least cost for the people it serves—the missed handoffs, the wrong person/wrong drug mistakes, the lack of engagement with the patient’s life, all that. [Note: My guess? You can come up with a better and longer list than I can. Every person I talk to who actually works in health care has buckets of this stuff for me, every time I talk to them.]

Now do a little imagination exercise: Go down that list, stop at each item, and imagine some way in which the system eliminated it. Imagine that there was some systemic change that made it nearly impossible to give the wrong person the wrong drug, some change that meant that everybody got good health coaching, nobody ever got an operation that actually won’t help them, whatever is the inverse of each frustration on the list. Imagine what each of those changes would mean to the effectiveness and cost of healthcare.

Now imagine that somebody, somewhere, has done just that. Somebody is solving that problem, in ways that can be duplicated where you are. Because that is what I am seeing happen all across healthcare, and it’s a breathtaking story.

A Word about Systems

Do you know how many people died in car crashes in the United States in 2010? 32,000. That’s the lowest number since 1949. That’s impressive, but wait: It’s far more impressive than it sounds at first, because people in the United States drove about 10 times as many vehicle miles in 2010 as they did in 1949. In other words, if you drove a car or truck in 2010, you were 10 times more likely to live through each mile you drove than your father or grandfather was 60 years ago.

Why? Are we better drivers? Nah. Seatbelts, airbags, tougher DUI laws, breathalyzers, graduated licensing for teenagers, anti-lock braking systems, better highway designs, crash barriers, rumble strips, median barriers, steel-belted radial tires that don’t blow out, crumple zones, better bumpers…system tweaks that work, that make it 10 times as hard for even a terrible driver to kill himself or you.

It’s the system, not the individuals. We have only started on the thinnest little wedge of that kind of thinking about healthcare. That kind of thinking will take us way beyond “evidence-based medicine” to what is coming to be called “evidence-based health.” Evidence-based medicine does everything necessary to stabilize diabetic shock patients, gets their blood sugar under control, gives them the right prescriptions and sends them home. Evidence-based health goes home with them, if necessary, does whatever it takes to find out why they were in shock in the first place, what it takes to make sure that they fill the prescriptions, eat better, get good advice and don’t end up back in the ER in a month.

The Reform Is Not the Change

The federal healthcare reform law is a catalyst, and enabler, and an accelerator of the change we are going through. It is not the change itself, and is not even the cause of it, because the change is driven by much larger economic and demographic factors, especially by the crushing cost of healthcare. If the reform law were to go away, the change would not go away.

Here’s why the change is actually happening: As all these factors have come together, everybody in the business has come to believe that their usual way of doing business is crumbling under them. Doctors, hospitals, home health agencies, insurers, employers—everyone is desperate to find a new footing. And no one has found a certain footing yet.

Eight Methods for Screwing This Up

So this is, as the sportscasters say, our game to lose. It’s our change to screw up. And we can screw it up, big time. In case you are interested in helping that happen, here are eight ways to go about it:

Pretending it’s not there. Denial. A few tweaks. Business as usual. Same-old. Flavor of the week. Hey, it’s not my problem. I can squeak through to retirement anyway. [Note: Hello.]

Pretending it’s there and we know exactly what it is. We know its address and its measurements, the forms to fill out and the boxes to tick off. It’s all execution. Trust me, I’ve done this before. [Note: Actually, you haven’t. Nobody has.]

Fending off risk. Going for the safe choice. Pulling up the drawbridge. Hunkering down. We can’t afford to extend ourselves in this budget cycle. If we try that, it’ll just piss off the doctors. Better wait until this whole thing settles out. [Note: Let us know how that works out for you. From here, it looks like the waters are rising really fast.]

Grabbing an answer. Downloading a package. Not recognizing the edge of panic in your voice when you say reassuringly, “This is what works. This is the solution.” [Note: When the problem is not simple or static, the solution is not unitary.]

Mistaking it for an opportunity for empire. Building ACOs as regional monopolies to push up our compensation and grab market share. [Note: Consider this. How would your answer change if the question was not “How do we grow the enterprise and make our careers safer?” but instead was truly (truly now—be brutally honest, at least with yourself) “How do we help the people we serve better? How do we ease the suffering? How can we do that for more people? Cheaper? Earlier?”]

Making it a turf war. Grabbing territory. Knocking out the other guy.

Pretending it’s not a turf war, and losing it. Standing by while the other guy eviscerates your hold on the market. [Note: Of course people are going to treat it like a turf war. When everyone’s livelihood is threatened and their value is challenged, that’s what they do. That doesn’t mean you have to. In some games, the only way to win is to not play.]

Gaming the system. Figuring the angles. Making “What’s in it for me? What’s in it for us?” the only questions worth asking. [Note: Here’s the invitation: Play a bigger game. The author Harriet Rubin said a marvelous thing. She said, “Freedom is a bigger game than power. Power is about what you can control. Freedom is about what you can unleash.”]

Consider This

“Since death alone is certain, and the time of death is uncertain, what shall I do?” Yes, I’m quoting somebody. Never mind who. No, don’t write it down. Don’t Facebook it, Tweet it, stick it in Evernote, e-mail it to someone. In fact, don’t even think about it. Don’t think it through, generate options, prioritize. Stop. Just sit with it, just for this one moment: “Since death alone is certain, and the time of death is uncertain, what shall I do?”

Whoever you are, however you have defined yourself so far, you have your hands on some portion of this great rambling chaotic sacred Grand Guignol parade we call healthcare. You have some influence. You can nudge it, poke and prod it, re-shape it, help it grow, make new connections, try new skills. Healthcare is where we bring our suffering, and our tricks to defeat suffering.

We can do this. It is as if the sky has opened up, a break in the pattern; there is an urgency, a swiftness to events, a tide, a moment, a momentum. Let’s roll.

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, imaginewhatif.com, where this post first appeared.

This piece was first published in the May 19, 2011 Hospitals and Health Networks Daily, from the American Hospital Association.

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22 replies »

  1. After I initially commented I seem to have clicked on the -Notify me
    when new comments are added- checkbox and now each time a comment is added I get 4 emails with
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  2. I too believe individuals play a major part in thinking bigger/changing the system. All of us need to be engaged. The frequent flyer needs education and needs help forming the questions to ask to keep her out of the ER. I found this helpful in forming Qs: http://tinyurl.com/4odprtz

  3. @Nate,

    “Why have all the greatest atrocities in life happened under Communist and Socialist regimes then?”
    Free market socities don’t starve millions of citizens and murder millions more for the greater good.”

    You may want to check out this little Fascist and Capitalist regime in the 30’s and 40’s. It took power in Germany and spread to Italy…

  4. I agree with BobbyG Its quite possible and implemented that Illness could be controlled by the medication. Although some Medicines are for mind relaxation check me out for it.

  5. Generally speaking, methodology, unlike method (which systematically details a given procedure or process), does not describe specific methods despite the attention given to the nature and kinds of processes to be followed in a given procedure or in attaining an objective. When proper to a study of methodology, such processes constitute a constructive generic framework; thus they may be broken down in sub-processes, combined, or their sequence changed. As such, methodology may entail a description of generic process or, metaphorically, may be extended to explications of philosophically coherent concepts or theories as they relate to a particular discipline or field of inquiry. By similar reasoning methodology refers to the rationale and/or the philosophical assumptions that underlie a particular study or a particular methodology (for example, the scientific method). In scholarly literature a section on the methodology of the researchers is typically de rigueur.

  6. And if men were angels there would be no need for government.
    So looking back in the record of human development, Nate, the society or civilization thus far to achieve closest to your ideal is __________________?

  7. “It’s the system, not the individuals. We have only started on the thinnest little wedge of that kind of thinking about healthcare. That kind of thinking will take us way beyond “evidence-based medicine” to what is coming to be called “evidence-based health.” Evidence-based medicine does everything necessary to stabilize diabetic shock patients, gets their blood sugar under control, gives them the right prescriptions and sends them home. Evidence-based health goes home with them, if necessary, does whatever it takes to find out why they were in shock in the first place, what it takes to make sure that they fill the prescriptions, eat better, get good advice and don’t end up back in the ER in a month.”
    ___

    See “The Hot Spotters”

  8. if we individually did what we could, and should, the collective problem would not exist. Would never have existed. I don’t think an “advanced” society would ever support such demands on its populous.

  9. “Americans utterly refuse to pay for the upkeep on their current roads and bridges through increased gasoline excise taxes or privatization & notably higher tolls on most highways.”

    Refusing to be ripped off is refusing to pay for upkeep now?

    “New Jersey toll-road managers said they would eliminate perks, bonuses, payouts, and free employee E-ZPass trips after an audit released Tuesday found the New Jersey Turnpike Authority had wasted about $50 million since 2007.”

    This is common on every toll system. Road paving is notourisly over priced with prevailing wage laws and corruption. Throw in enviromental lawsuits that set projects back a decade and the problem is not a shortage of taxes its government waste.

  10. “social dreams, socialist dreams. Individuals and individual institutions caught in the demands of a market economy can’t do enough of the small right things to balance all the self interest of all the actors in the market.”

    “Why have all the greatest atrocities in life happened under Communist and Socialist regimes then?”

    Free market socities don’t starve millions of citizens and murder millions more for the greater good.

    ” but ultimately it must be mandatory and universal”

    You can never balance this with Democracy. Its when man has the hubris to think he can that millions are murdered in its name.

  11. I find myself flabbergasted that anyone could interpret the quote (from Shantideva, 8th-century Indian Buddhist scholar) as a call to selfishness. Nearly every ethical religion and ethical philosophy carries the same thought (I remember hearing it as a boy from a Catholic pulpit): Contemplate your mortality daily, and you will make moral choices. As Castaneda’s Don Juan put it: “Your death is your ally.”

    We are all moral beings, but our wounded hearts can cause any of us to be more or less distant from what that means about out thoughts and actions. This post is entirely a moral call, and moral choice is something each of is individually in charge of. No individualism can absolve us of our part in the collective whole — and no collectivism can force us to do right.

    The argument, as if from first principles, between individual and collective action (especially government action) fails on many levels, but the most obvious one is empirical: Every situation that works, that produces the desired ends for both individuals and the society, is a matrix of both. To find any historical example of a pure strain of collectivism or individualism that really works requires a tortured and highly constrained definition of the word “works.”

    This post is to say: We in healthcare are in this highly complex, rapidly changing situation. We need to look at the big picture, make serious choices, and take action for the good of everyone.

  12. Very engaging. This post, as with Charlie Evans’ from last week are urging us to think big. To suggest as Evans put it, there is needed ” a new norm”. I encourage everyone to read his too. Perhaps the editors of the blog need a new section entitled the Big Idea where people like these two can have a forum.

  13. “The reality is, in my experience, just the opposite. In a society of one thousand, 800 well intentioned persons acting as individuals cannot achieve half the good that 501 individuals who democratically control a society and make decisions that are incumbent upon all can do.”

    Translation: Government knows best and soak the rich.

  14. Beautifully written, Joe.
    However, all through history and not just in this country, for people to come together in the selfless way that you suggest, there needs to exist a clear and present danger from a tangible, preferably flesh and blood, enemy that threatens our existence in very immediate ways.
    Of course, we all know that our so called health care system is a threat, probably as big, if not much bigger, than any random terrorist and any misguided foreign hostility, but it is not tangible and it is not immediate and it is not collectively understood as such, no matter how ephemeral human existence is acknowledged to be. It has no guns trained on our nurseries and it has no face that can be plastered all over special editions of the New York Times.

    Health care reform is being discussed in financial terms. How it affects the deficit, which trust fund is insolvent, percent of GDP, how much profit should be extracted , how should fees be negotiated, Shared Savings, medical school loans, premium support, value-based purchasing, and even “skin” is measured in dollars “in the game”.
    We want to keep diabetics healthy because it’s cheaper that way (or not), we want to pay for preventive care because it realizes savings down the road (or not), we want to keep folks out of the ER because ERs are expensive, and we measure every experiment in terms of dollars saved (or not).
    It is very hard, if not impossible, to mobilize our better selves in a war for who gets what amount of dollars, where victory is defined as the winning algorithm for Shared Savings distribution.
    This country is in dire need for visionary leadership willing and able to redefine the health care “issues” in a way that could possibly elicit the response you are hoping for.

  15. “We are invited to consider our lives and live as if time is short. But why?”

    Well actually, that is not what was said or implied. The quote speaks of uncertainty, not brevity. Within this zen-like mind set the challenge is to plan for mortality instead of immortality. Statistical evidence that the number of centenarians is increasing deludes many of us to imagine that dying is optional, that thanks to science the human lifespan is finally becoming extendable.

    Unfortunately that is not the case. As a caregiver for seniors I can assure you that making rational plans for the future means surrendering all you have lived for before (not when) you pass, selecting the circumstances of your care and safety as you very likely will no longer manage your own affairs. As we age we face two choices: make unpleasant decisions in advance or wait until someone else makes them on our behalf.

    I can also tell you first hand that your beloved marketplace is producing a swelling population of old people, most of whom, like you, refuse to face the reality of diminishing mental and physical resources, no matter how well they have feathered their nests.

  16. “despite the great advances in automobility over the decades” – Because the era of easy and cheap oil is over and Americans utterly refuse to pay for the upkeep on their current roads and bridges through increased gasoline excise taxes or privatization & notably higher tolls on most highways.

  17. Brilliant, and absolutely true! When I decided so long ago to become a doctor, I had no idea I would have a career smack in the middle of a revolution in healthcare. The author put it exactly as it is: every one of us working in healthcare today must decide which side we are on…the stupid, misguided, incoherent, suboptimal, and deadly status quo – or to join those who would dutifully serve the roles these times have thrust upon us to guide systemic change. If we do, the benefits will reach the ends of the earth; if we don’t, there very literally will be blood on our hands for standing by. There is much truth to this post. I personally have taken my own costly steps in these regards, and I join the author in urging all of us onward.

  18. Hard to know how to respond, so let’s begin with the discount rate here: “Since death alone is certain, and the time of death is uncertain, what shall I do?”

    We are invited to consider our lives and live as if time is short. But why? Because if our time is short enough, then there are no children to feed and educate, no retirements to fund, no travels to dream of…. all things which lead us to think of personal revenue optimization and to eschew the big and noble picture.

    Create a society in which the feeding and education of children, and the challenges of creating a good life in the last decades of life, are socialized to a greater degree and you create the conditions in which people can lift their nose from the grindstone of personal and business interests and “return the favor.”

    Exhort them to do so in a society in which the individual is forced o rely significantly on his or her own resources, and you are more likely to get a smirk and a shrug, and lots of verbal agreement while folks are rushing around making sure that other people don’t make suckers of them.

    American life is, in reality, nasty, brutish… and LONG.

    Live as if it is short and we are reminded in a thousand ways that we and our children will pay the cost. We do not know the day of our death, but we can be fairly confident that it is a long, long time away, and there will be hell to pay if we don’t figure out how to pay for it.

    Or is this article addressed only to 65 year old Type A executives of large institutions who are pushing themselves toward a heart attack anyway? Perhaps it is. Maybe they can relate? Most of us, however, are stuck in a more mundane economic reality.

    So I’m with you. We should dream. But our dreams must be collective dreams, social dreams, socialist dreams. Individuals and individual institutions caught in the demands of a market economy can’t do enough of the small right things to balance all the self interest of all the actors in the market.

    Only by socializing the system in one fell swoop can socialize the system, humanize the system. Otherwise noble intentions of individual actors can never swamp the economic fear and self interest that drives others.

    I would say this post is rooted in the liberal fallacy that the sum of a thousand individual good intentions adds up to more than the sum of its parts. The reality is, in my experience, just the opposite. In a society of one thousand, 800 well intentioned persons acting as individuals cannot achieve half the good that 501 individuals who democratically control a society and make decisions that are incumbent upon all can do.

    Change must come democratically, but ultimately it must be mandatory and universal, or else self interested bad actors will bring the system down. On those terms, let’s rock and roll.

  19. Not quite sure why we think that the situation/opportunity is different in 2011 than it was in 2001 or 1991 or 1981 or….. The political drivers seem the same. But I do think it’s interesting that the same federal government which now asserts greater control over our health care also wants to get us out of cars and into high-speed trains and other public transit – despite the great advances in automobility over the decades.

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