Forces of Change

New Strategies for the Evolving Health Care Marketplace

David A. Shore, David A. Shore

• Publisher: Jossey-Bass
• Year: 2012
• ISBN:
  9781118237007
• Edition: 1
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

A merican health care has made great strides in the past hundred years. Life expectancy has increased dramatically and advances in medicine and treatments have eradicated many life-threatening diseases. However, in today's health care arena there is divergence between our health needs, the structure of our health care system, and how health care is delivered and funded.

In Forces of Change, David A. Shore has collected the leading thinking from experts in the field on how our health care system can benefit from important lessons from other industries and effect transformational change that truly serves all stakeholders well.

Contributors include Max Caldwell of Towers Watson; Michael J. Dowling of North Shore–Long Island Jewish Medical Health System; John P. Glaser of Siemens Healthcare; Ashish K. Jha of the Harvard School of Public Health; Eric D. Kupferberg of Northeastern University; Lucian Leape of the Harvard School of Public Health; Jeff Margolis of the TriZetto Group, Inc.; and David Shoultz of Philips Electronics.

Part One

Can We Get Better?

1

Framing the Forces of Change

David A. Shore

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EDITOR’S INTRODUCTION

Many people outside the US health care industry focus their attention on national reform efforts, the most recent being the Patient Protection and Affordable Care Act passed by Congress in 2010. Because the course of reform is hard to predict, the real challenge for industry leaders is to improve their own organizations—to make them better today.

Doing so will not be easy, as this chapter explains. Leaders face a series of potential pitfalls, any one of which can derail change efforts. The chapter also describes a way forward. By discarding old assumptions and mapping out a path to change, leaders can avoid the obstacles and bring about real improvement in their organizations.

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The poet Edna St. Vincent Millay wrote, “It’s not true that life is one damn thing after another. It’s one damn thing over and over.”¹ That is certainly true of the attempt to reform health care in the United States. Theodore Roosevelt called for reform nearly a century ago. Harry Truman, in his 1949 State of the Union address, said, “Our health is far behind the progress of medical science. Proper medical care is so expensive that it is out of reach of the great majority of our citizens.”² Nearly every president since Truman has at least given lip service to the need for reform. Some have done considerably more, such as Lyndon Johnson, who signed Medicare into law in 1965, and Bill Clinton, whose effort to transform the entire system crashed and burned in the early 1990s. Most recently we have the Patient Protection and Affordable Care Act of 2010, derided as “Obamacare” by its critics. The new law is complex, ambitious, and controversial. Its ultimate effects will not be known for years, and it will be deter­mined not only by continuing wrangling in Congress but also by the writing of thousands of administrative rules and regulations.

One thing we can be sure of, however, is that the push for reform will not go away. Even those who most strenuously oppose the latest reform know that the status quo in health care is unacceptable to many Americans and likely to be unaffordable as well. Another thing we can be sure of is that the most recent law will not accomplish everything its supporters hope for. (It probably will not do all that its critics fear, either.) So there will be many more attempts at reform in the future. Aside from letting their opinions be known, health care leaders cannot do much to affect the outcome. As Doris Day once sang, “Que Sera, Sera”—whatever will be, will be. If we wait for Washington to create a great health system, chances are we will be waiting a long, long time.

Nevertheless, health care leaders can do a lot in the meantime. They can make their own organizations better.

“Better” is a useful term in this context, because it cuts through the tired debate about how good American health care really is. Everybody agrees on the positive aspects of the US system—leading-edge diagnostic and therapeutic technologies; safe, effective drugs and medical procedures; many world-class clinicians and institutions; and nearly unlimited health care information (80% of Internet users have searched for health care information online)³. Many wealthy people from all over the world come to the United States for certain kinds of treatments and procedures. Conversely, nearly everyone also agrees on the negative aspects of the system. The number of medical errors is appallingly high. The variability in care from one region to another—even from one organization to another within the same region—is substantial. Many people have no insurance coverage and do not have regular, easy access to care. Overall, health care costs far more per person in the United States than in other countries, yet it produces results that are often no better and in some cases worse. Even tiny Cuba has a lower infant mortality rate than the United States. Cuba spends roughly $900 per person per year on health care, compared with more than $7,000 in the United States.⁴ Perhaps the most troubling of all is that our “system” is far from systematic.

Rather than debating which list of factors, the positive or the negative, outweighs the other, as so many people do, let us pose a deeper question: If we are so good, why aren’t we better? And how can we get better? How can we create more effective and more efficient health care from the ground up? Health care leaders cannot solve all of the system’s problems, to be sure. But they can certainly help their own organizations improve. In this chapter, we look at the many factors and obstacles they must contend with, and we consider the essential elements of plotting a way forward.

The Context of Change

Most of the factors I describe here will be familiar—they are forces that every health care leader deals with all the time. But only when we add them up and consider them as a whole can we begin to see where progress might be made.

Multiple Stakeholders

What is the mission of a health care organization? This is a profound question, and a difficult one to answer. Some people believe it is to heal the sick. That is right, of course, as far as it goes. Still, the mission could be developed in other ways. Why are there so many sick people? What is the best way to realize the mission of healing the sick? And is “heal the sick” sufficient? Let us not forget—we have to heal the sick in a manner that costs less than the reimbursement we will receive from the government or the insurance company, or else make up the difference between costs and income some other way. Alternatively, perhaps the mission is to prevent illness. But now we are really on shaky ground. The last I checked, there was no reimbursement code for that.

It is not uncommon to hear people in health care say, “No margin, no mission.” One might conclude that their primary goal is to make money, like any other business. That, too, is fine. Everybody has to earn a living, and every organization has to produce a surplus over and above its costs. Would anybody really want to tell patients that the primary goal of the organization that is about to care for them is to make money? What about saying that to the companies and agencies that pay patients’ bills? Or to regulators? In one discussion at a world-class medical center, a senior physician I spoke with scorned the idea that the hospital should make money. He had a different view. The purpose of this hospital, he said, was to provide a place for physicians to practice. An unusual mission! I do not know of another industry on earth in which more than 80% of all revenue is generated by nonemployees—in most cases, by physicians.

The fact that “Americans pay more when they get sick than people in other Western nations—and get more confused, errorprone treatment,”⁵ is to a great degree an issue of stakeholder conflict, of differing views as to the mission of health care. Patients want the best possible care. Payers want the most cost-effective care. Clinicians want the freedom to do their work as they see fit. Regulators want to enforce standards. Boards of trustees and senior executive teams want to create notable and prosperous organizations. How on earth do we define better in this context? Everyone has an interest—a stake—and views of their own as to what would be better. In health care, where you stand depends greatly on where you sit.

Variability of Outcomes

Most stakeholders, we might assume, prize consistency—consistency of procedures, consistency of treatment, consistency of outcomes. After all, consistency is the hallmark of most industries. Air passengers virtually always get where they are going because the airlines have developed rigorously consistent methods of operation. Restaurant patrons eat billions of meals and very rarely get sick because restaurants follow prescribed food preparation and sanitation procedures. The movement for evidence-based medicine is essentially a push for consistency. Treat the same condition in the same manner—in whatever manner has been shown to bring about the best outcomes. Yet, studies have shown that patients receive only 55% of recommended, evidence-based care.⁶ They do not consistently adopt the treatment plans and procedures that their peers have judged most effective. This kind of inconsistency permeates health care. Operating room procedures have been at least partly standardized, but they still vary from one hospital to another. Some hospitals and medical centers have mounted effective programs to ensure regular hand washing among doctors and other clinicians. Others have not. Some have developed effective programs to ensure that every staff member gets a flu shot. Others have not.

The result of all this variability is a dramatic inconsistency of outcomes. Elsewhere in this book, you will read about the Dartmouth studies that found startling variations in treatment protocols, medical results, and costs from one part of the country to another. State rankings exhibit similar variation. According to the most recent United Health Foundation study, published in late 2010, Minnesota ranked as the healthiest state in terms of outcomes, whereas Vermont was number one on the factors likely to determine future health, such as rates of cancer, smoking, car accidents, and high school graduation. Mississippi ranked as the unhealthiest state overall, as it had for the previous nine years. It had high rates of obesity, children living in poverty, and pre­ventable hospitalizations, along with a relatively low high school graduation rate.⁷ The disparity between top-ranked states and those at the bottom was wide.

The performance of individual health care organizations varies widely as well. In 2011, for example, the ratings organization HealthGrades analyzed thirteen different kinds of “patient safety events,” such as postoperative respiratory failure and catheter-related bloodstream infections, among Medicare patients at every hospital in the United States, nearly 5,000 in all. The organization found that the top 5% of hospitals significantly outperformed the others. In fact, if all hospitals provided the same quality of care as that provided by the top 5%, nearly 175,000 patient safety events could have been avoided, more than 20,000 seniors might have survived their hospitalizations, and the federal government could have saved nearly $1.8 billion in health care costs.⁸

Unrealistic Expectations and Poor Behaviors

People have huge and often unrealistic expectations for health care. Because doctors can now do so much compared with what they were able to do in the past, patients expect to walk into a physician’s office or a hospital and walk out cured. (The story is told of the orthopedic patient who told his surgeon that he wanted to be back on the tennis court a day or two after his knee operation—and he hoped his game would be improved as well.) The trouble is, many patients fail to do their part. They do not eat well or get regular exercise. They fail to take their medicine as prescribed, follow their therapeutic regimens, or return for follow-up appointments. Some 70% of Americans with high blood pressure do not have it under control. Approximately 70% of asthma patients do not know how to use their inhalers. Low health literacy and a lack of education can contribute to counterproductive behavior. A study of inner-city adults with severe asthma found that more than half believed that they had the disease only when they had symptoms. Many of these people did not believe their disease was chronic.⁹ Unrealistically high expectations of medicine combined with poor lifestyle choices and noncompliance combine to create poor patient outcomes and dissatisfaction.

Low Satisfaction and Trust Levels

For the three stakeholder groups for which we have national data—physicians, patients, and other health care workers—all groups show declining satisfaction with the health care sys...

Table of contents

• Cover
• Title page
• Copyright page
• Editor’s Preface
• Dedication
• Acknowledgments
• The Editor
• The Contributors
• Part One: Can We Get Better?
• Part Two: The Elements of Change
• Part Three: Reshaping the Organization
• Index