Tuesday, December 16, 2008

A convergence of altruism and self-interest

See my new policy blog at: http://frissepolicy.blogspot.com/

These are strange times. There is growing talk of dramatic changes to our health care financing system in response to the economic crisis and renewed commitment to developing a robust national infrastructure, broadly defined. Yet large health care delivery systems - at least middle managers within these systems - follow a well-worn logical local strategy that may worsen their prospects in any reconstituted health care system. Specifically, while at the Federal level there is a Keynesian belief that increased investments will yield transformation, many health delivery organizations are taking the more traditional short-term view and arguing that they cannot invest in new approaches to patient-focused care because they don't have the money to do so in these difficult times. It's a bit like claiming that when one's car is almost out of gas, one doesn't want to pull off the highway to fill the tank because the side-trip will use gas.

Let's be more clear. There is a growing consensus on several factors:
  • Health information should be "patient-centric" so that information is available to support the care of the individual wherever required in a way that ensures their confidentiality and empowers their ability to use information.
  • Health care delivery organizations - hospitals, practices, intermediaries - should not compete over possession of data. This comes at the expense of both improved patient care and a badly needed step towards a more effective health care system.
  • Health information that is in paper form today must be made available in digital form under security and use provisions that ensure individual and public confidence.
But I continue to hear organizations with extraordinary cash flows and assets argue that in this time of financing crisis, they cannot afford the relatively small investments required to collaborate. In so doing, they abrogate to health plans and intermediaries any opportunity to participate in a patient-focused health care information market. Maybe that's what they want.

This is a strategy that General Motors would relate to. Quoting from Tom Friedman in the NY Times:

"As I think about our bailing out Detroit, I can't help but reflect on what, in my view, is the most important rule of business in today's integrated and digitized global market, where knowledge and innovation tools are so widely distributed. It's this:

Whatever can be done, will be done. The only question is will it be done by you or to you.

Just don't think it won't be done. If you have an idea in Detroit or Tennessee, promise me that you‚ll pursue it, because someone in Denmark or Tel Aviv will do so a second later."

Thomas Friedman, Op-Ed Columnist
While Detroit Slept (December 9, 2008)


Parker Palmer helps us understand what is going on. In a recent essay entitled "Repossessing virtue: Economic crisis, morality, and meaning: Trusting our Deeper Knowing: On Cataclysms, Contemplation, and Circles of Trust," Palmer says that if we look inside our spirit, we know full well what has happened and what will come. He speaks of broad economic terror but his logic seems to me to reflect the intuitions of both those in need of care and those who provide care.
Quoting Palmer:

"Alexis de Tocqueville, the nineteenth century French scholar famous for Democracy in America, wrote a less well-known book titled The Old Regime and the Revolution, arguing that the French Revolution happened long before it happened. The eruption that shattered French society at the end of the eighteenth century was the result of small seismic shifts that had been accumulating for decades deep underground. If people had paid attention to the tectonic instabilities caused by greed and injustice, and had responded wisely to the nervous needles on their inner seismographs, the "Reign of Terror" might have been avoided.

A parallel point can be made about the economic terrors that now engulf America: at some level, most of us knew they were coming. Who doesn't know that a society in which the rich get richer while the poor get poorer is a society that will someday have to pay the piper? Who doesn't know that when a relatively small fraction of the world's population uses its power to command and consume a disproportionately large fraction of the world's resources, the chickens will come home to roost? Who doesn't know that an economic system that encourages us to live beyond our means and refuses to regulate greed is one in which our avarice will come back to bite us? Who doesn't know that at every level of life, from personal to global to cosmic, what goes around comes around?"

What goes around, comes around. Failure to create a health care system focused around the long-term care of the individual and focusing instead on short-term return for the hours, days, or years during which an individual does business with you leads to risky transitions in care, financial inefficiencies, consumer confusion, and the perpetuation of markets that compete over almost everything but the quality of care and impact on public health. We know this to be the case, but many in positions of power seem unable to pursue a new and very obvious course that will improve their ledgers and in their public perception. It's not about short-term cash flow, it's about long-term public trust and the importance public trust in envisioning a more effective health care delivery and financing system.

As my daughters would say, Duhhhh...