I have been looking forward to 2016 and asking myself where healthcare should focus in the year ahead. In this connection, Don Berwick’s speech at the 27th Annual IHI Forum had a profound effect on me. You can watch it on YouTube. I appreciated his insightful and historically astute descriptions of Era 1 and Era 2 of healthcare. The first era goes all the way back to Hippocrates and Galen and was dominated by clinical autonomy and traditional professional values and mindset. Elements of that era persist today as we continue to try to be a self regulating profession and industry that often exists primarily for its own benefit. The second era was characterized by carrots and sticks and complex mechanisms of measurement and reward that became the objective and not the facilitators of a better system of care. Era 2 dates to the ’70s and in many ways was a response to the abuses and failures of Era 1.
I liked the fact that Don saw that there were values to retain from each of those earlier eras even as many of their components are discarded as barriers to understanding each unique patient and each patient’s orientation to the world. By calling for a new Era 3 he is pointing out the transformation required of all of us if we are to ever to make real progress toward the Triple Aim.
Don characterized Era 3, which is emerging now. In describing Era 3 he lists four things to correct from Eras 1 and 2 and five new attitudes to develop.
To move away from Era 1 and 2:
- Stop excessive measurement
- Abandon complex incentives
- Decrease the focus on finance
- Avoid professional prerogative at the expense of the whole
To embrace the possibilities of Era 3
- Recommit to improvement science
- Embrace transparency
- Protect civility
- Listen, really listen
- Reject greed
The entire speech is fantastic, but the real character and difference of Era 3 was capsulized in the last two minutes of the 55-minute speech. There he says that the challenge is in how we view, honor, and seek to serve each individual as a unique person who comes to us for help. He asserts that our patients deserve our focused respect and attention to their problems and each person should be viewed in the context of their limitless possibilities and not just in the context of their current complaint or problem. He stressed that our success will arise from the richness of our relationships with our patients and our ability to support one another.
My enthusiasm and my hope were renewed by this speech. Don positioned us to see even deeper meaning in all of the things that we have capsulized in the Triple Aim and all that we have come to understand that will be required of us if the Triple Aim’s lofty goals are ever to be achieved. In his speech he instructed us like a good teacher with stories and metaphors that allow us to attain, if only for a brief moment, a view of the possibilities that he sees. That brief view of the summit should give us hope for our climb. The view does not guarantee that we will ever arrive at the place we desire but it does give us guidance about what to look for on the way, how to plan, and what to avoid or change to enhance the possibility of securing. . .
Care better than we have ever seen, health better than we have ever known, cost we can all afford, …for every person, every time.
It is against the background of Don’s speech that we should consider the path we should follow in 2016. It is against his list of nine concerns that we should decide how we will focus our individual and collective efforts. A good strategic process always includes an assessment of current state, assets, liabilities, competencies and barriers. With his list and description of Era 3, Don has helped me focus on what I think my priorities should be for this year.
As I reflect on what has been gained, what is vulnerable, and what must improve, it occurs to me that at the end of the day the discussion in healthcare is pretty much the same discussion that exists both within our country and around the world. How do we listen to one another with respect as we search for solutions to very difficult problems that at their core concern personal and national security? In healthcare the obvious initial problem that has gotten some relief, but still plagues many, is access. The ACA has improved access, but its gains are vulnerable to expense as well as the diversity of political opinion. Concerns about costs threaten the small gains of the ACA in access, and I should also add safety and quality. Concerns about cost always exacerbate fear and concern about security and self.
Don shows his genius with his list of nine. With the list of four “don’ts” he rightly tells us that a focus on finance and incentives coupled with complex measurement systems will not produce better care or lower costs. We have tried that for a long time and have little to show for it. He also knows that if doctors and institutions only seek their individual will and without searching first for the collective improvement of the patient and the community, that will lead to ultimate failure.
Don’s “do’s” are designed to recharge our better instincts. He would create an open environment where transparency and civility encourage progress and innovation. He reminds us that the concerns of the patient dictate not only the management of an individual case but the direction of a profession and industry. He emphasizes that no one practitioner and no single institution can provide the services and coverage required in our complex world. We are all connected for a purpose. We must move forward together.
So, two things stand out for me on Don’s list of “do’s”. First is the recommitment to improvement science. For me that means redoubling efforts to help individuals and institutions make Lean or some form of continuous improvement the core of their culture and their operating system. Leadership, insight, will and a realization that improvement and innovation are easy to say and hard to do are all necessary for Lean–or, if you prefer, improvement science–to have a chance to help us. Second issue is a real lack of willingness to meaningfully engage in the effort to lower the cost of care.
It is amazing to me how easily we can pass on the responsibility to lower the cost of care. Recently the headlines of the Boston Globe read Health expenses surging in state. I was truly surprised to find that the most empathetic and insightful statement in the article came from the spokesman of the right leaning Pioneer Institute.
“People cannot sustain the amount of money they’re paying for health care, ” said Joshua Archambault, senior fellow at the Pioneer Institute, a right-leaning Boston think tank. “At some point, people really can’t afford it.”
Nowhere in the article was there a discussion of waste, pricing structure for medical services, or any of the issues that physicians and institutions control by continuing to practice in the modes that Don called Era 1 and Era 2.
The first realistic question to ask when trying to solve any complex problem is, “What part of the problem am I/ are we?” We cannot say that we respect patients or that we are empathetic to their plight if we continue to passively accept the rising cost of care and do not hold ourselves accountable for much of the pain that it inflicts on those who are the most vulnerable members of our community.
Drew Altman is the CEO of the Kaiser Family Foundation. He recently addressed the issue of the current cost of care in a blog post published in The Wall Street Journal, where he said
… the number of Americans who have problems paying their medical bills in a given year runs into the tens of millions, a survey conducted by the Kaiser Family Foundation and the New York Times found. These are not only people who are uninsured, have low incomes, or are very sick. For many, their uncovered medical expenses affect their ability to meet other basic needs–such as paying for housing, food, or heat–or make it tough for them to pay other bills.
Attention to cost must be the focus for 2016. Overcharging patients and putting them in financial jeopardy or forcing them to choose between care and other necessities of life is wrong. A first step that an individual physician or other clinician might take is to examine the charges that are generated after the visit and then ask a simple question: Was that a good value for my patient?
Is the cost of care that patients pay the top concern for most doctors in 2016? Not according to a recent Medical Economics article that reviewed the top concerns of physicians. They canvassed physicians to discover the ten biggest challenges of 2016. Challenge number 1 was “getting paid what you deserve.”
There is a growing body of data to show us specifically how the cost of care is a barrier to care for many of our patients today and a threat to everyone’s access in the future. Those concerns do not make the Medical Economics list because they are not the current concern of most physicians who demonstrate by their concept of the “challenges” for 2016 that they are still unaware of the reality that putting the best interest of your patient first is the best way to serve your own best interests. There is a lot of work to do in 2016.
