Changing Health Care is Hard
Roy Smythe–(Forbes)–It seems as if a large number of health care leaders have developed a new form of “Executive Tourette’s Syndrome,” whereby they have lost the ability to control the utterance of the word “Innovation.” At the very least, the use of this particular term has moved from urge past obsession, to an irresistible compulsion.
However, despite the claims of significant change in health care delivery as a fait accompli, the fact is that moving from a volume and intervention-rewarded system to promotion and maintenance of health is proving to be maddeningly difficult. The lack of correlation between involuntary proclamation and reality is due to the fact that there are a number of formidable impediments that must be clearly recognized and, if possible, overcome.
I was recently asked by Dr. Eric Von Hippel to speak at an MIT Innovation Laboratory Meeting on the topic of “Resistance to Innovation.” I offered up these four reasons for resistance in health care.
Innovation of Process vs. Tools
For the most part, medical care in America is still structurally delivered as it was more than fifty years ago – to those with acute problems, inside small boxes (outpatient clinics) or large boxes (hospitals) where doctors lay waiting for them to arrive, wielding a vast array of high-technology tools – the bright shiny objects of healing.
The problem is that unless we are willing to re-evaluate the actual processes of care (such as who or what delivers the actual care, where care is delivered, and what level of care is delivered to whom, etc.), the change we are seeking will not occur. We love bright shiny objects, and have exhibited great creativity and innovative energy around their development. However the outcomes we seek will only be achieved as we rebalance the importance of tools and processes and find ways to thoughtfully leverage what, admittedly, is a potential treasure trove of new technology.
The Yoke of Previous Success
The current model of health care delivery has generated trillions of dollars of revenue, as well as a large employed workforce and entire new ancillary industries. Billions of dollars of “sunk cost” investments have been made in facilities and infrastructure. These previous successes have a strong gravitational pull, and subvert the desire to develop or use innovative approaches to render change. Many – who are either emotionally attached or, more likely, financially yoked to the old models of care – are encouraged to adopt a siege mentality, i.e., “we can wait this out… and then get back to business as usual.”
A Poorly Aligned Payment System
With a few exceptions, the overwhelming majority of health care reimbursement is still allocated for provider visits, interventions and hospitalization. The Affordable Care Act makes provisions for government-payer exploration regarding what may best align the interests of all involved to promote more health and less intervention. In addition, commercial insurers are beginning to explore new approaches such as “shared savings” contracting with providers (admittedly, often where they can “cherry-pick” expensive disease entities that lead to high loss ratios) whereby some dollars saved by those providing care are given back to them.
However, the general application of these payment models will not occur quickly and are not overwhelmingly embraced by providers or insurers. This is in part due to the inertia caused by the foregoing impediments i.e. the focus on tools and their interventions, and the sunk costs associated with the old model.
A Risk-Averse Culture
It is no surprise that physicians are conditioned by education and training to minimize risk. After all, trying unproven things in the delivery of care can theoretically lead to suffering and loss of life if things don’t go well. This approach may be beneficial in the moment when caring for a patient, but it also may lead to resistance to change efforts in health care delivery.
A recent Mayo Clinic project is supportive of this claim. Clinicians were paired with designers with no health care background, asked to work together on a care improvement project, and to then relate the differential experience. One of the designers provided a consensus view:
“Physicians were deeply guided by tradition, and because they bore the responsibility for the patient’s life and well-being, they were, as a group, risk-averse. Physicians were scientists who needed to see data and proof before trying something new. This conservative culture affected doctors’ willingness to try not only new drugs and treatments but also new administrative procedures and educational methods.”
After the talk at MIT, a colleague from another industry approached me with a dark expression, and suggested somewhat fatalistically that, “Those are real embedded problems, it’s depressing, and frankly it seems insurmountable.”
It’s important to note that Tourette’s Syndrome is a challenging neurologic disorder, so my intent is not to minimize or caricature. The typical symptoms are involuntary body movements and vocalizations, and are first noted in childhood. However, the disease is not insurmountable – drug treatment can attenuate the symptoms and most improve as they mature.
The impediments to health care delivery innovation, too, are real, but also not insurmountable. Truly organized health care is young – a mere couple of centuries compared to the 300,000 or so years of existence for modern man. For the profession to transition from uncontrolled talk to deliberate action, and for it to focus less on bright shiny things, move past old habits and accept more risk some additional maturation will be necessary here, as well. But it will come.
Roy Smythe is a Forbes contributor and the Chief Medical Officer for Valence Health, a Chicago-based health care consulting, services and operating company that seeks to facilitate the ability of providers of care to manage medical and financial risk.