Chaos and Organization in Health Care

13. Accelerating Evolution

13 Accelerating Evolution The central argument of this book is that the organization of providers is an essential step in the development of a better health care system. Organization enables providers to bring order to the chaos generated by technological progress. Organized providers can use EMRs, patient registries, disease management programs, and other systems described in this book to make health care more efficient, reliable, and safe. Perhaps because we are optimists, we believe that the adoption of such systems and the resulting improvement in health care is already under way. But because we are realists, we know that the pace of improvement is not fast enough. Rising costs threaten access to care for tens of millions of Americans—which is reason enough to confront the barriers that slow the evolution of health care. In our prescription for improving health care, we assign the greatest responsibility to our own colleagues—the providers of health care. This provider-focused perspective is shared by nonproviders who assert the need for a “market-based but physician-led” future for health care [1]. Physicians and other clinicians could surrender to their fear of uncertainty and try to delay inevitable change. Or they can play their more appropriate leadership role and actively shape the development of a better health care system. There are good reasons why many health care providers have not embraced this role with enthusiasm to date. The financial stakes for providers are high, and their current profit margins are thin. Many organizations do not have the financial reserves or access to capital for major investments in information technology and other structural needs. The cultural issues are even more formidable. Organized care requires physicians to surrender some of their individual autonomy and work in teams. They must learn new computer and interpersonal skills, and adjust to new types of incentives. 230 Chapter 13 Providers need help in addressing these issues. As we will discuss, health insurance plans, employers, patients, and health policymakers all have roles to play in facilitating change. But the ability of health care providers to rise to the occasion will dictate how quickly highperforming health care systems develop in the United States. Collectively , we need to create an environment that makes it possible for providers to lead the change—and unwise for them not to. Multiple Strategies A first step in the development of a better health care system is acceptance that no single solution to our problems exists. No single payment system such as capitation or a single market strategy such as consumer activation can drive the needed change. Every potential strategy offers some potential benefits, but each one also has potential liabilities. To advocate any single strategy is to invite skepticism and consolidate resistance to that approach. A more productive approach is to accept that we have to pursue several strategies simultaneously. Every one of those strategies will have its flaws; after all, whenever money changes hands, there is the potential for perverse consequences. Each strategy should be used in ways that maximize the benefits and minimize the risks. Through the thoughtful management of financial and nonfinancial incentives, we believe the pace of improvement in health care can be accelerated. For providers, a difficult challenge is the transition from critic to playwright. Providers should continue to speak out about what they oppose, but they also have an obligation to say what they are for. If we providers are to be serious participants in shaping the health care marketplace, we actually have to be supportive of several strategies for improving efficiency and quality—even though each and every one will generate angst among our colleagues. Our job as provider leaders is not to fight change but rather to mitigate risk and optimize effectiveness as multiple strategies are deployed. So what potential strategies exist, and what are their likely effects? We have our own opinions, of course, but to get broader input, we conducted an informal survey of twenty-six health care leaders from the United States and the United Kingdom who were attending a meeting in Boston in July 2008. These experts included government officials, economists, health plan executives, and provider leaders. We Accelerating Evolution 231 asked them to rate each of five strategies on their potential effectiveness for driving improvement in quality and efficiency. A rating of 0 would indicate no beneficial impact at all, while...