Cultue, Effect iof It’s The Culture, Not the System

What Shapes American Health Care Values

Q: You’ve now submitted 214 consecutive daily blogs on medical innovationblog.blogspot.com on the health system. That must be a real grind. Why punish yourself? What are you trying to do?

A: I’m trying to prove beyond reasonable doubt the U.S. culture – not government policy, not consumer-driven care – that shapes U.S. health care and how health professionals and patients behave. I’m suggesting constructive solutions, like innovative public-private partnerships, as one of the solutions. In the U.S. culture, the marketplace, not the government, usually determines what people do and where they go for care.

Q: That must be an uphill battle.

A: It is. Everybody, for ideological reasons and to preserve their status quo position, believes they have the right answers. They don’t. The answers transcend ideology and their stake in the system. Liberals will be liberals, conservatives will be conservatives, bureaucrats will be bureaucrats, and innovators and entrepreneurs will be innovators and entrepreneurs, and never the twain shall meet. It’s a stand-off. Control, equality, choice, and freedom have unpleasant trade-offs

Q: As a physician, what’s your position?

A: I’m a cultural anthropologist at heart. But I appreciate how important the physician culture is. Physicians, after all, are the second oldest profession – or culture – if you prefer to think of doctors that way.

Medicare, then Managed Care, and now Market Forces, have sought to change physicians from being independent professionals to businesspersons and corporate personages. These various controlling forces want doctors to cross the t’s and dot the i’s of practice management, serve as quasi-employees of government or health plans, or become team members in large multispecialty clinics or academic centers.

Being led by other physicians in teams has worked best, but independent physicians don’t widely accept being led by other physicians in big organizations. They don’t like the overhead or the politics. That’s why 75% of physicians are in practices of 5 or less. It’s possible independent doctors will go the way of the corner grocer, and become submerged as employees of hospital grocery chains, or as professional technicians for corporations, but it hasn’t happened on a large scale yet.

The general thinking of medical outsiders seems to be, if we grab doctors by the tender parts of their anatomy, their hearts and minds will follow. It hasn’t worked, not yet anyway.

Q: What is the health care culture like?

A: You ask excellent questions, if I don’t say so myself. Here’s how I explain it.

Healthcare cultural problems exist at three levels:

1.The Culture of American Society

As J.D. Kleinke has written:

"Such is the culture of medicine in America. We demand the best, accept nothing less and reward lawyers handsomely for making sure we get it. Even the imminence of certain death does not attenuate this cultural fact, as the clinical behaviors, costs and outcomes of typical intensive care illustrate. Our national consciousness is steeped in optimism, hostile to all processes and manifestations of aging and enraptured by a limitless faith in technology; as a people we have come to revile death as much a personal defeat as a personal loss.”

In other words, given America's medical culture, physicians, patients, and lawyers are likely to keep on doing what they're doing.

2.The Culture of Large Health Organizations.

Remaking Health Care in America: Building Organized Delivery Systems is an excellent book on the culture of large health systems. The authors – Stephen M. Shortell and four other consultants – describe the cultures of 10 large multi-hospital systems, which had 1994 total revenues of $500 million to $1.5 billion. These hospital systems have worked hard, with mixed success, to create physician group cultures stressing teamwork, cooperation, sharing of information, pride in the organization, and attentiveness to physicians.

Salaried physician stakeholders drive certain tightly integrated organizations – nonprofit HMOs such Kaiser and clinics such as Mayo. These successful models, led by physicians selected for their dedication to the organization's mission, have not been replicated on a broad scale.

Academic medical centers have special cultural problems. These centers, burdened with educational expenses, are fragmented, overspecialized, notoriously difficult to organize, and not very enthusiastic or good at training primary care doctors in outpatient settings. Too often the culture of academic health centers consists of sharply departmentalized and overspecialized independent fiefdoms, connected only by a common plumbing systems and grievances over parking.

3.The Culture of Physicians

Health industry leaders have repeatedly told doctors they must consolidate into larger groups or integrate with hospitals to survive; achieve greater size, critical mass, and scale; cultivate managerial care expertise; work in multidisciplinary teams; seek capital offered by large companies; follow evidence-based or standardized guidelines to practice good medicine; practice preventive medicine; develop systems approaches to managing chronic disease; enter into primary care specialties to assure a less costly health system; install information technologies in their offices; establish practice web sites; offload business functions to the Internet; communicate with patients through the Internet and by e-mail; convert to paperless offices, prescribe electronically; standardize codes and transactions for diagnostic procedures and develop leadership skills.

These admonitions from health leaders have left many clinicians unmoved. Physicians have not bought into the argument that bigger is better or that managed care and corporate models for achieving quality are in their best interests or their patients’.

To understand why physicians have resisted, you have to get inside their minds and skins. The way many physicians think can be illustrated in the following list of ideas:

1.You became a physician to serve patients, not hospitals or business corporations.

2.Your customers are “patients,” sick individuals who need your help, even when that help is expensive and experimental.

3.You're "the patient’s advocate," a protector and a guide through a world fraught with obstacles to care.

4.You see patients one at a time, and you don't feel responsible for "population health."

5.You don't really care about the financial health of investor-owned HMOs who profit from minimizing care.

6.You realize patients spent 99 percent of their time outside your office, and you know ill health often stems from flawed life styles and rarely rests on your advice, which you are not paid for offering.

7.You distrust group activities. Your success has always been by dint of your individual effort, whether that effort has been getting good grades in college, doing well in medical school to qualify for the residency of your choice, or caring for sick patients in academic medical centers or inner-city hospitals.

8.Your rewards have come through working hard, mastering your specialty and impressing colleagues, not through participating in hospital, HMO, or corporate bureaucracies.

9.You dislike organizational politics. You detest meetings. You turn a wary eye toward any activity that takes you out of the operating room, off the wards and away from your office, for those locations are where the patients, your joy in doing well and your income are.

10.What has any managed care organization, hospital or business corporation done for you? HMOs, in your mind, manage cost not care. Has any HMO medical director or health executive ever helped you care for a patient better? Has any HMO policy improved quality of care for your patients? Has adherence to clinical guidelines really helped you find the right answers to your patient’s problems? Has any managed care organization placed at your fingertips in the waiting room, at the “point-of-service,” an easy-to-use information system that saves you time by telling you what drug to use, what diagnosis to consider and or whether the patient can pay?

11.Everything that relates to the new competitive environment has discounted your fees, driven down your revenues, compelled you to hire more personnel to deal with HMO clerks or “Doctor Denial” HMO medical directors and forced you into organizations where autonomy is less, rules are stricter, income is lower, work is harder, and a production-line mentality is at work.

12.You are a professional. Not a "provider" to be ordered about. What do these health care executives and those on the other end of an 800 line know about practicing medicine anyway?

Q: Your explanation reeks of physician tunnel vision. You can’t see the light in your dark tunnel. What about the common good? What about guaranteed and consistent quality and better outcomes? What about equity and equality? What about providing affordable care for all? Health care culture is just a sub-segment of the greater American culture. Where does the health care culture fit into our egalitarian culture?

A: That, of course, is a philosophical as well as an historical question. It goes back to Adam Smith and his theory that everyone acts in their own-self interest and to the tenets of our founding fathers in establishing American Democracy 231 years ago.

Our health system is a creature of our culture. When asked what Americans believe, Garry Orren, a professor of political science at Brandeis, who polls for the New York Times and the Washignton Post, said,

“A good place to start is to remember we are pro-democracy and anti-government. It comes down to ideas that are essentially anti-authority and tend towards self-regulation. If there were an American creed, I think it might begin.

One: Government is best that governs least.

Two: Majority rule.

Three: Equality of opportunity.

Q: What does that set of values portend for the health system?

A: I don’t know, but it explains why Americans,

•prefer local health solutions,

•health care varies from one region to the next,

•so far have rejected sweeping universal coverage with rationing,

•feel capable of making their own health care decisions,

•seek equal opportunity access to high technologies,

•prefer choice of pluralistic payer systems,

•allow market-based and public-based institutions to co-exist and compete,

•permit doctors to behave democratically, seeking their own locales to practice, often acting independently of hospitals, health plans, and government, and making their own decisions;

•are reluctant to jump into a government-run system;

•do not embrace a tax-based system that punishes the rich and rewards the poor and that assures equality of results but dampens equality of opportunity,

•want to be free to make their own choices of doctors, hospitals, and other providers, based on their own judgment.

American democracy is full of cultural conflicts, paradoxes, and tensions. That’s what we seem to like -= controlled chaos with a mix of choices and opportunities. We want our care when we want it, where we want it, on our individual terms, not the terms of the government, the insurance companies, or the market. That cultural mindset causes profound problems – as well as unprecedented opportunities.

Q: You haven’t mentioned the role of government.

A: Ah, yes, government. It’s a subject that lends itself to metaphors – the bloated and ballooning bureaucracy, the elephant in the room, a sun never setting on government programs. The role of government, in my view, ought to allow public-private health partnerships to flourish in areas like disease management and prevention.

Look, government in health care isn’t going to go away. With aging babyboomers, Medicare’s slice of government expenditures will only grow. It may even lead to a national bankruptcy. Already the CMS budget is the fifth biggest budget on the planet – behind Germany, France, China, India, and perhaps California. The government has shown no talent for containing costs over the last 40+ years. As a nation, our government spends more per capita than any single-payer system. If the U.S. were to adopt a single-payer system, it could easily bankrupt us and would be subject to severe political manipulation. Congressmen and senators and president wanna-be’s need money to run, and a lot of that money comes from health care special interests.

Q: And what should be the physician’s role?

A: It ought to be constructive, and it ought to be based on innovations – creative public-private enterprises, new forms of practice, new technologies, new, less costly, more convenient sites of delivery, new collaborations and partnerships with hospitals. Much of this will only happen if the government gets out of the way with its Stark laws, Certificate of Need, IRS and OIG regulations, and its traditional compulsion to regulate and make rules.

Perhaps naively, I believe the best options for doctors are to pull themselves up by their own innovative bootstraps by pleasing patients and improving their care, rather than depending on federal largess. Doctors have little choice. The government will continue to cut doctor reimbursement, perhaps as much as 40% in the next five years if the current reimbursement formula holds. Outside of the VA, few really wants care at government facilities. They want government benefits at someone’s else’s expense. But my thoughts on government are not all negative. We need government, and we need government innovation. I’m an optimist. I like Winston Churchill’s observation. You can always trust the Americans. In the end they will do the right thing, after they have exhausted all the other possibilities.