Wednesday, August 27, 2008

Medical megatrends - The Great Disconnect: Altitudes and Attitudes in Politics and Health Reform

In the course of my work, I have been overwhelmingly impressed with the extent to which America is a bottom-up society, that is, where new trends and ideas begin in cities and small communities, not New York City or Washington, D.C. My colleagues and I have studied this great country by reading the local newspapers. We have discovered trends are generated from the bottom-up, fads from the top-down.

John Naisbtt, Megatrends: Ten New Directions Transforming Our Lives, 1980

I admire the writings of futurist John Naisbitt, in Megatrends (1980) and Mindset! (2007), for Naisbitt understands, more than anyone I know, the importance of altitudes and attitudes.

In discussing the politics of health care, it is crucial to understand altitudes, as seen from above, and attitudes, as viewed from the grassroots, for the two are inextricably intertwined. Nowhere is this more evident than in health care.

If you start from a top-down altitude, whether that be in Washington, D.C, the rarified heights of a think-tank, or a command-and-control corporate or helaht plan board rooms, you have a certain mindset, that you know best what should be done at the grassroots. It is an easy trap to fall into, for you command the heights of decision-making, for that is what you are paid to do, and you either pay the bills or advise those who do.

Consider those who control national health and corporate health policies. In 1965, America decided Medicare and Medicaid officials would henceforth know best what was good for the old, the poor, and the disabled. Roughly ten years later, managed care started in earnest, and business payers decided that health care decision-making in the streets, hospitals, doctors offices, and other myriad care locations was too important to be left to patients and doctors.

In all of these setting, the altitude dictates the attitude- the mindset of the powers that be. To a large extent, these altitudes and attitudes are understandable. For every social tasske of importance is entrusted to large institutions organized for perpetuity and run by political leaders and managers. But we are an individualist society, dominated by pluralistic forces. And as time has passed, patients, as well as physicians, have become increasingly critical , disenchanted, and suspicious of the ability to top-down powers to perform, to understand what is transpiring on the ground, and to use tools such as information technologies, to control and guide what wells up from below.

The consequences of these differing views from different altitudes and attitudes has been a giant disconnect –a yawning chasm between those above who profess to know and those who practice below.

Take managed care as an example. Those who profess to know first thought costs could be controlled and channeled by restricting utilizations and dampening referrals to specialists and hospitals. This set of attitudes has been a colossal failure because of a misunderstanding of American culture. Now those who profess to know have changed course and have decided the best way to control costs and better care lies in concentrating and coordinating course is through primary care offices and through offering small rewards for “performance.” Small wonder, given the track record of managed care, that doctors harbor dark suspicions that this too may not work.

It does not seem to have dawned on top-down decision-makers that that the primary care professions, due to a series of missteps from above – burdensome and expense-producing rules and regulations requiring large office staffs, misguided reimbursements, over-reliance on high tech, a worship of data, and a lack of respect – has thrown the primary care professions into total disarray, indeed on verge of destruction, because primary care no longer appeals to pragmatic struggling doctors.

Nor has the idea seem to set in that doctors, as members of a profession, do not respond to small financial incentives to perform higher quality care. For God’s sake, they say, that is what we are obligated to do in the first place. And neither do we respond to giant check lists sent down from above to tell us how to manage patients, or to anguished cries of uneven “quality,” as defined by payers sending down proclamations. We are doctors, not airline pilots, and we march to our own drummer – what’s good for the patients.

Doctors want understanding of what top-down meddling has wrought – overworked physicians, overcrowded offices, misguided reimbursements, over-written rules that often serve no useful purpose, incentives that don’t incent and may even dis-incent, and over-engineered medical record systems that are neither patient or doctor friendly.

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