Sunday, September 27, 2009

On the Importance of Innovation in Draining the Health Reform Swamp

When you’re up to your neck in alligators, it’s hard to remember your original intention was to drain the swamp.


The alligator-draining the swamp metaphor aptly describes a widespread health reform dilemma , viz, that the brute-forces of reality invariably overwhelm lofty, soft thoughts of idealism.

Ideally, of course, health care ought to be a right, everybody ought to have immediate access to care, and it ought not to bankrupt or financially to inconvenience anyone. Ideally universal coverage ought to mean universal access, but because of growing doctor shortages and changing doctor behaviors, such is not the reality on the ground.

So much for dashing of the dream. Now back to sinking in the swamp.

Cynics often compare American politics in general, and health reform in particular, to a swamp. It is low-lying, boggy, teeming with prey and predators, rotting vegetation, stinging insects, snakes, and vermin. It is hot, it smells, and it emits noxious gases. Health care has its own rules for survival, and it is hard to escape from if you’re part of its ecology. It will never be fit for precise cultivation of singly planted crops all arranged neatly in a row and free of weeds.

I have long been aware its Darwinian features. In my book, Innovation-Driven Health Care; Thirty Four Concepts for Transforation (Jones and Bartlett, 2007), I maintained the only way to thrive in the swamp is through innovations, which will vary whether one with individuals organization, and even nations.

It might be ideal, of course, if one big innovation – such a single-payer or all payer collaboration – were to emerge and drain the swamp.

In liberal eyes, draining the swamp of villainous for-profit organizations, or bringing them to the government’s heel or forcing them to pay government prices is the answer.

To conservative minds, the answer, as much as possible, resides in ridding the swamp of governmental rules and regulations.

To me the solution may lies in-between, with say, a universal private payer system with thoughtful government oversight, the situation in the Netherlands and Switzerland and Germany.

After my book was published I interviewed Lyle Berkowitz, MD, who leads the Northwestern Memorial Physician Group in Chicago and the Szollosi Healthcare Innovation Program at that institution, “Fixing Healthcare from the Inside,” Physician Leadership Forum.

His position, then as now, is that the most powerful innovations are most likely to occur and take root within large institutions who have the resources to pursue systematic innovation. The favorite models among policy wonks rare Mayo and Geisinger and in general feature integrated systems with salaried physicians.
Berkowitz has just sent me a copy of the California Healthcare Foundation’s September report “Reinventing Halth Care Delivery: Innovation and Improvement Behind the Scenes” detailing the work of a series of innovation centers based at large health systems, among them, Northwestern Memorial in Chicago, Kaiser Permanente in Oakland, Vanderbilt in Nashville, Geisinger Health in Danville, Pennsylvania, Massachusetts General in Boston, The Mayo Clinic in Rochester, Minnesota; Ascension Health, in St. Louis; Alegent Health in Omaha. They are all part of a loose Innovation Learning Network, spearheaded based at Kaiser.

These organizations differ in their approaches to innovation but focus on such things as facility design, operational efficiency, optimial IT, improved patient experiences, and care quality. Together the organizations form an innovation Learning Network that communicates regularly and meets periodically to share information.

What these big learning organizations generally fail to mention is that innovations are also occurring at a rapid pace among independent physicians. These innovations, often engineered by practice management firms, are happening at the solo and small group level and include such things as- patients creating their own medical histories using computer algorithms before visiting the doctor, doctors making more liberal use of medical technicians for history taking and drug use documentation, practice management and information management techniques to speed patient flow, concierge practices, the dropping of HMOs and PPOs patients, the growing non-acceptance of new Medicaid and Medicare patients, the significant shift towards cash-only practices, and, course, imaginative use of IT technologies.

These changes in practice patterns not have gained much attention, either because they take place in small practices or because they are considered negative individual innovations, outside the conventional big organization or government mainstreams, but collectively when taken together, independent practice innovations represent massive practice innovations that are changing the fundamental nature of medical practice.

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