And so dies pragmatism, on the altar of principle.
The NYT reports on the case of a woman in England who is being denied cancer treatment in the public NHS if she pays privately for a part of her treatment. It sounds as misguided as Canada's Principle of Universality.
Health care is expensive and there are multiple potential levels of effectiveness, including one of cost-effectiveness. The NHS and Canada's Medicare should function as a subsidy for those interventions that are well-documented and cost-effective and consistent with the values of each country. Anything more is not sustainable in the long-run. It should be clear that a public health system is not as good as a private one; fewer items are covered and convenience suffers, but not items that are important to the public health.
To repeat what I state in my previous post: I don't believe that anyone anywhere has a right to everything at all times. But there is no reason that a subsidy should be voided for paying into the parallel private system.
Sounds like old labor is back. I grieve for the lap dog's absence, now I see the shaggy mongrel growling in the shadows.
Friday, February 22, 2008
Wednesday, February 20, 2008
Political Comedy and Health Care
Between Hillobama (my wife says it should be Baralinton now) and accusations that Senator McCain is a skirt-chaser, all I can say is that I have always been proud of my adoptive country. If we are still talking about being ready for a woman or a black person in the White House, then we're not ready. Unless it's Condi Rice. Hey, I'd vote for a Phillipino, as long as nobody asked if we were ready for an Asian-American.
But the polarized political discourse is not so funny, nor is it something to be proud about.
Ya, I'm back to reminding readers that political centrism is a good way to avoid the extremes of either side. Obama's rhetoric sounds like we'll just give everything to the poor and working class of this country because rich people should have no influence or say on how their tax money is used. Conservative talk-radio will pillory all candidates because their positions are not sufficiently selfish, which is the real word for American Conservatism. It's not conservative at all, it's just plain hypocrisy.
So I find myself in a truly awkward position. I work for a publicly subsidized facility which has as its mission the care of poor and vulnerable populations, but I am opposed to the very notion that guarantees everyone such health care.
The crux of the matter revolves around the nature of human rights as they relate to health. Our constitution guarantees a right to life, liberty and the pursuit of happiness. The wording is careful, apparently not to guarantee that anyone has the right to a life without misfortune. By the same logic, no one can reasonably expect a right to health. In fact, health itself is best recognized as a gift, at least as precious as life itself.
Wikipedia gives us a brief lesson, reminding us that basic rights include the right to freedom of expression and equality before the law amongst others. There are several philosophical positions that can drive the definition of rights. I can understand a prohibition of actions that impair the well-being of others. But I need to understand how a right can exist where it requires an active intervention by a trained and licensed professional? Can any government force an individual provider to deliver a specific service? If the government cannot mandate that a physician take care of an individual person in a specific circumstance (except in exceptional and dire emergencies) then no encounter can take place. Thus, no health care can occur. Thus, it's not a right.
There are laws to enforce the rule of law to make sure that people cannot unfairly take advantage of others by force or sleight-of-hand. I can understand how people have the right to work and enjoy the fruits of their labor. I can understand that people should feel they have a right to the environment that makes it possible to exercise their full social, economic and cultural rights. But health care (and day care, for that matter) is different. It appears that current plans to expand health care access rely, not on the government creating an environment where national goals can be accomplished, but mandating the delivery of a service and its price.
Nobody can mandate that every child has a right to an MRI if they have a headache. You can't have a bone marrow transplant if the chances of success are less than 5%. It is unreasonable to insist a surgeon do a procedure if the mortality is high, even if the patient wants it. The surgeon still has a say. I have a problem with health care as a right because I don't believe that anyone anywhere has a right to everything at all times. Especially on my tax dime.
There are good social and economic reasons to exercise government muscle and expand access to subsidized health care. Hillobama's new entitlement is not it. McCain's tax credits are not it. We need a well-thought out way to improve primary care access, acknowledge that cost and capacity considerations mean that not all testing, treatment and convenience is possible for all, provide clear targeted coverage for the most important public health issues in the country and allow continuing business opportunities in health care, albeit better regulated than the current special interests' free-for-all.
Awkward.
The right wants to offer nothing. The left wants to raid the pockets of those who create the most value in society (as measured by income, which may not be the best measure of value but is the most practical.) Hillary's plan is expensive and impractical, Obama just sounds like he's gunning for my tax dollar even if his plan doesn't work as well and McCain just doesn't understand it at all.
Just laugh about it. We have the candidates we deserve, primarily because the wing nuts on the right have driven moderates into hiding, as far as I'm concerned. McCain is the best we have on the political spectrum, but his shortcomings are already pretty obvious.
But the polarized political discourse is not so funny, nor is it something to be proud about.
Ya, I'm back to reminding readers that political centrism is a good way to avoid the extremes of either side. Obama's rhetoric sounds like we'll just give everything to the poor and working class of this country because rich people should have no influence or say on how their tax money is used. Conservative talk-radio will pillory all candidates because their positions are not sufficiently selfish, which is the real word for American Conservatism. It's not conservative at all, it's just plain hypocrisy.
So I find myself in a truly awkward position. I work for a publicly subsidized facility which has as its mission the care of poor and vulnerable populations, but I am opposed to the very notion that guarantees everyone such health care.
The crux of the matter revolves around the nature of human rights as they relate to health. Our constitution guarantees a right to life, liberty and the pursuit of happiness. The wording is careful, apparently not to guarantee that anyone has the right to a life without misfortune. By the same logic, no one can reasonably expect a right to health. In fact, health itself is best recognized as a gift, at least as precious as life itself.
Wikipedia gives us a brief lesson, reminding us that basic rights include the right to freedom of expression and equality before the law amongst others. There are several philosophical positions that can drive the definition of rights. I can understand a prohibition of actions that impair the well-being of others. But I need to understand how a right can exist where it requires an active intervention by a trained and licensed professional? Can any government force an individual provider to deliver a specific service? If the government cannot mandate that a physician take care of an individual person in a specific circumstance (except in exceptional and dire emergencies) then no encounter can take place. Thus, no health care can occur. Thus, it's not a right.
There are laws to enforce the rule of law to make sure that people cannot unfairly take advantage of others by force or sleight-of-hand. I can understand how people have the right to work and enjoy the fruits of their labor. I can understand that people should feel they have a right to the environment that makes it possible to exercise their full social, economic and cultural rights. But health care (and day care, for that matter) is different. It appears that current plans to expand health care access rely, not on the government creating an environment where national goals can be accomplished, but mandating the delivery of a service and its price.
Nobody can mandate that every child has a right to an MRI if they have a headache. You can't have a bone marrow transplant if the chances of success are less than 5%. It is unreasonable to insist a surgeon do a procedure if the mortality is high, even if the patient wants it. The surgeon still has a say. I have a problem with health care as a right because I don't believe that anyone anywhere has a right to everything at all times. Especially on my tax dime.
There are good social and economic reasons to exercise government muscle and expand access to subsidized health care. Hillobama's new entitlement is not it. McCain's tax credits are not it. We need a well-thought out way to improve primary care access, acknowledge that cost and capacity considerations mean that not all testing, treatment and convenience is possible for all, provide clear targeted coverage for the most important public health issues in the country and allow continuing business opportunities in health care, albeit better regulated than the current special interests' free-for-all.
Awkward.
The right wants to offer nothing. The left wants to raid the pockets of those who create the most value in society (as measured by income, which may not be the best measure of value but is the most practical.) Hillary's plan is expensive and impractical, Obama just sounds like he's gunning for my tax dollar even if his plan doesn't work as well and McCain just doesn't understand it at all.
Just laugh about it. We have the candidates we deserve, primarily because the wing nuts on the right have driven moderates into hiding, as far as I'm concerned. McCain is the best we have on the political spectrum, but his shortcomings are already pretty obvious.
Thursday, February 14, 2008
... the Worst of Times
No, not Valentine's Day. I may have gotten my titles backwards but I wanted to continue some themes from my previous post on dysfunctional environments.
Health Punk commented that "Sounds like a level of dysfunction that requires drastic measures. Jolting an organizational culture can only happen with a severe enough shock." That insightful response is certainly part of the answer. A radical change requires some indication of the change - a signpost, perhaps something as vacuous as a symbol - that things are not the same as they ever were. I am fearful of quoting the Healthcare Anarchist, since the suggestion suffers from Che Guevara's heel (as opposed to Achilles, Che was a great proponent of social justice but for whom violence, killing and destruction where the only way to indicate that social change had taken place). Few of us have Ghandi's inscrutability, but an approach resembling peaceful disobedience may be slightly more attractive.
There are several responses to a dysfunctional environment, the most familiar of which is to go in fighting. The one that strikes me as the most potentially fruitful is one based on openness and transparency, clarity of expectation, investing in staff and laying out a method for resolving conflicts. Of course, there is nothing new here, it represents what is best in American business. We make decisions based on facts and data, performance and information flow. We do not make decisions based on friendships and family or tribal ties, historical maladaptations and the wish to punish prior misbehavior.
One of the questions becomes what happens when a single player behaves transparently, but not all. Transparency works best when everyone makes an credible attempt at it and does not pretend that the need to control the flow of some information has mysteriously disappeared. Lipstick on a pig doesn't mean it not still a pig, but it's pretty pig.
Transparency puts the value of information the most at risk. There are some individuals who recognize that the easiest way to make themselves indispensable to an organization is to control the flow of information. The person who functions as an information bottleneck feels valued. Opening the floodgates of information flow strikes some people as unthinkable. It's sort of like putting your newspaper on the internet for free.
On the other hand, in some contexts, information has intrinsic proprietary value (probably not as much as managers would like to think). In the context of government, for example, a regulatory agency's decision-making process has huge value to those entities being regulated. Can you imagine knowing CMS regulation decision-making process every step of the way. It is quite possible that by making such information freely available, lobbyists and special interests could make the agency's regulatory function impossible to execute.
But management regularly over-values their internal management data and processes. I have recently asked several organizations to share their physician productivity formulas. The responses have ranged from cricket-sounding silence to the delivery of the entire current plan and minutes of the last meeting minutes, so I could anticipate specific objections to specific clauses. There are valid reasons for such variation in response (anti-competitive concerns being foremost), because every situation is different. So is mine. Even using someone else's plan as a template will not reduce the change-management work that will make our performance plan unique to our organization.
As the internet has shown us, our relationship to information precipitates a need to protect it. Controlling the flow of information seems like a reasonable approach, but often contributes to personal and organizational dysfunctions. The free flow of information is inherently threatening and changing the way it flows is one of the greatest challenges.
If one player is transparent, that player must make sure that the very same information does not boomerang to harm it. In time, persistent and consistent transparency of process should begin to encourage other players to try it. Eventually, the more that disparate parts of an organization share their information committed to a common goal, their successes will begin to erase organizational memories that are at the root of so many dysfunctions. Perhaps the goal is not erase them, as much as to replace them with the traces of functional progress.
But attacking the greatest challenges contains some level of fun that minor challenges cannot offer.
Health Punk commented that "Sounds like a level of dysfunction that requires drastic measures. Jolting an organizational culture can only happen with a severe enough shock." That insightful response is certainly part of the answer. A radical change requires some indication of the change - a signpost, perhaps something as vacuous as a symbol - that things are not the same as they ever were. I am fearful of quoting the Healthcare Anarchist, since the suggestion suffers from Che Guevara's heel (as opposed to Achilles, Che was a great proponent of social justice but for whom violence, killing and destruction where the only way to indicate that social change had taken place). Few of us have Ghandi's inscrutability, but an approach resembling peaceful disobedience may be slightly more attractive.
There are several responses to a dysfunctional environment, the most familiar of which is to go in fighting. The one that strikes me as the most potentially fruitful is one based on openness and transparency, clarity of expectation, investing in staff and laying out a method for resolving conflicts. Of course, there is nothing new here, it represents what is best in American business. We make decisions based on facts and data, performance and information flow. We do not make decisions based on friendships and family or tribal ties, historical maladaptations and the wish to punish prior misbehavior.
One of the questions becomes what happens when a single player behaves transparently, but not all. Transparency works best when everyone makes an credible attempt at it and does not pretend that the need to control the flow of some information has mysteriously disappeared. Lipstick on a pig doesn't mean it not still a pig, but it's pretty pig.
Transparency puts the value of information the most at risk. There are some individuals who recognize that the easiest way to make themselves indispensable to an organization is to control the flow of information. The person who functions as an information bottleneck feels valued. Opening the floodgates of information flow strikes some people as unthinkable. It's sort of like putting your newspaper on the internet for free.
On the other hand, in some contexts, information has intrinsic proprietary value (probably not as much as managers would like to think). In the context of government, for example, a regulatory agency's decision-making process has huge value to those entities being regulated. Can you imagine knowing CMS regulation decision-making process every step of the way. It is quite possible that by making such information freely available, lobbyists and special interests could make the agency's regulatory function impossible to execute.
But management regularly over-values their internal management data and processes. I have recently asked several organizations to share their physician productivity formulas. The responses have ranged from cricket-sounding silence to the delivery of the entire current plan and minutes of the last meeting minutes, so I could anticipate specific objections to specific clauses. There are valid reasons for such variation in response (anti-competitive concerns being foremost), because every situation is different. So is mine. Even using someone else's plan as a template will not reduce the change-management work that will make our performance plan unique to our organization.
As the internet has shown us, our relationship to information precipitates a need to protect it. Controlling the flow of information seems like a reasonable approach, but often contributes to personal and organizational dysfunctions. The free flow of information is inherently threatening and changing the way it flows is one of the greatest challenges.
If one player is transparent, that player must make sure that the very same information does not boomerang to harm it. In time, persistent and consistent transparency of process should begin to encourage other players to try it. Eventually, the more that disparate parts of an organization share their information committed to a common goal, their successes will begin to erase organizational memories that are at the root of so many dysfunctions. Perhaps the goal is not erase them, as much as to replace them with the traces of functional progress.
But attacking the greatest challenges contains some level of fun that minor challenges cannot offer.
Thursday, February 7, 2008
The Best of Times...
I have not had much time to read, much less write any blogs recently. Needless to say, my current job is much more challenging than the last one.
The environment is dysfunctional, but more to the point, it is more dysfunctional than the average clinic, family or corporate entity. A series of chief executives and turnover amongst the leadership have left the ship somewhat rudderless. The current CEO has made some much-needed changes, but only time will tell if it was too little too late, or if it was too much too soon.
My favorite Master's course was "Organizational Behavior." Organizations have a life of their own and no leader -- not even a command-and-control CEO -- can ever hope to really control a situation. Organizations self-organize and old dynamics are hard to change, even when individuals are fired, quit or move on.
I remember one situation with two people in adjoining offices who were always bickering. The two departments had no overlapping areas of responsibility and there was no structural reason to think that they could be at odds. These two just bickered.
One got sick and was replaced. The two offices still had problems working together. The other was transfered to another job in another building on campus. They still bickered. The boss decided to try replacing them both at the same time, but there was something in the air that kept the two offices in conflict. Perhaps it was a sort of homeopathic molecular memory, or the subtle expectations of all the other co-workers, or just the simple fact that all self-organizing systems have informal mechanisms for establishing organizational memory.
In all this administrative chaos, there is one constant; everything is driven by what happens when a medical practitioner closes the door and provides a medical service to a patient. Strangely enough, in the midst of a very dysfunctional and difficult environment, we are still seeing patients. Morale could be better, but I cannot discern any deterioration in the level of care. Our partners are nervous, but there does not appear to be any impact on the floor.
There are appropriate responses to dysfunctional environments. I would argue that this is the environment where change must come fast and furious. Sometimes it is better to make a break with the past than deal with incremental improvements. Part of evaluating the environment is determining how insecure everyone is because prolonging uncertainty makes people more insecure rather than confident.
I will elaborate more after this weekend's wedding in Sacramento. Time to break out the ouzo. I really need it!
The environment is dysfunctional, but more to the point, it is more dysfunctional than the average clinic, family or corporate entity. A series of chief executives and turnover amongst the leadership have left the ship somewhat rudderless. The current CEO has made some much-needed changes, but only time will tell if it was too little too late, or if it was too much too soon.
My favorite Master's course was "Organizational Behavior." Organizations have a life of their own and no leader -- not even a command-and-control CEO -- can ever hope to really control a situation. Organizations self-organize and old dynamics are hard to change, even when individuals are fired, quit or move on.
I remember one situation with two people in adjoining offices who were always bickering. The two departments had no overlapping areas of responsibility and there was no structural reason to think that they could be at odds. These two just bickered.
One got sick and was replaced. The two offices still had problems working together. The other was transfered to another job in another building on campus. They still bickered. The boss decided to try replacing them both at the same time, but there was something in the air that kept the two offices in conflict. Perhaps it was a sort of homeopathic molecular memory, or the subtle expectations of all the other co-workers, or just the simple fact that all self-organizing systems have informal mechanisms for establishing organizational memory.
In all this administrative chaos, there is one constant; everything is driven by what happens when a medical practitioner closes the door and provides a medical service to a patient. Strangely enough, in the midst of a very dysfunctional and difficult environment, we are still seeing patients. Morale could be better, but I cannot discern any deterioration in the level of care. Our partners are nervous, but there does not appear to be any impact on the floor.
There are appropriate responses to dysfunctional environments. I would argue that this is the environment where change must come fast and furious. Sometimes it is better to make a break with the past than deal with incremental improvements. Part of evaluating the environment is determining how insecure everyone is because prolonging uncertainty makes people more insecure rather than confident.
I will elaborate more after this weekend's wedding in Sacramento. Time to break out the ouzo. I really need it!
Friday, February 1, 2008
I Really Worry About Quality
We are in a political race and when I hear Mrs. Clinton talk up quality in health care as she did on last night's televised debate, I get really nervous.
I have seen an organization's ratings for patient satisfaction rise from dead last to number 2 in three months. It is a testament to the effort of the organization and its response to poor performance -- as well as to statistical over-sensitivity to minor changes.
We don't really know what quality is in health care, but we know that there are processes that should be paid attention to. Our measures are being used in prime-time, although they show wide variation and are sloppier than slapping a horse-shoe on a seal flipper. We have made great strides, but we are in the infancy of a new field.
We should be unafraid to use the best data available, but we must also retain a sensitivity to the limitations of our data. Sometimes our best data is not really actionable.
Hillary's position sounds sensible, as far as any political platform can sound like anything at all. Quality health outcomes was the passion that motivated my pursuing a higher degree and together with management skills put me in the middle of performance improvement time and again. But awareness of the power and limitations of PI is important.
We are attempting to reduce variation amongst numerous process measures that we know are important to obtaining good health outcomes. But the link between process and biological outcomes remains inferential and subject to numerous additional extraneous influences. The socio-economic obstacles, for example, to patients' participation in their treatment plans affect performance that is over-attributed to physicians. Never-events are really rare "accidents" that can be systematically and impressively reduced, but it is helpful to remember that the random nature of the universe is impossible to deny, even if its effects can be mitigated.
It seems inevitable that a health care plan of some sort is coming, we'd better start looking at details to make sure that political rhetoric does not morph into magical thinking about health care quality. " The other $55 billion would come from the modernization and the efficiencies that I believe we can obtain," Hillary declared.
I certainly hope we can become so much more efficient at work as to save $55 Billion.
I have seen an organization's ratings for patient satisfaction rise from dead last to number 2 in three months. It is a testament to the effort of the organization and its response to poor performance -- as well as to statistical over-sensitivity to minor changes.
We don't really know what quality is in health care, but we know that there are processes that should be paid attention to. Our measures are being used in prime-time, although they show wide variation and are sloppier than slapping a horse-shoe on a seal flipper. We have made great strides, but we are in the infancy of a new field.
We should be unafraid to use the best data available, but we must also retain a sensitivity to the limitations of our data. Sometimes our best data is not really actionable.
Hillary's position sounds sensible, as far as any political platform can sound like anything at all. Quality health outcomes was the passion that motivated my pursuing a higher degree and together with management skills put me in the middle of performance improvement time and again. But awareness of the power and limitations of PI is important.
We are attempting to reduce variation amongst numerous process measures that we know are important to obtaining good health outcomes. But the link between process and biological outcomes remains inferential and subject to numerous additional extraneous influences. The socio-economic obstacles, for example, to patients' participation in their treatment plans affect performance that is over-attributed to physicians. Never-events are really rare "accidents" that can be systematically and impressively reduced, but it is helpful to remember that the random nature of the universe is impossible to deny, even if its effects can be mitigated.
It seems inevitable that a health care plan of some sort is coming, we'd better start looking at details to make sure that political rhetoric does not morph into magical thinking about health care quality. " The other $55 billion would come from the modernization and the efficiencies that I believe we can obtain," Hillary declared.
I certainly hope we can become so much more efficient at work as to save $55 Billion.
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