Adaptive Strategies Blog

The foundation to good critical thinking is coming to grips with the issue at hand. Saying that “the system is broke” is meaningless until you define system and all of its components. To rail against “Obamacare” is meaningless unless you can explain what you mean by Obamacare. So, what’s the issue?

I’ve been reading T.R. Reid’s excellent overview of healthcare, The Healing of America, wherein he compares healthcare in Germany, France, Japan, the U.K., Canada, and the United States and his framework is very instructive for considering “the issue” about healthcare. His framework is composed of four factors: coverage, quality, cost, and choice. With just these four words, you can start to better define some of the many issues.

• For the 30 to 45 million uninsured, it really is all about coverage. However, for the business owner coverage means added cost.
• For the well-to-do, or the retired person pondering Medicare Part D, it may be about choice so as to maximize benefits. However, for the insurance company with a near lock on a state, choice is the last thing they want.
• I want to know exactly how much an operation is going to cost, but my doctor has no way of knowing until after the fact!
• All of us want “the best” but someone (“not me”) has to pay for it.
• And on, and on, and on.

And here is the nasty part of trying to define “the issue.” We can be pretty sure that some blend of the four factors is going to change. We just don’t know what the blend will be.  So what is a healthcare executive to do? As I said in response to an earlier post comment, the answer is not to stand still and react after-the-fact.

Whether you are a hospital exec, an insurance exec, a doctor, an employer, a supplier or an individual the issues are explored and defined by knowing what is in your control and what is not and then determining what it will take to remain viable as the system changes. Here are some hypothetical responses to possible futures of healthcare. Consider the plight of a hospital exec if…….

• Universal coverage is enacted – How much will ER capacity and staffing go down if patients see docs earlier?
• Electronic medical records are legislated to improve quality – How many older docs will take retirement rather than make the change?
• Patients can choose from hundreds of insurance funds – How many billing clerks will have to be added unless standardized forms are used.

You get the picture. We know the system will change. We don’t exactly know what will change. It’s a human tendency to wait – but that may be too late.

OK, I’m not foolish enough to think that healthcare executives are reading this blog. So let’s make it personal. MY issue with healthcare is simple – since my wife and I are on an individual policy and can be dropped or priced-out if either of us dare to get too sick, our actions are to exercise and eat healthy and hope Medicare is there in a couple of years. It’s my responsibility to stay out of the system, because I know I can’t afford to get sick. Depressing, but true.

See if you can define YOUR issue with healthcare. They say that all politics are local, and nothing gets more “local” than health. Consider Reid’s factors of coverage, quality, cost and choice.

My last post considered ways to think about the healthcare system and I offered five snippets addressing ways to think about the future of the health care system. The fourth of the five snippets was a simple statement to “think critically.” Easy to say; hard to do.

This is the first of eight posts that will take a deeper look at that simple piece of advice. Today I’ll provide an overview of seven components of critical thinking and in subsequent posts I’ll dig deeper into each of the components.

I’ve decided to focus on health care for a few reasons: (1) it’s REALLY important to a lot of people; (2) the “debate” has been highjacked by people (left and right) with very strong opinions who do not want us to actually think about healthcare, just follow their line of thought; and (3) I’m having a hard time getting my mental arms around this issue and feel that maybe a little writing will help me clarify my own position. I need your help here.

CRITICAL THINKING: It’s the process of figuring out what to believe and then what to do about your beliefs. It starts with “figuring out what to believe,” which takes time and is darn hard work. It’s easy to parrot a talk-show host; it’s uncomfortable to examine your own beliefs and figure out if they are built on a good foundation.

As you work on figuring out your beliefs, here are seven components of critical thinking to consider:  

• What’s the ISSUE and how does the issue look from various points of view. From a moral perspective do you believe that everyone has a right to quality healthcare? From a fiscal perspective, who should pay for this right? For that matter, what about our individual responsibility to live a healthy lifestyle. Should I pay for your smoking habit and should you pay because I like to eat a lot? Paying for the system has come front and center, but it’s not the only issue. Step One of critical thinking: get clarity about the set of issues and work at prioritizing them.
• What QUESTIONS bring clarity to the issues? And the most important question to ask is: Are we solving the real problems? With upwards of 90,000 people dying every year because of mistakes, misuses, and care-acquired illnesses, is the main issue about payment or quality? We have LOTS of smart people who can answer questions. Are we asking the right questions?
• What CONCEPTS are we using to organize our thinking? I’ve had healthcare executives (angrily) tell me that “We are not a factory making widgets!” True. But the concept of standardization seems to work in every other industry. Might it be applied to some of the issues affecting healthcare? Concepts help us organize our thinking and then explain it to others. What’s your concept of a hospital? (Remember, in the late 1700’s they were literally “a place to go to die.”)
• As we think about the health care system what are the ALTERNATIVES to today’s practices? The general hospital was right for medicine at the beginning of the 20^th century because it did everything for anybody. A hundred years later is it still the right way to deal with injury and sickness? For that matter, what are the alternatives to staying healthy and never having to use a hospital?
• ASSUMPTIONS are the foundation of all strategy and all plans. And when assumptions degrade, the plans are usually out of line with reality. What assumptions underpin the insurance industry? What assumptions are the foundation of the “medical home” concept being touted? What assumptions are employers making about their role in keeping employees healthy? What assumptions are you making about your health needs as you age?
• “Truth” often depends on your POINT OF VIEW. What does the system look like from the point of view of a retiree who is in the Medicare system? What does the system look like from the point of view of the owner of a small business? What about a self-employed bloke like me? Who’s right? All of us. Who’s wrong? All of us.
• As I write this all I know for sure is that Congress is going to do “something.” Not sure what it is; but I do know that whatever they do will have both intended and unintended CONSEQUENCES. People following an ideology tend to see the intended consequences of their actions and “get surprised” by the unintended consequences.  All of us should think about “what else” were getting when we take an action. It will play out – but later.

HELP!  I really want to get my arms around this and I need a conversation. Please comment – challenge – add-to – etc. Please pass this on to friends and colleagues who are in the system. What does it look like from the inside?

(Jodi, if you’re reading this it’s time to comment.)

OK, now it’s your turn.

Today’s New York Times has an OpEd piece by Paul O’Neill (http://www.nytimes.com/2009/07/06/opinion/06oneill.html?th&emc=th) that made me sit back and think about looking at problems from multiple points of view. Many of the articles about our “broken” health care system lead off with a statistic about the incredible cost of the system (more than any other country in the world on a basis of percent of GDP) and then launch into expensive, big-picture solutions to consider. And everyone asks “Where will we get the money?”

O’Neill’s article was about the small-picture. Infections, medication errors, patient falls and other preventable problems add up to about a trillion dollars of annual “waste.” And the kicker is that we already know how to reduce every one of these without a massive new program! And here is the kicker in his article: “What policymakers tend to forget is that only the people who do the work can make this happen. Legislation can’t do it, regulation can’t do it, infection-control committees can’t do it, financial incentives and disincentives can’t do it. ….. Where it works, the common denominators are strong leadership and a committed work force.”

And for those of us with a bit of grey hair, this has the ring of déjà vu. When the U.S. auto industry was shocked by the quality of cars coming from the Japanese auto companies we were “shocked” to find out that it was not fancy automation and wiz-bang technology, it was leadership and a dedicated (and trained!) workforce that made the biggest difference.

I’m not saying that we don’t have to proceed with big, system-wide issues; but maybe the first place to start is to fix the problems we already know how to fix. And the solution can be found in the team we already have. But it will take real leadership and that will not to be found in a government program developed by people far removed from the real problems. Improving the health care system or any system often comes down to plain hard work.

Now go visit your boss and demand some real leadership.  The future of your organization is at stake.

We seem to live in a world of extreme points of view: liberal OR conservative; management OR union; Red state OR Blue state; black OR white. My rant is not about any one of these in particular, but about the mis-use of ideology.

Ideology is helpful when it is used to underscore the principles that we use in critical thinking. It helps use explain our values and use these values when we think about the problems and opportunities we face. Unfortunately, ideology is sometimes used as a substitute for thinking. And that is dangerous for all of us.

What ever happened to “give and take?” How come the word “compromise” is often associated with “lose?” Are we teaching our young people that they can only color their world with black or white crayons? I LOVE grey because it allows for all of the nuances of “the real world.”

Give me your thoughts. Is “compromise” a dirty word?