Adaptive Strategies Blog

The healthcare system is fascinating because it will touch EVERYONE at one time or another. You may work in the system, or supply the system, or use the system – but it will touch you, one way or another, over the course of your life. I have friends who never fly and, therefore, don’t care about the airline industry. I have friends without cars who don’t care about the car industry. But I don’t have any friends who have never been sick or never needed medical help.  Healthcare is one of a few systems that touch all of us. So we had better think about its future.

Many people have written about healthcare as a “broken system.” I think of it as a rapidly evolving system that that is affected by a lot of strong forces, from technology to demographics to political posturing. In other words, the future of our healthcare system is uncertain.

How did we get here?  Well, the system that serves us today is the result of the predominant targets of the healthcare system in the past. Consider the role of doctors, nurses, and other healthcare professionals as they responded to the following:

• 1850 to 1900: Epidemics are prevalent. Food, water, sanitation and other aspects of city life cause health problems for masses of people.
• 1900 to World War I: Individual trauma (wounds) and infections are the focus
• World War I to World War II: tuberculosis, malaria, pneumonia, venereal disease and industrial hygiene are big issues to be resolved in the United States.
• World War II to 1980: We are living the “good life” and heart disease, cancer, and strokes are on the rise.
• 1980 to Present: Chronic diseases, emotional and behavioral conditions, terror, war, and genetic inheritances come to the fore.

Now think about the next age of healthcare and consider the forces that will hit the system in the coming years: more and more people are uninsured or underinsured at exactly the same time as families have become smaller and more dispersed. The massive Boomer generation is aging. There are fewer people moving into healthcare. More and more healthcare has become a “for profit” business. The bottom line is that the system and its participants will be stressed in ways we have never precisely encountered before.

That said, this system has evolved in the past and is not a stranger to new ways.

The overriding challenge is for people affected by the system to think about its future and take appropriate actions. Doctor, administrator, nurse, patient, taxpayer – ALL have a stake in the future of this sytem.

The future of the healthcare system

Esteemed doctors, academics, economists, and consultants have written a great deal about their view of and prescription for healthcare and healthcare providers. However, much of it is built on a particular point of view and, when taken in total, a contradictory picture arises. Some see the future of healthcare providers operating in the context of a “consumer- driven” system. Some see the future of providers in the context of information-empowered “personalized medicine.” And others see the entire industry changing as we move (in their view) to a single-payer system. GE Healthcare sees a fundamental shift in the nature of the healthcare provider as the system moves from “late disease” to “early health.” Because all of these points view are about the future, all we know for sure is that no one is right and no one is wrong – yet. We are uncertain.

Healthcare is filled with smart and well-educated people. And that single fact is a cause for hope and concern as we face the future of this vital industry. Because we have so many smart people, we hope that we will be able to “figure it out” as the system changes. However, because we have so many well-educated people, we may be trapped into the viewing the evolving system through mental models that may no longer be appropriate.

As you reflect on the position you want to take in the current “debate” about the future of a system that affects all of us, I suggest that you might want to consider one or more of five ways of thinking.

• Think about the speed of industry evolution. Our hospitals and providers have to keep up with the speed of evolution (on a global basis) or risk becoming irrelevant.
• Think about the larger system. Our hospitals are part of a larger system and the answer to the question “Why is my hospital changing?” is always found in the larger systems of healthcare and economy.  
• If you work in healthcare, think about your business model. Whether you are a solo practitioner or a team leader or the CEO of a hospital you have customers and they will the ultimate arbiters of your value.
• Think critically. The world is loaded with people who have opinions. Are your opinions well founded on accepted principals of good thinking? Or, heaven forbid, are you simply repeating someone else’s opinions as “fact.”
• Think across time. The past can inform actions we take in the present. All present day decisions have a “futurity,” both good and bad. And thinking about the future forms the visions we create for our organizations today.

When you think about OUR healthcare system do you throw your hands up in the air and say it’s too confusing? Don’t – your health depends on it.

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.

The Fifth Discipline was a business book phenomenon in the very early 1990s. Written by Peter Senge from MIT it launched a whole movement (that, unfortunately, turned into a buzzword) for organizations to aspire to become “learning organizations.”

The titled fifth discipline was, and is, the discipline of systems thinking and in my opinion we need it more than ever. We especially need it to properly position the heated debates and warring camps associated with “fixing our broken health care system,” or words to that effect.

The foundation of systems thinking is that we operate within systems possessing both detail and dynamic complexity. In other words, there are lots of parts and most are changing all the time.

Chapter Four in Senge’s book enumerates the eleven laws of the systems thinking. Here they are, with a bit of commentary about our health care system and attempts to fix it.

1. Today’s problems come from yesterday’s solutions. In the WW II era, big businesses used company sponsored health insurance as a way to get around wage controls to capture and keep the best workers. Now the costs are onerous and harmful to our competitive position in the world market.
2. The harder you push, the harder the system pushes back. A current proposal to deal with the shortage of general practitioners and family doctors is to cut the Medicare reimbursement to specialty docs, since they make the most money. Gee, do you think they might push back?
3. Behavior grows better before it grows worse. Politicians will be tempted to enact some simple solutions to appease interest groups (hard to believe!) and costs might actually go down for a short period. However, if they don’t consider the larger system, they may not see the delay in feedback that will (later) add costs.
4. The easy way out usually leads back in. Universal health care might seem like a humane response to the needs of the uninsured and underinsured and might appeal to a majority. However, if the system is not made more effective or efficient we will find that we cannot afford the humane solution.
5. The cure can be worse than the disease. As we put policy and technology in place we have to ask how “the burden” is shifting and to whom.
6. Faster is slower. My concern about health care reform is that it will get connected to an election cycle and our friends in Washington (after watching this thing go from bad to worse of decades) will rush legislation to show that they are doing something. Point solutions will slow the repair of the system.
7. Cause and effect are not closely related in time and space. So, for example, let’s say that they legislate the wholesale switch to electronic medical records. Will they think through the long-term impact on costs, privacy and integration?
8. Small changes can produce big results – but the areas of highest leverage are often the least obvious. If we focused on wellness we might not have the costs of dealing with sickness. Unfortunately, the system is not designed to make us healthy; it’s designed to fix us when we’re sick.
9. You can have you cake and eat it too – but not at once. New information technologies may make the system more cost effective over time – but the upfront costs will be significant.
10. Dividing an elephant in half does not produce two small elephants. The private healthcare system is not separate from the government (VA, Medicare) system. Trying to keep them apart is senseless. 
11.  There is no blame. Give me a break! That’s all Congress knows how to do!

So, what if we resurrected a good idea from the very early 1990s and give it another shot? Which of the laws do you think we might use? Which are useless in this situation?

My buddy Brad has suggested that I occasionally post something with a little “heft” to it. So, inasmuch as I’m working on a book project to help people become better prepared for the future of healthcare, I thought I’d point out the need for people to be better prepared for the future. Comments, please.

I collected articles and newspaper clipping about the world of healthcare providers. Here’s a sample and thoughts that try to go beyond the simple facts of the story and address the issues of being prepared.

·         “Medicare Won’t Pay Hospitals for Errors,” chicagotribune.com, February 18, 2008. The lay person reads this and says “Darned right!” Healthcare professionals think about the reality of dealing with human bodies and the near impossibility of taking these incidents to zero. A person who takes the time to think about the future wonders about the unintended consequences of this action.

One of the truisms of systems thinking is that all solutions inevitably create a new set of problems. Furthermore, these problems usually show up later and in different places. People prepared for the future have to consider the system of which they are a part and how that system reacts (predictably) to bending and breakpoint forces.

·         “Innovation in health care: An interview with the CEO of the Cleveland Clinic,” McKinsey Quarterly, March, 2008. The article explores an interview with Toby Cosgrove, MD, the CEO of the renowned Cleveland Clinic. In the article Dr. Cosgrove explains the three seismic shifts he sees in health care. The first is prevention; the second is the drive for value for dollars spent; and the third is that healthcare providers are being judged on the patient’s total experience, not just the clinical outcome. In order to address the third shift, he hired a chief experience officer “whose entire responsibility is to look at the hospital experience from the eyes of the patient and to translate that message back to the caregivers.”

Some hospitals have a tax status of “for profit;” others a status of “not-for profit.” But all hospitals are a business that competes for patients. Healthcare providers prepared for the future will consider their “value promise.” Why should patients come to your organization? Transparency of the total experience will only increase in the coming years, especially with the generation who “Googles” everything.

·         “Health Care that Puts a Computer on the Team,” The New York Times, December 27, 2008. The article describes the Marshfield Clinic an early adopter of health information technology and how it is a forerunner of medicine’s “digital future.” Much of the article goes onto explain the advantages of electronic medical records and how the Obama administration sees them as necessary. However, midway in the article it shifts to an examination of “predictive medicine” and the impact that it could have on the health of the population and the reduction of health care costs.

We’ve been down this technology road before and should know to think about the second and third order effects of a new technology. Leaders who are prepared for the future often have a great sense of the past.  The invention of radio did more than replace local singing groups – it enabled changes that ranged from national advertising to Blitzkrieg warfare. Electronic medical records will do more than replace paper records; and predictive medicine is only one of the more obvious effects. Be prepared for the future by learning how to “look across time” and really learn from history.

·         “How to Revive Health-Care Innovation,” Harvard Business School Working Knowledge, March 9, 2009. Clayton Christensen is a respected innovation guru and he has recently set his sights on evaluating the world of health care. He states that business model innovation, one of the three enablers of industry disruption, was common in health care until about thirty years ago. If he’s right, and we think he is, the current ranks of managers and executives are only beginning to feel the pressures of industry-wide disruptive innovation.

Leaders can prepare for the future of changes in their industry by analyzing the changes that other industries have experienced before them. Health care leaders like to remind us that “they don’t make widgets.” True; but human nature is pretty consistent, irrespective of the nature of the work to be accomplished. Do you want to prepare for the future health care innovation? It might not be a bad idea to analyze the reactions of people in industries ranging from automotive to consumer electronics to newspapers. Patterns emerge that might be helpful.

·         “Scalpel, suture and tweet: Surgery in 140 characters,” Chicago Tribune, April 8, 2009. The article explains how a spokesperson for a hospital in a Chicago suburb tracked the progress of an operation and sent “tweets” to a group of “followers.” Why? Because the hospital is experimenting with social networking as a marketing tool. Think this is silly? Questions came in from as far away as Switzerland.

Like it or not, different groups want different styles of communication. In a broader, more connected world, prepared leaders will have to flex to the needs of their stakeholders. Great thinkers always consider multiple points of view and what you see may not be comfortable. Like it or not.

·         “Virtual colonoscopy at center of policy debate,” Los Angeles Times, April 18, 2009. This article presented the pros and cons of paying for virtual colonoscopies and whether or not they are effective and saving money. Toward the end of the article the author explains that some studies have shown it to be pretty good but others “have suggested that it is not as good as detecting some smaller polyps.”

Ask yourself another question: “Is this as good as it will get?” Remember your first “car phone” or bag phone? How fast did they progress? Preparing for the future requires the ability to develop “impact maps” of current technologies and mentally play-out paths of progress. Die hard technologies generally assume the impact of a new technology sooner than it actually happens. But many of us get “surprised” by how fast technology progresses. Learning to assess varying “winds of change” is essential to thinking about the future. And technology is one of the winds affecting health care.

·         “Health care options focus on paying hospitals and doctors for quality, not quantity,” StarTribune.com, April 28, 2009. This was an AP article that gave an overview of the announcement of the Senate Finance Committee as they prepared to go into closed door discussions. In the announcement they quoted Senator Max Baucus, the Finance Chairman: “The key to healthcare reform is delivery system reform – reimbursing providers on the basis of quality, not volume.”  Here are our questions: How would a liberal interpret that sentence? What about a conservative? What about the CEO of a hospital? Without solid critical thinking skills that sentence is wide open to interpretation.

Now is not the time for uninformed opinions. Now is the time to think about the future and preparing for the future requires solid critical thinking skills. A key skill is the ability to ask GREAT questions. What assumptions are being used? What’s the scope of the “delivery system?” How does he define “reform?” He’s presented the problem in terms of a solution. What’s the real problem and what are the root causes of the problem? And on, and on. Preparing for the future requires an understanding of today and that requires more than opinions.

·         “A doctor in your pocket,” The Economist, April 18, 2009. The article explains how cell phones are being used in sub-Saharan Africa and part of Asia. The applications are simple, such as self-reporting and getting messages from a health care provider. However, the power of the story comes at the end when the article mentions the cell phones as part of a “global surveillance system” that can be used for prediction.

We have no data from the future. However, we have been blessed with imaginations. Unfortunately, many adults have disconnected their imagination in search of “the numbers.” Being prepared for the future requires a fertile imagination and adults need to rebuild what they had aplenty as children. Not only can it be done, it has to be done.

Healthcare will account for over 15% of GDP in the coming years.  What do you think they need to do to be prepared?