Monday, 24 of November of 2014

Tag » thinking

Healthcare, Uncertainty, and Thinking

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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.

uncertainty

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.


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Fifth Disciple redux — healthcare systems thinking

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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?


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Hong Kong Thinking

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I flew to Hong Kong on Friday; I’m running a workshop for a client on Monday and Tuesday. Here are some random observations:

  • Plane departed 15 minutes late because, according to the pilot, “we were a bit heavy” and they had to offload some cargo. What did they do, put a 747-400 on a scale? How did they know?
  • Facinating mix of old and new technology in use in HK. I was walking down the street observing the scaffolding used for the rebuilding of an older 10 to 12 story building. It was all hand-lashed bamboo. Tried and true technology at work. At the same time a bus pulled up and I watched a young man pass his wallet near a fare-reader by the driver. RF technology at work. Interesting mix of pragmatism.
  • Cell phone ubiquity — I walked down a busy shopping street. More than half of the young people I passed had a cell phone to their ear. Less than 10% of old people (like me) had a phone. I wonder what will seem old about the young people when they age? I wonder if they think they will ever get old?
  • Great public transportation. Lots of busses and trolleys and most of the riders were young. How will they feel about public transportation in the years to come?
  • Went for a walk, took a wrong turn and got lost. Fascinating experience when you don’t speak the language. Thank goodness for maps. I wonder if we could make better use “maps” in business to help the people who don’t speak the language of business find their way?

I’ve been traveling for about 40 years now — hate the travel — love the trip. It opens eyes. Comments?


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