Change the System, Stupid (Part 1 of 3)

By J. Deane Waldman

When Bill Clinton was running for President in 1989, his campaign manager James Carville had three short but powerful messages printed on poster board and displayed in the wings so that Clinton couldn't miss them as he went on stage to speak. They were the following.

1. "Change versus more-of-the-same,

2. The economy, stupid,

3. Don't forget health care."

It worked for Clinton. Maybe it will work for our broken health care system with slight revisions and in reverse order.

1. Don't ignore (healthcare) causes.

2. It's the system, stupid.

3. Change versus more-of-the-same.

The following series of three articles � one for each of Carville's slogans � discusses what is really wrong with healthcare and how to cure it, not just make things temporarily seem or sound better. The first (below) will describe some causes of healthcare dysfunction: wrong measurements; fiscal fantasyland; as well as cultural confusion and conflict. The second will show why the system is at fault, not its parts: internal contradictions; medical malprocess; and ineffective decision-making.

The first two articles are descriptive: they describe what is wrong. The third is prescriptive: it suggests what we need to do to cure the patient. Details on all of these issues can be found in the forthcoming book Medical Malprocess, and at www.thesystemmd.com, which is also where the recommended national dialogue could start.

DON'T IGNORE (HEALTHCARE) CAUSES

When describing our sick healthcare system, most people confuse what doctors call signs and symptoms with causes. Rising costs; unequal and diminishing access; errors and bad outcomes (not necessarily the same); and shortages, especially of nurses and doctors: these are all symptoms. If we treat Them, we will mask the real problems and not cure the patient. Therefore, the first step in true healing is diagnosis of why, the causes of the sickness in our healthcare system.

OOOPS, WRONG MEASURING CUP

Experts in business and management constantly remind us that you get what you measure. This means that what you pay attention and measure is what the workers will do better and more of. The outcomes measured in healthcare are: deaths; complications; errors; costs; and lawsuits. Is that what we want? That is what we get.

Healthcare tracks deaths, errors and costs because measuring them is simple: they are all short-term and easy to quantify. The outcomes we truly want are hard to measure and long-term: long, healthy life; less money spent; continuously better and better care. If we start measuring the outcomes we seek, many of the inconsistencies, confusion and symptoms in healthcare would vanish.

FISCAL FANTASYLAND

The word "cost" does not have the same meaning in healthcare as it does in common usage. When you go to the cleaner to pick up your skirt, you pay a bill that is equal to the cleaner's actual cost plus some profit. In healthcare, no one knows the true cost of anything. That is no exaggeration and bears repeating: no one how much your hernia repair or heart surgery actually cost! In healthcare, so-called cost is an allocated number and has nothing to do with what gets paid. That statement too bears repetition: what gets paid in healthcare is generally a very small fraction of what is billed.

For all healthcare services and products, there are payment schedules regulated by the government and the insurance companies follow suit. So, payment or supply (of money), called allowable reimbursement, is fixed. Demand (for services) is variable. Anyone who have ever balanced a checkbook, much less a trained economist, will tell you that a system with fixed supply and variable demand cannot be stable. This is a recipe for disaster. Welcome to healthcare fiscal fantasyland where words do not mean what they usually mean and where people running for high office promise better and cheaper and quicker. They cannot deliver, not with the system we currently have.

CULTURAL CONFUSION AND CONFLICT

The culture of healthcare is a third source of dysfunction. It is complicated by confusion and conflict.

Confusion is ubiquitous. Providers � nurses, doctors, social workers, allied health personnel � are constantly told to put the patient first: in school, by their mentors, and according to the sign at the front door of every hospital, clinic and office. Then reality sets in. Talk to the patients, sure, but we do not have enough translators: the budget does not allow. Be caring of course, but do the history, physical, think, make decisions and write out the prescriptions in 14 minutes: doctors must be efficient. Sorry, but that catheter or particular drug or certain specialist is too expensive, not covered in the plan, and therefore you cannot use it or consult her. Yes, it is very hard to get to the hospital from the parking structure, but that is the cheapest way to build the structures. Etc. Etc. The provider is imbued with a cultural value that the welfare of the patient comes first, but the budget is king.

Those who deliver the care, called the white coats, have a different culture than those who control the resources needed to deliver that care, called the blue suits or suits for short. Even though they work in the same place and share (unknowingly) core values, they think differently, were socialized to different standards and approach problems in fundamentally different ways. Worst of all, each sees the other as the enemy. This conflict, coupled with limited resources, oppressive rules, and a mountain of contradictory regulations assures that collaborative problem solving will not happen.

CONCLUSION, PART I

In order to cure anything, from your golf slice to our healthcare system, we must treat the reasons for illness not just the symptoms. Some of the major causes have been discussed above. You can consider these and others in greater detail at www.thesystemmd.com. In Part 2 of this series, it will become clear that the system as a whole, not individuals or parts of the healthcare system, is at the root of our problems. Part 3 will show what we can and must do to fix healthcare.

Note: Every statement made herein can be supported by evidence: they are not simply the author's opinion or bias. For examination of these references, feel free to contact the author.

By J. Deane Waldman, MD MBA http://www.thesystemmd.com