Addressing Health Care Culture
In a thought piece published by my friend Rita Numerof, called “Built to Flail: Why the Culture of Healthcare Needs to Be Addressed, Stat!”, she has pointed out changing human behavior is hard, so to accomplish tasks that require it you must be intentional.
“There is ample evidence that healthcare is on the cusp of significant change. Consumer expectations about the affordability, reliability, and accessibility are changing as out-of-pocket costs grow, the population ages, and demand for more convenient, just-in-time access increases. Value-based and capitated payment arrangements account for a growing percentage of health care revenues.
Seizing on the rampant inefficiencies in the health-care industry, well-funded entrants are challenging incumbents with targeted population health management, telehealth and care management solutions. Existing companies like Amazon, CVS, and Google are introducing new business models that challenge the role of traditional providers.”
She outlines four steps organizations need to create a “value culture” which are sensible, but likely difficult to achieve. These are 1) establish a strategic vision; 2) develop an enabling organizational structure; 3) recalibrate performance measurement systems; 4) create a tight feedback loop. But perhaps first, we need to return to the question of what business are we in?
Dr. Numerof has outlined the competitive aspects of the health care system. Unstated, but equally true is no one is competing for the chronically sick, the seriously hurt, or the uninsured! She also states “unlike healthcare systems, nontraditional providers such as Google, Amazon, and Apple have a laser-like focus on the consumer.” So, a related question might be “what does the consumer want?” My experience, without a lot of data, suggests one answer is most of the time they want “Walmart” care—open 24 hours at “everyday low prices.” But when they get really sick or need really difficult care, they want “Neiman-Marcus” care—only the “best” is good enough.
For a business, the choice to focus on either of these markets as the primary activity means foregoing the other end of the business. In healthcare the profit is mostly in the high- volume, low-cost care, and the individually costly care is mostly provided at a loss. So, if you are running a traditional health care organization and committed to the idea you must change with the times, what options do you have?
While the answer may vary depending upon local circumstances, it seems to be the best choice is a two-handed strategy. On the one hand, for the essential, but expensive services, for which there is little competition, the goal is necessarily cost-containment, while for the cheaper, but more profitable services, the goal is being customer friendly. Now don’t misunderstand, I am not suggesting customer service for in-patients is unnecessary, but I am suggesting the goal is to make an unpleasant necessity as pleasant as possible. I think those of us in the business sometimes forget people don’t really want to be in the hospital, even when they agree it is necessary. And this reality persists, no matter how fancy the hotel in healthcare. Prior to the pandemic, many hospitals thought they could compete on this aspect of care. Maybe now we can appreciate it is the care, not the facility, patients really want. We have been spending on stuff and scrimping on people—it is time to do the reverse.
I also think the current approaches to cost-savings are misunderstood. Dr. Numerof mentioned care management programs. These are often touted as cost-saving measures. Data from numerous programs, governmental and otherwise, though, show most of the “savings” occur from keeping people out of the emergency room and out of an extended care facility. Fundamentally, it suggests to me care management is firstly a means of providing extended access. Rather than having the patient with an issue come to a single location, a phone call is made to see if the issue can be resolved safely without seeing the patient in person.
Secondly, care management can be seen as a way of plastering over the cracks in our current dis-integrated care system. Everyone knows the gaps in care created between hospital and doctor’s office and between independent doctors’ offices, not to mention free-standing “clinics” located in pharmacies, create mistakes, hurt patients, and increase the cost of care with no corresponding benefit. Robust care management can reduce these things. Ten years ago, we thought computerized records systems would “fix” this problem. We now know the EMR illustrates the kudzu principle is alive and well. The cure is as bad as the problem.
Third and perhaps most important, a well-designed care management system may be able to serve the role previously occupied by “Marcus Welby, M. D.” For those too young to remember the television program, (1969-1976), he was an older GP who made house calls, assisted at surgery, and was the avuncular source of medical wisdom. Now he was a dramatic anachronism even when the show was new, reflecting a longing for the family doctor, while at the same time showcasing advances, then new, resulting from the biomedical revolution. Perhaps in some ways we have spent so much time focusing on medical “progress” we have forgotten what we knew about what people really want—to be cared for by people they think care about them.
As articulated in the article on the profit motive in medicine, (25 October 2021), I don’t think the practice of high-quality, compassionate medicine is really compatible with the profit motive. As I have also said previously, I have never been asked, “How much care can I get for $100?” But if healthcare systems are to survive, they must learn to focus not only on the profitable patient, but also think about what can be done to make their care more humane, and perhaps more human, for those for whom there is no other option.
Yes, there are problems with medical culture, but maybe the better solution is to change our culture in ways that support our traditional mission of healing rather than trying to make us better businessmen. There has always been a tension between the art and the science of medicine, but I am seeing signs of renewed focus on the art. Likewise there has always been tension between money and mission. Is it time to redress the imbalance?
8 November 2021
 Numerof R. Built to Flail: Why the Culture of Healthcare Needs to Be Addressed, Stat! Accessed 3 November 2021 at https://nai-consulting.com/built-to-flail-why-the-culture-of-healthcare-needs-to-be-addressed-stat.html.
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