Health Care Rationing is Inevitable - Unless We Build the Alternative

As President Obama makes it increasingly clear we are going to reform health care this summer, the parties are drawing lines in the sand and everyone is choosing sides for the long-haul. For the Democrats, the public health insurance option is a key part of the agenda. Meanwhile, the Republicans remain strongly opposed to a public insurance program because it would indicate "a federal government takeover of the health system."

Bipartisanship on this issue, if it was ever alive, is dead as a doornail. That means the "moneyed interests," - the hospital, Information technology, insurance and pharmaceutical industries - are pouring millions into whatever side looks best for them. It's a lobbyist's dream.

It's not going to pretty. In fact, as the divide widens, it's getting uglier every second. Far-leaning political commentators are accelerating their bombast. Although they may not have the answers, they certainly have the TV and radio clout to pour oil on the fire and create lots of unnecessary "sound and fury."

When the story of the "Great Health Care Debate of 2009" is told in the future, will it be Shakespearian?

.... a walking shadow, a poor player
That struts and frets his hour upon the stage
And then is heard no more: it is a tale
Told by an idiot, full of sound and fury,
Signifying nothing.

Will there be strutting and fretting? Of course.

And will there be tales told by idiots? I fear so.

But what will it all signify? Is it possible that all the lines in the sand and all the bloody battles fought over them will ultimately amount to "nothing?"

Certainly not. For me, you, our loved ones, and our futures, this summer's debate will bring America's leaders to one terrifying, yet vastly important truth - no matter who pays, we can't afford our current care system.

The first shoe dropped this weekend as President Obama announced another $313 billion in cuts to health care programs for the elderly and the poor. He has no other options because we are out of money. He is taking hospitals and other providers at their word that they will reduce costs. That's a problem because the record shows they can't deliver.

I have been a physician for 40 years, as well as a health care executive, academic scholar, advisor and, most importantly a patient, immersed in our chaotic health care system. In my experience, there is almost nothing in current cost control proposals that has not been tried before and failed to control health care spending.

"Almost nothing" means something has worked. That "something" is care rationing. I will guarantee that no matter what health care reform legislation passes though Congress this year, your care and your family's care is going to be rationed in the future. It won't matter if you're a Democrat, Republican, rich, poor, executive, worker, advantaged or disadvantaged. There is no other option beyond care rationing because there is simply no money left.

I've worked in systems that ration care and I don't like it. But since rationing is inevitable, now is the time to start developing the alternative - a system that is not so costly, but always delivers exactly what the patient needs. Rather than working to reform the existing system with no money, no resources, and an overabundance of sound and fury about what should and shouldn't be done, America must refocus on building a new system that meets these fundamental goals of health care. Such a system will slowly, surely quiet all that sound and all that fury.

Building such a system is the subject of my forthcoming book, "Designed to Adapt: Leading Health Care in Challenging Times" (Second River Healthcare Press, 2009).

Based on my work as a Visiting Scholar at Harvard Business School studying those few organizations that excelled at managing complex, dynamic, unpredictable work, I've developed a process for redesigning health care organizations to always get patients exactly what they need at continually lower cost. I call it "Adaptive Design." It's a method that enables management, staff and physicians to problem solve the system when patients don't get what they need as part of everyone's everyday work.

Capturing the knowledge and creativity of everyone in the organization always pays dividends. For example, one operating room in an east coast hospital working adaptively increased the number of cases done by 16 percent at the same time that they decreased overtime by 14 percent and made their operating room much safer for patients. In other words, they lowered the cost of care and improved quality - simultaneously!

As more and more organizations begin to work adaptively, we will create health systems that are accountable to the patient and meet their needs at lower cost. What's more, we'll arrive at a clear alternative to care rationing, and we might be able to avoid the inevitable.

No sound, no fury. Just a better way to fix health care.

Comments

[Oregonlady]

Oh sure, rationing is inevitable so why should we demand a public option or SINGLE-PAYER--the one solutionthat DOES save money (namely, by cutting the costs of insurance companies' profits, dividends, CEO salaries, etc.---and instead just go buy this fellow's book. Hey, lots of us have books to sell. Healthcare rationing probably exists, to an extent, in every country--but the point of a social structure, of a society, is to give everyone as close to an equal share of necessities as possible, yes? So why do we not do a single-payer health-coverage system--with the government (that is, ourselves, as taxpayers) paying for all healthcare but with free-choice delivery of healthcare, and with decisions made strictly between patient and doctor---? If it fails to work without costing too much, then we can, as a nation, decide where to make cuts---perhaps by drastically trimming hospital CEO and medical groups' administrators' salaries, for starters, and limiting nonmedical consultants' fees. Better yet, we could have the decency to acknowledge that 15 or even that (alarmists' projection of someday) 30 percent of a nation's budget going healthcare for its citizens, rather than our present ungodly percentage going for war and prisons, is a GOOD thing, a sign we are finally joining the civilized nations. Rather than to start taking medical treatment away from the old, disabled, and very poor, as the presently announced "reforms" would do.

[John Kenagy - Huffpost Blogger]

Thanks, Bill for your thoughtful comment. We agree our current payment system is a mess - inefficient, cumbersome and expensive. It's a great temptation to wipe it out and start over. I've been there myself in the 1980's and 90's with HMO's, capitation, managed competition, etc.

The problem, in my experience, is current health care costs will swamp any payer without rationing care. There is no top-down fix on the horizon that will make a rapid difference in cost.

Research and experience, however, have demonstrated that you can rapidly decrease the cost of care by starting at the patient and working back. The method is called Adaptive Design. It focuses on getting patients exactly what they need and challenges the system to problem solve and deliver at continually lower costs. It has been tested and validated over the last 10 years many places in health care, so we know it works.

The challenge is that it is simple but not easy, because it is new, different and does not fit current top-down structures, methods and values. It's "disruptive." So, I don't seek to fight the current system. My goal is to help create the new system that makes the current system obsolete. The history of transformational, disruptive innovation suggests that's the best and fastest way to fix health care.

[Merlin7]

The proposals for health care reform being debated in Washington remind me of Jonathan Swift's suggestion for eliminating poverty in Ireland: Have the Irish eat their children.

[Billl]

Hundreds of billions of dollars of annual savings could be realized for Americans, while eliminating debilitating financial burdens for individuals and businesses by using these health care reforms. This would also be the best economic stimulus package ever. Ask OMB.

1. Set up a civilian, VA style, public health care system for delivering all government funded health care and medications free to everyone choosing to use it, no restrictions, rich, and poor, Medicare, Medicaid, etc everybody who wants public care has it free, all services, all medications, free period.
2. Pay for it with a national sales tax.
3. Let private insurers and care providers compete for everyone who wants private care, unfettered by government mandates, dictating who must be served, at what level, for what price, and totally unregulated but for safety.
4. Businesses that choose public care for their employees will have no financial obligations or any other responsibilities concerning health care.
5. Dispensing health care efficiently, and collecting the money to pay for it cheaply, that's the purpose of the exercise, and no one can compete with the government at these two tasks.

[pontesisto]

If you would like ot help pressure Congress to pass single payer health care please join our voting bloc at:
http://www.votingbloc.org/Health_Bloc.php

[tompoe]

The good doctor warns that no matter what healthcare system is pursued, rationing of patient care is inevitable . . . . unless we read and follow his plan found in his forthcoming book. Well, each to his own, I guess.

[kacy234]

Health care is already rationed by your health insurance company. They can deny you coverage for pre-existing comditions such as teenage skin problems. They can deny payment for procedures that have already been approved and performed and you have no recourse. They can deny a medication or procedure that your physician recommends that you have. They can raise your premium as much as they desire and you have no say except to change companies. If you change insurance companies, none of the illnesses that you were being treated for under the old policy will be covered because they were pre-existing conditions, if they accept you at all. Health care is already being rationed though the high premiums that people have to pay. Along with the high premium a good many policies have such a high deductible that the insurance ineffect is unusable. As for your doctor, you can only use one on the plan. If you change plans, you change doctors if they are not on the new plan.
Learn the facts. Listen to the problems that people have with their health insurance. "Rationing" is already here.

[Crumbx]

"Along with the high premium a good many policies have such a high deductible that the insurance in effect is unusable"

This is the case with Commonwealth Care Tier B policies in Massachusetts. If you pay a "low income" subsidized premium you are still facing a $2,000 deductible every year until the policy pays for any healthcare. Most low income people use it as "catastrophic" coverage and wouldn't use it for preventative care. But the private insurers are certainly very happy to get the premium from the Commonwealth of Massachusetts and the "insured".