The truth about change in health care was never more perfectly captured than in an episode of Sex and the City, when Carrie Bradshaw lamented that we keep “should-ing all over ourselves.”
In the past decade, those of us on the front lines of health care have seen the passage of nine major pieces of federal legislation that, combined, have profoundly affected how they work. We’ve seen the number of people with a chronic illness grow to almost 50 percent of the population. We’ve seen an incredible number of new medical technologies, new cures, and new treatment recommendations. The pace of change in health care — from every direction — is unparalleled in any other industry.
Through every change, we’ve seen the national discussion about health care increasingly focus on strategies and ways of thinking that just aren’t working. As a nation, we’ve been bogged down in the “shoulds” for too long — what our providers “should” be doing, what patients “should” be experiencing, what we “should” be achieving. In the hunt for high quality, cost-effective, satisfying care, the top-down approach to engineering behavior on the front lines is actually moving us further away from our goals.
The “shoulds” have been driving a lot of well-intentioned change that hasn’t created much “is.” Instead, all of that change has created vast unintended consequences, or roadblocks. And the people and organizations operating on the front lines — physicians, patients, practices — are increasingly frustrated and disengaged. Why? Because the business of medicine (how we pay) and the science of medicine (how we treat) are overwhelming the art of medicine (how we care). And what we on the frontlines know is that health care works best when these three are allowed to work in balance — each doing its part and no more to help Americans get healthy and stay healthy.
So, we keep sending the same messages, no matter what hot-button issue has made it to the front page or the 6 o’clock news: We need more time, we need simple solutions, we need the freedom to build relationships, we need greater focus on outcomes, and we need less antagonism and more cooperation. But the truth we’re sharing in op-eds, in advisory panels, in testimonies, in interviews, in memoirs, and in actions — when some of us simply walk away from our calling — is consistently ignored.
It’s time for those who have the power to remove the roadblocks to the art of medicine to start listening, and start building a new paradigm for change based on what they hear. To help start the process, I’ve mapped the five basic shifts we need to see in how we think, in what we prioritize, and in the changes we propose, as a nation.
Shift one: From money as an incentive to time as an incentive
We shouldn’t be opposed to incentives that reduce waste or achieve lower costs, but only if the time needed to carry out the art and science of medicine is factored in. Rather than starting with the question, “How do we use money to reward good behavior?” we should insist that payers and lawmakers ask, “How do we use time to encourage good outcomes?”
Shift two: From more complexity to more simplicity
What if regulators, insurers, and policymakers agreed that for every new responsibility they want to require of patients, physicians, or medical practices, they first must take away one? The answer to improving a complex industry is not to propose solutions that add more complexity. It is to simplify — because simplicity is the key to balance.
Shift three: From more metrics to more relationships
Instead of spending so much of our national time, resources (at least $15 billion each year), and attention in medicine on creating, tracking, and reporting artificial metrics designed to incentivize good physician behavior while unwittingly reinforcing bad behavior, let’s measure just the few right things and free physicians to build trusting relationships that actually improve outcomes and costs.
Shift four: From process driven to outcome driven
An obsession with process as a way to gain control amid all of the variability in health care has distracted us, decade by decade, from the ultimate goal — the patient’s welfare — and from the art it takes to achieve the best results. With those elements as guides, we can reverse-engineer any process to achieve meaningful efficiency: the best outcomes with the least waste of energy, time, and money.
Shift five: From zero-sum (“I win; You lose”) to non-zero-sum (“We all win”)
We tend to believe that health care has become a zero-sum game: that for one side to win, somebody else needs to lose. But this is not true, and has never been true. Health care has always been a nonzero practice. Without one of the critical players — those responsible for the art, the science, or the business — the entire game comes to a standstill. It’s an industry in which each side can only win together, at least on the things that truly matter.
With every change in medicine, we have a choice: push the industry toward actually achieving our goals, or hold it back. There is no reason we can’t begin a new conversation that puts people at the center of the industry again, that reaches beyond mediocrity to excellence, and brings the art, science, and business of medicine back into balance to create a better path forward for all of us.
Halee Fischer-Wright is president and CEO, Medical Group Management Association and author Back To Balance: The Art, Science, and Business of Medicine.
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