As the reality of health care reform begins to sink in and the various elements of the new laws go into effect, health leaders across the nation and in every conceivable health related enterprise are beginning to ask where they can get the direction they need to respond to the opportunity that we have been told is once in a lifetime. From community clinics to professional groups, to health plans, to hospitals, and across the various clinical and non-clinical professions, everyone seems to be looking for the operating manual. It is not there. Jokingly, I posed this point in a talk last week, and in an off-handed way indicated that I had found the instructions for implementation on page 256 of the Patient Protection and Affordable Care Act. I was not encouraged when about 15% of the audience took the time to write this down.
What we have in the Act is a framework for health care reform. There are important and courageous changes in the policy structures around health care, but there is little in the legislation to actually direct a particular response from any quarter of the health care landscape. There are several reasons, however, why there should not be such direction. First, Americans would never stand for a single plan that everyone fit into in the same way. Personally, I am for more standardization of utilization all the way to evidence-based practice guidelines. However, many consumers don’t get the value of this and balk at the thought of it. A more important reason why there should not be such direction is that we do not have all of the answers to how to actually reduce health care expenses. Therefore, we need the creative and innovative responses of our variegated health system to see if we can come up with some major disruptions in the way we organize, finance, and deliver care, and our vaunted American exceptionalism needs to be a bit more entrepreneurial if we are to come up with winning strategies. Finally, I think we suffer a little too much from trying to make one size fit all. Let’s take primary care and our steps toward a patient-centered health home. We do not need one model, approved of by the professions, that applies to all. What we need is a host of models that can respond to a great variety of needs; these models should use every type of professional, and deploy technology in new ways to transfer knowledge and allow consumers to more actively engage their needs.
So, we need 10,000 experiments between the new policy framework and the enormous challenges facing our nation’s health system and our overall economic and social well-being. Lately, I have been thinking about how these experiments will best come about. I increasingly believe that we will all be best served if we focus these experiments on making tight business cases for innovation and change; these business cases should focus in the three broad areas of compliance, improvement, and enhancement.
Compliance - someone or some organization requires you to do something. Examples include a hospital that has decided to work with a consulting group to change the processes around patient-provider interactions. Perhaps CMS, the Joint Commission, or the CDPH has promulgated new guidelines for safety or quality, mandating a change in procedures or process. These types of changes have the advantage of having the force of internal or external authority. We have to comply because it is the law or because they are the bosses. However, these types of changes may not have as much internal authority and credibility, and are often traps for mid-level leaders and change agents. Many times these changes are more costly in the short or even long-run, and the benefits for making the change may not be immediately evident to those directly involved.
Improvement – Something is broken and you want to fix it. With improvements, we can assume that most of the internal participants in the process have bought into the goal that the current process provides and there is support for these outcomes. However, there is also likely to be a considerable stake in doing this in the way in which it has always been done. Change resistance will likely come from those who are most immediately invested or impacted by the change. To go forward, these stakeholders will need to grasp the measured value of doing something in a different way. They will also have to be assisted in the emotional adjustment needed to give up the security of doing it in the “tried and true” manner. Much reform of the past two decades has been driven by an improvement mentality and it now needs to apply more generally to reform.
Enhancement – Finally, there are changes that leaders will want to make that enhance a process that is working well now, involve a new undertaking, engage a new customer, or provide a new set of services. The resistance to these sorts of changes comes from the entropy that surrounds any new venture. The rejection might be by individuals or the entire organization. However, this approach will be essential because we cannot get to the ultimate goals of health care reform without creating some new structures for health, ways of organizing care, and mechanisms for financing these efforts.
My greatest fear right now is that we will fall back into old ways of doing our work and not make an aggressive case for the future.