Last month I laid out four issues that should be addressed to help recreate our system of care before we launch any of the current proposals for health care reform. The essay got a lot of response and many people contacted me asking for specific actions to take in the four areas. To review my main points from last month, our health care system is about 40 percent more costly than any other in the world, has enormous problems with patient safety and quality and leaves most people, patients and providers alike, befuddled as to how it works and disenchanted with the experience of working in it or consuming its service. So, how is paying for the 40 million uninsured to get the same expensive, poor service going to make things better, unless the plan is to drive what we have into economic meltdown faster? My questions were around the capacity of the system, growing burden of chronic disease, practice organization and models and the growing misalignment of the larger system of institutions.

Last month we encountered two significant proposals for health care reform in the US. California Governor Arnold Schwarzenegger has put forth a plan to cover the state’s 6.5 million uninsured through a combination of professional taxes and employer mandates. Not to be outdone, the President has called for his own set of employer mandates and, even more remarkably, new taxes for the insured to provide some of the resources needed to pay the expected increase in costs. As important as both of these proposals are, they fail to address the real problem of the US health care system: its costs.

It has been a bad week at the Center for the Health Professions. It started in a nursing leadership class where every story of hospital failure seemed to return to the same complaint. Just like a bone that breaks again along an old fracture line, each tale of poor communication, endangered patients and disheartened nurses, all came back to the broken professional relationship between physician and nurse. This in turn led to the vicious circle of blaming, poor communication, more stress and worse outcomes. Later at a planning session focused on improving patient safety, there were more tales from pharmacists about their inability to get the attention of physicians to help them with the medication reconciliation process. The pharmacists have the knowledge, experience, skills and commitment to address this issue, but they consistently felt left out of a process in which they see physicians struggle. The pharmacists ended the discussion by deciding to withdraw effort, leaving the doctors on their own. Another missed opportunity. Finally, I facilitated a meeting with some primary care providers focusing on their leadership profile. The discussion soon left leadership, turning to their feelings of being overwhelmed by the work of being a doctor. In quick measure they also expressed frustration, resentment and anger over the way things have turned out. Like anyone in such a place they looked for someone to blame. The list was familiar: managed care, health plans, the government, regulators, even the ungrateful patients. I didn’t leave the meeting feeling as if I had advanced their ideas of leadership and responsibility.

As an integral component of most of the leadership development programs that the Center for the Health Professions runs we usually try to sharpen skills around visioning. Over the past fifteen years I have been awed and humbled by the understanding, breadth, compassion, and wisdom of the visions developed by my clinical colleagues. A part of one of the exercises we use to stretch these skills is to ask participants to think about and record the barriers to achieving these passionate visions for a better health care world. Invariably the first barrier named is resources, not enough budget, to do the things that seem so right and are so needed.

Two months ago I had the privilege of welcoming 29 new graduates of the California HealthCare Foundation’s (CHCF) Leadership Fellowship to the program’s alumni network. This alumni group now represents over one hundred health care leaders across a wide spectrum of professions, organizations and sectors and offers as diverse a set of perspectives as are represented in all of health care here in California. In welcoming them, I also challenged them to develop their own manifesto or change agenda for health care reform in our state.

Two important principles in modern organization change theory, conflict management and power development are diversity and interdependence. They interact in some curious ways to produce complexity in most social systems and enterprises. They are useful constructs to help explain some of the difficulties we face in changing health care organizations and perhaps, more importantly, can help direct the attention of health leaders to more effective remedies of our current situation.

Last month in this space I identified four structural impediments to innovation. They were the lack of an aligned financing mechanism, overly burdensome regulatory structure, disconnected educational programs and a workforce that reflected the first three. There is one more barrier that is not as tangible as these four, but may be an even bigger impediment to innovation: individual clinicians’ reluctance to change.

“You can’t get there from here.” It is both a punch line from an old joke and a common comment on the process of reforming the current US health care system. While we long for a comprehensive reform that would sweep away all of the dysfunction and waste, the reality is that culturally and politically we are incrementalists and are far more likely to nibble away at the edges to improve the system a little bit at a time. These small scale improvements are frustratingly slow; the challenge is, after all, changing one of the top ten economic undertakings on the globe and we are doing it with dental tools. What prevents us from moving faster and a bit more expansively on these reforms? I believe there are four areas where new policy and practice could help promote innovation.

Now that I have your attention, it may not really be the death knell for primary care, but it is fair to say that primary care is increasingly moribund as we have come to know it over the past fifty years. In 2004 the American Academy of Family Physicians released its The Future of Family Medicine Project Final Report concluding that the public was poorly served and Family Physicians at risk if the current financing and organizational arrangements for physician care continued. This report is based on the idea that effective use of primary care resources would create a system of care that was more effective and less expensive. It continues to be a rallying call of these and other studies that the US health care system, the most expensive in the world, deploys primary care in the reverse ratio to every other country and that this high level of specialization our outcomes are no better and we leave a large part of the population out of the payment system.