The faithful reader of this space will note a modest change from issues past. This month column has a dual byline pointing to an upcoming change in the leadership of the Center for the Health Professions at UCSF. Ed O’Neil, who established the Center and for the past 20 years has directed its effort to frame policy issues around health workforce, will retire from the university in June 2012. Assuming the role of Interim Director will be Sunita Mutha, a long-time member of the senior faculty at the Center and a Professor of Medicine at UCSF. This transition will be an opportunity for the Center to take stock of its accomplishments and position itself to continue to play a vital role in pursuing its mission to transform health care through workforce research and leadership development. 

Last month I gave a quick sketch of what I see as the key elements of producing value in a reconfigured health system. This aim is the very best way for health care leaders to ensure that their institutions remain viable and driven toward a future state that can improve the health of those they serve and not damage the overall economy of our nation. Nowhere will this value pursuit be more challenging than in the nation’s hospitals. In large measure, the difficulty that hospital leaders face is a function of the niche in the health care ecology that they occupy. Because they have housed many of the highly specialized, technologically driven and expensive services, they have come to represent the excesses of the system and are targets for change from every quarter. The addiction of hospital finance to the revenue stream that flows from the emergency room through the ICU to the step down unit means that quitting the habit developed during the era of cost plus reimbursements will be hard, if for no other reason than that there is little, if any, experience at running hospitals in other types of business models. 

After we get everyone enrolled in a health home. And the silos of the old provider world are merged into organizations that can account for care. And budgets that are global emerge, heralding the return of capitated care. Then we will finally get around to the real work of providing health care services that are valuable to those that purchase them. And then, and only then, will we do something that is really new.

No, it is essential.

At the most macro level it has always been interesting to me that those nations that seem to take better care of their citizens for less money have the exact reverse proportions of providers--greater numbers of primary care providers than specialists; whereas the U.S. has more specialists than primary care. When you make a statement like this you can be attacked for wanting to dumb down the system of care. I know I have been attacked on this for many years.

In a recent Wall Street Journal article, David Gelernter was interviewed and in effect asked what was on his mind.(1) Gelernter, as the IT intelligentsia will know, is the Yale Professor of Computer Science, Unabomber victim and the individual some credit with coining the term “cloud” for that amorphous aggregation of the data of our lives. The whole article is worth a read for its value in helping provide a different framework as to how we think about information and its manipulation and use in the future. Gelernter sees an expanding future in which almost boundless information is readily and inexpensively available on a ubiquity of devices of increasingly smaller size and elegance of design.

As the health care world changes over the next five years, leaders will need to develop and articulate strategies that move their institutions toward success. Their instinct will be to create plans that focus on maintaining what they have done in the past: providing the same services to the same clients, with the same delivery structures and being paid in the same way. Such an approach will not lead to much change and it will not make a significant contribution to the overall improvement of care in the US. If truth is told, such efforts will not even contribute to the long-term successful positioning of their institution. Health care leaders should take the time to develop the ability to ask more fundamental questions about all of what their organization does, but four particularly critical areas are: business model, practice model, human resources, and partnerships.

It is the most common question I am asked these days in leadership development sessions: How do I get buy-in? It is not surprising given the nature of the challenge that health care leaders face. We are confronted with the need to bring almost tectonic changes to an enormous $2.6 trillion industry that for the past half century has been left to chart its own independent way. The challenges include bringing new models of care delivery online, using comprehensive new technology to manage information, joining with new partners to integrate care along a continuum, responding to the consumer needs of patients and always delivering better service while reducing costs.

I had a large number of responses to last month’s essay on how we will execute the health care reform. Not “execute” as in do away with, I had more of “bring to life form” of executing in mind. My basic premise here is that reducing access to care as a way of controlling cost or reducing the payment for specific inputs is not a sustainable pathway for reform. It will be difficult if not impossible to do and moreover, will not bring the level of reductions in cost and improvements in service that are needed. This is a strange alchemy I realize, reducing cost and improving quality, but we do it on other parts of our economy: think Southwest Airlines here.

How will we get there? The task is pretty daunting, but most of the people I speak with these days about health care are committed to changing things; they just don’t know how to take the first step. Or they see the specific thing to do, but do not have a good grasp on the framework that needs to surround the improvement or reform that is just in front of them. Here is a quick review of the challenge and what leaders need to do to sustain the change process.