How not to fix health care3 December 2015
Last week’s TWOG, the first in a series of three, discussed two myths of health care: #1 that it is a system, #2 which is failing, In fact this non-system is succeeding, brilliantly, at least in the treatment of diseases that are acute more than chronic. The problem is that it is doing so expensively, and we don’t want to pay for it. So we try to fix it, in all kinds of dysfunctional ways, and herein lies the failure. This week’s TWOG looks at the most popular of these fixes—five more myths.
Myth #3: Health care can be fixed by measuring like mad. Administrative engineering marches on: when in doubt, measure. As a senior official in the British health department replied when asked why they measure so much: “What else can we do when we don’t understand what’s going on?” (How about leaving your office to find out what‘s going on?) The fallacy here is the assumption that we can measure everything that matters. Another is that doctors can be incentivized like Pavlovian dogs.
Myth #4: Health care can be fixed by relentless reorganizing. This fix is popular because it’s so easy. Shuffle people around on pieces of paper, and off you go. The fallacy here lies in the assumption that hierarchy is organization: change who reports to whom and people magically coordinate with each other. Does all this reorganizing make a difference where managerial authority is so easily trumped by medical sovereignty? Actually it does: it drives all the providers to distraction. Patients beware!
Myth #5: Health care institutions can be fixed by making them bigger. There may be economies of scale in assembly lines, but the patients and providers of health care are not automobiles. We care about how we are treated. We prefer intimacy. Yet the problems of health care institutions are frequently dealt with by making them bigger–the institutions I mean, although usually the problems too. A corollary of this myth is that mergers are magical: combine one happy health care organization with another happy health care organization and together they will be blissful.
Myth #6: Health care institutions, not to mention the whole non-system, can be fixed with more heroic leadership. Sure leadership matters, especially when it replaces a leadership that was worse. But how can some leader siting on “top” render more effective all those people working on the ground–unless, of course, he or she gets off that pedestal, to find out what’s happening on that ground. But that means forsaking heroic leadership for engaged management.
Myth #7: Health care can be fixed by making it more competitive. Health care? It already has too much competition, thank you, albeit among physicians fighting over beds and administrators fighting over budgets. How about a little more cooperation guys and gals, for the sake of the patients, who are, after all, people? As for market competition, I have three words: American health care.1 And as for the related myth, that health care can be fixed by running it more like a business2, I have three words for that too: American health care. Beware of caveat emptor when the seller knows a lot more than the buyer. That’s why the best of health care is a calling, not a business.
So what can we do? For starters, we can recognize that the real failure of health care may well lie in these fixes: mergers, measures, and markets, leading, organizing, and businessing. Remember that if we always do as we always did, we will always get what we always got. Tune in next week to hear about doing differently.
© Henry Mintzberg 2015 HM is the Founding Director of the International Masters for Health Leadership (mcgill.ca/imhl), which brings together people from all over this field and this world to get beyond such myths.
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1 The United States has the most expensive health care costs in the world, by far, and outcomes that are mediocre compared with other developed countries (see Davis et al., Commonwealth Fund, 2010, also Nolte and McKee in Health Affairs 2008). As for administrative costs, the U.S. spends about twice the percentage as Canada, which has more government controls and so less market competition (Woolhandler et al. in the NEJM, 2003). An article in The New York Times attributed this higher cost to excessive competition: “Duplicate processing of claims, large numbers of insurance products, complicated bill paying systems and high marketing costs [plus all the “paperwork required of American doctors and hospitals that simply do not exist in countries like Canada or Britain”] add up to high administrative expenses” (Bernasek, NYT, 2 January 2007).
2 In a Harvard Business Review article, Regina Herzlinger referred to “one-stop shopping” for health care, to hospitals as “focused factories”, to the “customers” and “consumers of health care” for whom “the passive [term] ‘patient’” seems anarchistic”, and to physicians as “industry players” (HBR, May 2006:59).