Thursday, November 14, 2013

Who Should Be Accountable for Bringing About Change?

"Every system is perfectly designed to get the results it gets."

Reminiscent of Confucius or one of Yogi Berra's infamous isms, this quote offers us wisdom beyond just simple word play. In the case of system performance, especially when thinking about a particularly complex system such as U.S. health care, the above statement provides us with insight to explain why we're getting the results we're getting (which as we saw, in begging the question of "...How m'I Doing??", are not all that great) - and it isn't by happenstance. Rather the opposite, our health care system can be thought of as being finely tuned to get the results it's getting. The "tuning" in this case could come in the form of efforts to reform health care, but it need not be so deliberate, as our system of health is constantly having its dials turned by a countless number of shifts in processes that directly or indirectly link to our health. To help us get a handle on what matters in the world of health and what doesn't, health experts have created the term "determinants of health" to capture this comprehensive network of interactions associated with our health.

If you haven't already done so, before looking closely at the contents of the image below, try to come up with as many factors of health as you can on your own (write them all down if you'd like!) - after we'll gauge how closely our intuitive senses match the real thing.

The Institute for Healthcare Improvement provides us with this useful depiction of our health hemisphere. 
So how'd you fare? Did you account for all of the factors mentioned above? - leave me a comment with your thoughts!

As we see depicted in the above diagram, there's much more to our health than what we traditionally might have thought. "Health care", which receives an overwhelming majority of the funding for health matters in the U.S. (upwards of 90% of the $2.6 trillion dollars spent on health annually), comprises only one piece of the schematic's hemispherical puzzle. The rest of the amphitheater is occupied by our genetics, behavior, social environment and physical environment as well as interventions made on the part of society to promote or deter healthy living, much of which are the subjects of our attention in public health (which mind you, gets less than 5% of our financial attention in the form of funding). When we think about making changes to our system of health, we're going to need to think big picture about how any number of these factors could have an effect on our health outcomes.

Continuing on this matter, we find that significant improvements to our system of health tend not to arise spontaneously. A principle from the field of system performance sums up this notion succinctly in stating that "change can happen without improvement, but improvement cannot happen without change". A two-liner of which even JFK would be proud, and, I imagine, not just for its rhetoric, as we are able to unearth from it the concept that improvement never arrives unaccompanied by intervention (otherwise known on this blog as a "wedge"!). While observing properties of the natural world some centuries ago, Isaac Newton was coming around to a similar realization that culminated in his monumental laws of motion, which still stand true. Following a similar rhyme to the aforementioned adage of systems, his first law states that "an object at rest will stay at rest and an object in motion will stay in motion at a constant velocity, unless acted on by an external force." A concept cutting across historical and disciplinary divides has retained its relevance from the founding of classical physics all the way to the health care reform efforts of today.

Since we've seen that the U.S. healthcare system has significant room for improvement across the board (with a few exceptions like emergency care), we're now left with devising a means to change our ways as we've come to the realization that business as usual, i.e. no change, will not cut it. So what will we do? At present, much of our answer to this question can be found in the federal legislation as key decisions regarding domestic healthcare reform have already been drafted into law with the passing of the Affordable Care Act in 2010 - so at this time, the more appropriate question then, is not what are the changes that we are looking to make, but instead, HOW will we make them and WHO will be responsible or held accountable for carrying them out?

*Yearning for further coverage on how Congress came to the "what"? Refer to the perspectives offered in "Massachusetts: America's Next Top Model...".

"Who Accountable???", the healthcare reform spin-off of the classic "Who Done It??"

Are you ready to give it a whirl??

The question of accountability is certainly a valid one since politically change is often resisted by many, especially those presiding over and most likely benefiting (disproportionately) from the status quo, and tends to be carried out by a chosen few. In order to address who might be accountable for bringing about this change, however, I think it's first necessary that we work to identify who exactly are the WHO involved - i.e. who has a stake in healthcare?

What follows is a quick summary of the players involved in the American healthcare system. As you read, try to think about who might be liable for taking on the responsibility pertaining to imposed reforms in healthcare.

  • Providers- e.g. physicians, hospitals. Those who deliver the care and receive compensation for their service.
  • Payers- e.g. private insurance companies, Medicaid/Medicare (public). Those who compensate providers for their services.
  • People- the ill (patients) and the not yet ill. Those who receive the care, in most cases also contributing partially or entirely to compensation of providers.
  • Employers- Relevant here, given that health insurance is tied to employment for many Americans and employers cover part of the cost of insurance.
  • Policy makers and other elected officials- e.g. Congress (The House and Senate), the President. Those who draft legislation and authorize laws.
  • Regulatory bodies- e.g. Food and Drug Administration (FDA), Massachusetts Health Policy Commission. Those who provide oversight for the markets of consumer products or health insurance on federal and/or state levels.
  • Pharmaceutical and medical device companies, other research & development- Those who seek to innovate and create new forms of medicinal and technological intervention.
    • Fun Fact: A pharmaceutical intervention or drug can sometimes be thought of as a molecular "wedge" as it binds to the target site of a protein or cell disrupting its ability to bind to other ligands or "signals".  

After taking a gander at this cast of characters, it should appear that they're all likely candidates to bear some added weight atop their shoulders in carrying our country forward into our future system of healthcare. But are they all equally liable? Who, if anybody, might be the most responsible? And in the end, who, in totality, should be accountable for bringing about this change? How we go about answering these questions will lay the foundation for how our change is implemented down the road, so it would behoove us to tread lightly on this train of thought as it has implications for the likelihood that our change is ever realized.

In this instance, the two things that make up the proverbial hot potato to get passed around between our candidates are the time tested issues of money and time [devoted to this effort]. Who will finance (capital with a capital $) this change and who will put in the effort (manpower) to see these changes through?

Holding fictitious court in a room accompanied by all of the aforementioned stakeholders, we proposed this very same set of questions. What follows is a summary of the resulting discourse:

-Since much of the recent innovation in the American healthcare system is focused on making care more affordable, one might suggest that the providers, payers, pharmaceutical/medical device companies and employers should be tasked with bringing prices down, and the regulatory bodies must be held responsible for being more stringent in their oversight to make sure this happens.

-One might also reason that the people are to be the main beneficiaries of said change, since they are the ones receiving the coverage and care after all, so it would make sense if they were the ones most liable.

-A large faction of people, however, claim that they never asked for this change, so they see that it's on the policy makers and the President to bear the responsibility. Some see access to health care as their inalienable right, while others believe that health care should be left up to the individual - at any rate, again, we find it's on the government slash society at large to ensure that these rights, whatever the consensus may be, are ensured.

With the all too expected finger waiving and pointing that comes along with any discussion political in nature (politics is a game of deciding who wins and who loses after all), we're more liable to end up knotted like our friend Skeeter here...

Remember when he tried to teach Doug how to dance? Pure 90's gold.

...than we are to effect real change!

Nevertheless, somebody is to be held accountable for bringing about this change. Much in the same fashion of how I proceeded in discussing our health in sharing the diagram of the "determinants of health", I will say here that we also need a big picture view of change that requires all to be held accountable in some way. No one person or population can be held responsible for change that bears some effect on all. In order for this change to be lasting and net positive in its impact, we're looking at a full scale team effort!

Unsurprisingly, therein lies much of the source of innovation in health care reform as we seek to design new ways to coordinate, finance, budget and charge for our care. Massachusetts was the first to put this concept of "shared responsibility" as it pertains to health care reform into print with their bipartisan backed law from 2006, Chapter 58 of the Acts of 2006. In the years that followed, Massachusetts added other reforms on the back of that hallmark law as it forged its way forward to become the nation's pioneer in health reforms that it is today. Another innovation that resulted from this incubation, and a term you're going to see more and more as this change comes underway is the concept of an "accountable care organization" or "ACO" - as this is one of the main ways that have been proposed to help us achieve our systemic goal of improving population health by bettering our quality of care and lowering and containing costs over time. But, we'll save our discussion on that for another time...

Today, I'll leave you in same manner in which you were received, with a trinket of wisdom about change from one of America's greatest thinkers in recent history.

"Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it's the only thing that ever has."- anthropologist Margaret Mead

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