When I was an undergraduate student, I was convinced by my professors of healthcare policy that the solution to what ails American healthcare—unequal access, extreme variations in quality, high costs and disparities in outcomes—lay in smart policymaking. We need healthcare policies that enable the right things to happen to patients more often than not, I was taught.
More than a decade after the passage of the Affordable Care Act and the HITECH Act, I am less convinced of the certitude of this well-intentioned teaching than ever. Both pieces of legislation and the regulations that ensued from them were magnificent in their intent but incomplete in their real-world execution. Having spent my career across all sectors of healthcare—government, healthcare delivery, payer side, pharmaceuticals, and frontline care provision—I have come to believe that what stops us from addressing our healthcare problems is not a lack of good policymaking.
No, the enemy is us.
Don’t get me wrong. There are a lot of very smart and truly dedicated people working in all sectors of healthcare. But more often than not, their good intentions are stymied as they fall prey to these “Seven Sins That Slow the Pace of Change in Healthcare Organizations.”
1) Risk aversion and fear—Over and over again we see organizations capable of making big bets (i.e. organizations with big balance sheets) stop short of implementing those big bets because of endemic risk-aversion and fear of the unknown. We speak a lot about value-based care, emerging tech, and startups intent on disrupting the industry, but the truth is that if the 800-pound gorillas in healthcare are not willing to experiment, try out news things—and, yes, fail—then what hope is there for other companies with less ability to weather setbacks?
2) Slow-walking progress. For years, many people—including myself—speculated that digital health would become a dominant mode of healthcare delivery. But it didn’t. Until the Covid-19 pandemic came along and, within a matter of weeks, (and in some cases, days), we vastly accelerated the pace of adoption of telemedicine and telehealth.
What stopped medical practices and health systems from adapting digital health tools sooner? In many cases, it was the mistaken belief that the pace of change in healthcare has to be slow. Sometimes leaders think patients won’t adapt well to change. Other times, they think clinicians and other providers can’t implement big changes quickly. But as we learned from the quick growth of telemedicine during the height of the COVID-19 pandemic, patients and clinicians alike can adapt quickly. So instead of putting every good idea through an endless barrage of pilots and studies, let’s instead put them into adoption right away and watch the outcomes instead of watching the clock run out.
3) Lack of true performance measurement. There’s a lot of money floating around the healthcare sector, in case you didn’t notice. Over the last decade, private equity has pumped $750 billion into healthcare, with most of it going to outpatient and home health care. Every day, it seems, we hear about some company promising to improve outcomes—with little data to support true impact. Unfortunately, more often than not it seems like the only thing these companies seem capable of improving is their own valuations and EBITDA. And that’s because they don’t measure anything else. Performance measurement in healthcare has become overly complicated and divorced from what matters most: patient outcomes and experience. We have an imperative to get out of our own way and simplify the ways we measure and report both.
4) Shame and Blame. Ask physicians why American healthcare costs so much and produces poorer outcomes than our peer nations and they’ll tell you it’s the insurers’ fault. Ask the insurers the same question and they’ll tell you it’s the hospitals’ fault. The hospitals will, in turn, blame drug companies, who will assign blame to government bureaucrats. These and various other entities will also assign blame to liability lawyers and patients. It’s all part of what Brian Powers, Christine Cassel, and I have called “a cycle of blame and shifting culpability—a futile pattern that stymies meaningful reform.”
Instead of assigning blame, it would be much more productive for each group to accept at least some responsibility. Of course, that’s unlikely—who would go first? one wonders. Which is why Powers, Cassel, and I proposed that instead of focusing on the specific actions of individual stakeholders, we instead focus on “inadvertent causes: unforeseen consequences, inefficiencies, and misaligned incentives.” As we wrote, “This recasts the system as a whole, not its component parts, as the appropriate target for reform.”
Moreover, once the problem is seen not as lying with individual stakeholders but with the system itself, those stakeholders can, without having to confess their sins, come together productively to address the issues through a collaborative focus on the common goals of improving outcomes while lowering costs.
5) Profiting off the maze instead of breaking down the walls. I’ve worked in healthcare for a long time. I know that there are a lot of barriers to overcome on the path to success. And sometimes breaking down the barriers can present minor opportunities to profit. A great example of this is risk adjustment. Yes, I know that risk adjustment allows organizations like my own to properly allocate resources for the treatment of patients and reduces disincentives for us to take on and provide treatment for the most difficult cases. At the same time, how many third-party risk adjustment specialists have entered the marketplace? By endlessly adding to risk scores, these interlopers can enrich themselves and inflate the cost of care without truly bringing anything new or beneficial to patients, claiming low medical loss ratios (MLR) that are based more on inflated revenues than on true medical cost reductions.
6) For-Profits Acting Like Non-Profits…and Non-Profits Acting Like For-Profits. Among hospitals, clinics, insurers and other entities, healthcare has its not-for-profit and its for-profit entities. Is one group better for patients than the other? Do a quick Google search and you’ll find that plenty of non-profits and their leaders have engaged in all kinds of malfeasance. At the same time, you might be surprised to find a range of for-profits implementing programs that lower costs and improve outcomes for patients—even at the expense of their bottom lines.
Non-profit organizations are not inherently altruistic or benevolent. Nor are for-profit organizations always greedy or rapacious. It’s the organization’s values that matter most, not their tax status. And if those values are central to their mission, they’ll instill them in their employees, which in turn will lead to better care for patients. On the other hand, when greed dominates any entity’s outlook or when organizations fail to commit resources to innovation, change becomes nearly impossible.
7) Commodification of the healthcare workforce. You don’t have to look much further than stories of burnt out physicians and striking nurses to know that healthcare is hard work. It’s stressful. Lives are on the line and saving them requires a delicate balance of know-how, ingenuity and compassion. Yet all too often, well-intentioned reformers come to believe that improving care outcomes requires that more burdens be put on front-line clinicians. Even when these additional responsibilities make sense, they often fail to yield success because they fail to take into account the clinicians’ well-being. That’s no way to run any business, particularly one as intricate as health. And it’s just common sense that if you want to implement change, you’d better make sure your front-line staff is along for the ride.