Tuesday, March 29, 2005
More on Responsibility for Fixing the System
This will continue the exchange with Leo Greenawalt on fixing the health care system.
In a March 7 posting, I suggested that this is a job that politicians may not be able to do. In the posting of March 22, Leo suggests that they can.
Perhaps a useful next step in the discussion would be to explore what is meant by “fixing” the system and what, therefore, the “fixer” would be expected to do.
Not being among those who see national health insurance as a solution likely to be adopted, I would offer the following as the initial steps of reform:
1. Clearly assign responsibility and accountability at the local level for the cost, quality, and safety of care. My candidates for that role are hospitals and large group practices.
2. Create an economic environment – a market structure, if you will – that rewards good performance and penalizes poor.
Both can proceed concurrently, but for a market system of rewards and penalties to work effectively, those responsible and accountable for the quality of performance must acknowledge and accept their role.
Suppose, then, that a politician came to me and said, “OK, I agree with you. What do you want me to do?”
On the market issue, there are several things I might say, such as “repeal all certificate of need laws” and “use Medicare and Medicaid to give managed care and global capitation a hard push” and “enforce anti-trust in the health field more strictly.”
But on the matter of responsibility and accountability, I don’t have a ready answer. It seems to me to be mainly an issue of culture. It requires, for example, that the traditional boundary between the professional (e.g., physician) and institutional (e.g., hospital) components of care be got rid of and everything gathered under a common corporate umbrella with institutional governance and management exercising jurisdiction over all aspects of care, including the practice of medicine. While the boundary is being steadily eroded, it is still very much there.
Except for the constraint of laws forbidding so-called corporate practice (which clever lawyers always seem able to find a way around) there are many institutions in which that sort of unified approach could be implemented already if there was the will and desire to do it. The Mayo Clinic, the Henry Ford Health System, and Kaiser Permanente come to mind as examples.
The problem is that the medical profession wants to maintain its traditional autonomy, the public supports its position, and so governance and management of health care institutions are reluctant to exert themselves in clinical matters.
So long as that is the case, it is a briar patch that no politician worthy of the name would want to jump into, particularly without knowing what he would do once he got in there.
What are your views?
This will continue the exchange with Leo Greenawalt on fixing the health care system.
In a March 7 posting, I suggested that this is a job that politicians may not be able to do. In the posting of March 22, Leo suggests that they can.
Perhaps a useful next step in the discussion would be to explore what is meant by “fixing” the system and what, therefore, the “fixer” would be expected to do.
Not being among those who see national health insurance as a solution likely to be adopted, I would offer the following as the initial steps of reform:
1. Clearly assign responsibility and accountability at the local level for the cost, quality, and safety of care. My candidates for that role are hospitals and large group practices.
2. Create an economic environment – a market structure, if you will – that rewards good performance and penalizes poor.
Both can proceed concurrently, but for a market system of rewards and penalties to work effectively, those responsible and accountable for the quality of performance must acknowledge and accept their role.
Suppose, then, that a politician came to me and said, “OK, I agree with you. What do you want me to do?”
On the market issue, there are several things I might say, such as “repeal all certificate of need laws” and “use Medicare and Medicaid to give managed care and global capitation a hard push” and “enforce anti-trust in the health field more strictly.”
But on the matter of responsibility and accountability, I don’t have a ready answer. It seems to me to be mainly an issue of culture. It requires, for example, that the traditional boundary between the professional (e.g., physician) and institutional (e.g., hospital) components of care be got rid of and everything gathered under a common corporate umbrella with institutional governance and management exercising jurisdiction over all aspects of care, including the practice of medicine. While the boundary is being steadily eroded, it is still very much there.
Except for the constraint of laws forbidding so-called corporate practice (which clever lawyers always seem able to find a way around) there are many institutions in which that sort of unified approach could be implemented already if there was the will and desire to do it. The Mayo Clinic, the Henry Ford Health System, and Kaiser Permanente come to mind as examples.
The problem is that the medical profession wants to maintain its traditional autonomy, the public supports its position, and so governance and management of health care institutions are reluctant to exert themselves in clinical matters.
So long as that is the case, it is a briar patch that no politician worthy of the name would want to jump into, particularly without knowing what he would do once he got in there.
What are your views?
