Friday, September 15, 2006

The Gorbachev Syndrome

A few days ago, friends were telling us about some frustrations they had recently experienced while receiving health care. I tried to explain how what happened to them arose in part out of the way health care is organized and conducted, but had the feeling they were not really listening.

It later occurred to me – as, perhaps, should have been obvious all along – that Americans don’t want their health care system redesigned, or even seriously reformed. They like it the way it is. They just want it to work better.

It reminded me of Mikhail Gorbachev, the man who presided over the collapse of the Soviet Union. Mr. Gorbachev thought that with a better way of thinking, and with a willingness to be more open – what he called perestroika and glasnost - the government owned and operated economic system he headed could function successfully. He was wrong about that. The fault was more in the system itself than in the way it was managed.

In a way, the Gorbachev experience illustrates our attitudes toward health care. We think that if we can get the incentives right (as in pay-for-performance), or change the way of financing (like adopting some kind of single-payer program), or make better use of computers, or tinker with things in some other way, we can get our outmoded, undisciplined and unaccountable system of health care to provide reliably high quality care at reasonable cost. Not likely.

It is improbable that our health care system will collapse like the Soviet Union (although some alarmists suggest that it might). But if it is to perform in the way it can and should, there needs to be a fundamental change in the way it is organized and operated.

My suggestion is that we hold hospitals (by which I mean their trustees and executives) responsible and accountable for the cost and quality of care in their communities – including the care provided by physicians. Maybe there are better solutions. If so, let us hear them.

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