Monday, February 04, 2008

The Constraints of Culture

bev M.D. commented as follows on my recent posting titled Unmanaged Care:

“I have no knowledge of what Kaiser, Mayo or Ford do, but what leads to your supposition that they don't impose the necessary discipline either? I am asking because that would be a blow to my pet theory that a "shotgun marriage" of hospitals and large physician groups, a la Mayo, Cleveland, etc., would go a long way to ameliorate the total lack of coordination and continuity in our present system.”

Managing care means deciding the best way to deal with a certain type of case and then being disciplined enough to get it done that way.

That runs counter to the prevailing culture that proscribes interference in how individual physicians treat their individual patients. It is the culture that leads politicians to be in favor of “putting medical decisions back into the hands of doctors and patients.”

Kaiser, Mayo and Ford are not immune from that. Their doctors were trained like all other doctors and their trustees and managers reflect the culture of the society of which they are a part.

This unwillingness to tolerate interference in the doctor/patient relationship is one of the tenets of our culture that stands in the way of meaningful reform of health care. It might work if people paid for care from their own pockets, but with health insurance a sacred doctor/patient relationship says that doctors and patients can do whatever they want, but the insurance company has to pay for it. That is the equivalent of a blank check.

That is changing – as it eventually must – but ever so slowly. One hopes that organizations like Kaiser, Mayo and Ford are in the vanguard of that change.

But there is a limit to how far those organizations can get out ahead of the prevailing culture and so far there has not been enough change to allow Kaiser, Mayo, Ford or anybody else to impose the discipline needed to effectively manage care.

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