Learning from Health-Care Reform and Other Things That Didn’t Happen
Written by: Dr. Michael Weiss
Do you remember when Bill Clinton announced his health-care reform initiative in 1993? In one of the great dramatic moments of the decade, he held up a wallet-size card and promised to unite all players — providers, payers, patients and policy makers alike — in an effort to achieve meaningful reform.
As the audience whooped and cheered, Clinton predicted that, simply with a flash of our card, every American would have access to high-quality health care that was both abundant and cost-effective.
Didn’t happen.
As I was thinking about this recently, several questions came to my mind: One, why did I stay up late to watch Clinton’s speech? Two, why did I then spend the next six months fretting about it? Three, how many other predictions about health care have gone unfulfilled? And, four, what lessons can we learn from this?
The answer to the first and second questions? Beats me.
The answer to the third and fourth? Lots.National health-care reform may be the most visible example of a predicted change that never materialized, but it’s not the only one. In retrospect, conventional wisdom has been wrong a lot when it comes to projecting the future course of health care.
Let’s talk about another predicted change that never came about: vertical integration.
Not long ago, conventional wisdom held that this expansive approach would allow for effective management of health-care resources across the continuum. Many organizations tried vertical integration. Few succeeded.
Why? Because vertical integration is based in part on assumptions that are arguably flawed. It assumes that one component of the health-care system can skillfully manage all the others. It assumes that the others want to be managed. And it assumes that, once the components integrate, costs across the continuum will be easier to control. Organizations that were shrewd enough to clear the first two hurdles now face the third. It’s a bear. Vertical integration has the potential to dilute the relationship between providers and their customers to such a degree that the incentives for remaining productive and competitive may disappear.
Most predictive models failed to consider this dynamic. As a result, vertical integration is not yet the force it was expected to be. We’ve seen this in other markets in the country. We’ve seen it here.
There are many other things that were supposed to happen in health care by now, but didn’t.
Health-care construction hasn’t stopped. Numerous hospital closings haven’t occurred in Pittsburgh. Payers haven’t shifted all the risk to providers. Changes in the system haven’t deterred future physicians from entering medical school. HMOs haven’t maintained the stratospheric profit levels of the early 1990s. For-profit providers haven’t achieved total dominance over the system. And, most importantly, health-care consumers haven’t agreed to sacrifice choice for cost.
At least, not yet. I suspect not ever.
As I mull over this list, it’s clear to me that there are some lessons to be learned.
First, our system will undergo revolutionary change at an evolutionary pace. We will see a few unpredictable moves by key players, but these rapid shifts in direction will be the exception, not the rule. Given the pace and relative certainty of change, knee-jerk responses are ill advised. A thoughtful, patient approach works better.
Second, for every action in health care, there is an equal and opposite reaction. Payers, providers, patients and policy makers keep each other in check. When one faction runs amok, the others intervene. Sure, there may be periods when one appears to dominate the others, but the balance of power virtually assures that the dominance will always be short-lived.
Third, predictions are only as good as the information we have when we make them. Health care is notorious for its moribund accounting systems and its rudimentary attempts to measure quality and outcomes — not to mention its historic aversion to dealing with business issues head on. How can we expect to make accurate predictions about where we’re going when we haven’t fully grasped where we are?
Finally, despite the change, we’re still functioning effectively. So while things may not be as good as we hope, they’re also not as bad as they seem.
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