Tuesday, July 28, 2009

Musings From A Drive Home From Washington DC About Democracy and Health Care: Are They Incompatible?

The Disease Management Care Blog was on Capital Hill for the last two days. While staffers' cards are being held close to the chest, it really appears that no one has any idea if health reform will pass.

Democracy in action, especially when the nation’s health is at stake, shouldn’t be so difficult, should it? While there are real policy issues around the role of government and the use of our treasury, the process should be aided by common-sense changes involving primary care, population-based care, insurance benefit designs, premium subsidization, expansion of current programs, rigorously assessing new technology, not paying for mistakes and stopping insurance abuses. Instead, a faction of Congressional Democrats are not playing nice, the Congressional Budget Office keeps coming up with inconvenient truths, key leaders are missing in action, key supporters are being undercut by their rank and file and momentum is decreasing. Delay means opponents will have the summer recess to sink reform with bail-out fatigue, fear of Federal deficits, cap n' trade second thoughts and what's-in-it-for-me politics. The ever-wise information markets are down to a 35% chance that the U.S. will have a government run health insurance plan in place by the end of December.

And yet, that great shining light on the hill is still there: the vaunted Integrated Delivery System (IDS), where hospitals and physicians align their incentives, concoct best practices, charge less, work more, use EHRs anyway and stomp out complications in a paradise of access, efficiency, value and innovation.

It was just in such a setting years back that the Disease Management Care Blog and some of its colleagues were engaged in what can be generously described as a vigorous dialog with a nudnink of a Chairman. The clinical and revenue issues at stake were also common sense and the Chair was simply not going along with our logic. Unable to achieve consensus, the Chair concluded with the meeting with a telling observation: ‘This is not a democracy.’

Indeed. The DMCB cautions, based on personal experience and lots of gossip with other colleagues, that while on the outside IDS’ may appear to be enlightened institutions that use the most modern approaches to capital allocation, use of human resources and clinical program design, inside they have more than their fair share of internal strife. In fact, the past issue wasn’t important and the DMCB suspects the Chair was right. What’s important is that the Chair and other centers of power in IDS’ are always right because they don’t function as democracies.

Which may be why the well-meaning Madam Speaker is having so much difficulty. The DMCB wonders if good health care delivery, in addition to being evidence-based and market-driven with good incentives and a strong mission and all that stuff, is also something of a dictatorship. Congress’ misbehaviors, competing factions and wonky debate remind the DMCB of its dysfunctional yet halcyon IDS days. Perhaps the critical missing ingredient inside the beltway is what IDS’ possess: central command and control that can suspend the exercise of democracy.

The DMCB suspects the odds of passage may need to be rated at less than 35%.


Bill Baar said...

The DMCB wonders if good health care delivery, in addition to being evidence-based and market-driven with good incentives and a strong mission and all that stuff, is also something of a dictatorship.

The crux is who's the dictator: Patients voting through the market constrained by their insurance (or lack of it) and what providers will supply, or civil servents manageing the market constrained by budgets and what providers will supply.

So do you want to manage your own constraints, or let a civil servent do it for you?

Jaan Sidorov said...

Bill makes a good point: our country doesn't really have a pure market-based track record that it can turn to to assess how well an unfettered health care system would work. I'd only caution, however, that Medicare is generally viewed as an unqualified success. Prior to it's inception, the elderly were being screwed by the market. Another untold story of Medicare is how it used Federal law to address unequal access to care on the basis of race.