Health care reform: believe it or not, the ball is back in our court.

Some characteristics of the existing U.S. health care nonsystem are shown in figure 1, page 10. The insecurity built into this nonsystem is not limited to the poor and needy. Many who are relatively well-to-do find their nest eggs threatened by preexisting medical conditions and by aging parents in need of long-term care. And insecurity is not just economic. Many have experienced, as patients and family members, inconsistent performance by doctors and hospitals on some occasions, and near-malpractice on others.

On Sept. 22, 1993, President Bill Clinton challenged Congress to help the White House take a step toward creating a U.S. health care system characterized by security, simplicity, savings, quality (dependable performance), choice, and responsibility.[2] At this writing, Congress has only shown the public that the spectacle of self-interested political activity is a far cry from the system of self-government visualized by our forefathers (an example of need for a new scenario in addition to some changes in the system). It is unlikely that reasonable discussion and compromise will lead to what is needed, which is a uniquely U.S. system combining the best features of competition (on the basis of dependable performance) and the administrative simplicity of the single-payer model (figure 2, page 11).

Some Insights

Whether or not it results in meaningful political action, the national "health care debate" is useful. At the very least, providers should have gained several valuable insights that can help us change the scenario in U.S. health care. Here are 10 examples.

* The health care reform issue has four dimensions, not just one:

* Where should the money come from? Political effort is unidimensional, focused on finding an acceptable financing mechanism.

* Where does the money go? In the existing system, people's health care dollars are being drained away from paying for health care services into legal fees, consulting fees, marketing of the public and of physicians, and other trappings of a model based primarily on economic competition. (The managed competition model does not change this scenario).

* How should care be made available on someone's scary day? For reasons of both economics and quality (consistently dependable performance), the answer is through integrated or at least cooperating health care networks.

* How can individuals with no medical training determine whether or not they are being exploited? We are ill-prepared to confirm dependable performance with objective data. What data should be collected, how should they be interpreted, and through what means should they be released to the public?

* The biggest issue in the health care reform debate is not money; it is trust. The primary objection heard to the managed competition model is distrust of big business. The primary objection heard to the single-payer model is distrust of big government.

* "Reform" is a commonly heard word these days. Reform education. Reform management practices. Reform politics. Reform collegiate and professional athletics. Reform health care. Actually, the problems in health care are reflections of attitudes and motivations in today's society that affect many areas of our lives.

* The constant, nagging presence of aggressive and unrelenting reporters eager to call attention to themselves does not result in reporting a story, but in changing the story. Who is to deny that fact in the O.J. Simpson case? And in government, eager reporters suggest that because the seed was planted yesterday and there is no blossom today, both proposed plans and well-meaning people attempting to be effective leaders are failures.

* The existing alignments in health care are wrong. New public/ provider/business coalitions are needed to better deal with the politician/insurer complex.

* Money will not flow easily to separatists, whether a freestanding hospital or clinic, or a physician in "private practice."

* "Managed care," "the profit-taking model," and "competition in health care" are not synonymous. In the context of treating an individual patient, "managed care" means learning to use practice guidelines and critical pathways, within the context of a responsible practitioner's clinical reasoning and judgment. (Pathways are a good idea, but someone must decide which pathway to place the patient on, what the starting point is, and when modifications of the pathway may best suit the needs of this particular patient). In a "profit-taking model," the primary goal is to maximize profit. Cutting economic losers is an acceptable means of accomplishing that goal, even if it means ignoring community need for a particular health care service. "Competition" in business can mean focusing on either the needs of customers or on "beating" - defeating - others engaged in the same business. The first interpretation of competition made America strong. The second interpretation of competition makes America weak. That's why "continuous quality improvement" caught on.

* A U.S. health care system that works will not be driven by the attorney/consultant complex. It will be driven by physician and executive leaders who are effective decision makers and motivators.

* Desirable changes are occurring in the health care system/scenario. So far, in many instances, progress is the result of innovative leadership in U.S. health care centers and in large and small businesses, not of political action.

* Perhaps the most important insight: The public, having been disappointed by business-as-usual in U.S. politics after new leaders raised expectations that gridlock could be avoided, will welcome positive, productive, patient, and public-centered efforts by health care providers to take the point in changing the existing U.S. health care scenario.

Changing the Scenario

These insights suggest some things we might do to control our own destinies, instead of just waiting to see what laws are passed and what bureaucratic regulations are issued to implement the new laws. Here are 12 examples.

* Take a new look at the concept of "value." Discuss (such as at a retreat) the possible relationship between economic value and personal values. Personal values beget motivation. Motivation begets an establishment of priorities. Priorities determine actions. Actions breed results, or consequences. In business, our personal values determine the relative priorities we assign to service and profit. And a proper balance between service and profit determines the economic success or failure of the business that we direct.[3]

* Take a fresh look at the issue of "confidentiality." When a major issue is trust, those who resist the notion of providing sufficient data to confirm dependable performance invite the suspicion that performance is indeed not dependable. Convert the organization's "confidentiality policy" to a "release of information policy" that can still include specified information that it is not necessary to release.

* "Us vs. them" bickering must stop. Whatever the acronym for, and contractual structure of, physician/hospital integration, such integration must occur. This must include persistent efforts to clarify the reasons that overzealous application of antitrust laws can defeat well-meaning efforts to provide affordable and dependable health care services to a community.[4]

* Adequately state the new "quality" paradigm. In the context of the health care debate, in which a primary issue is trust, "quality" means consistently dependable performance from the standpoint of patients and family members." Leave more erudite discussions and descriptions of the ephemeral, ethereal nature of "quality" to academic philosophers.

* The executive staff, physician leaders, and the governing body must consider the establishment of quality/performance initiatives as a senior leadership function, rather than as a task accomplished by middle management only to the extent necessary to satisfy requirements of the Joint Commission, state inspectors, and federal mandates.

* Focus on the patient-protective nature of "credentialing." Beginning in 1919,[5] the purpose of credentialing was to protect patients from undertrained, underqualified physicians. In the 1980s, credibility of physicians and hospitals was damaged by "economic contamination" of this patient-protective function. The public promise was still patient-protective activity to confirm each physician's qualifications and dependable performance. But the private reality was use of credentialing as a weapon in the economic wars between physicians and hospitals. The issue of "economic recredentialing" is causing reconsideration of the value of physician "reappointment." Periodic reappraisal of physician performance and updating qualifications is necessary. But it may not be any more necessary for the physician to reapply for staff appointment than it is for an employee undergoing annual reevaluation to reapply for his or her job.

* Lead a local effort to formalize reasonable practice guidelines, which all physicians use but which many are still afraid to formalize. Suggest a three-part medical executive/governing body policy stating that use of practice guidelines and critical pathways is encouraged, that practitioners may at any time depart from practice guidelines in the best interests of the patient, and that departures from practice guidelines are included in information evaluated as a part of quality/performance initiatives.

* Be public educators. Educate members of the public in groups and in individual encounters. In talking with the public, more support is gained by emphasizing people's needs than by whining about physicians' incomes.[6]

* In the political arena, encourage Congress and the White House to authorize state initiatives. The unique characteristics of your state may be better served by a health care plan developed closer to home.

* Cultivate and reward three different kinds of physician leaders:

* Physician leaders who are primarily practitioners, such as elected or appointed chairs of clinical departments in hospitals, multidisciplinary groups, or managed care plans.

* Physician executives.

* Informal, personal development leaders. These physicians may or may not hold positions of authority, but they are important leaders because they are respected by their peers, who look to them for guidance.

* Create an environment in which decisive action and problem-solving efforts are rewarded, as opposed to a fearful environment in which risks of decision making result in turning over important decisions to attorneys and consultants. Together (such as at a retreat), create and discuss the following four lists:

* Five reasons to call in a consultant.

* Five times when we don't need a consultant after all.

* Five reasons to ask an attorney for advice.

* Five times when we don't need an attorney after all.

* Help those drawing conclusions from data to understand some practical aspects of using data in the health care field. For example, one might compare the performance, in aggregate, of two hospitals using statistics such as valid postoperative rates and mortality rates. However, one cannot take the same approach to drawing conclusions about, and comparing, the performance of two physicians, because physician performance is not the only factor contributing to infection or death.

What are the chances of health care reform? Not good, if "health care reform" is a euphemism for political action focused only on creating an acceptable financing mechanism and other features of a desirable health care system. Excellent, if "health care reform" is taken to mean innovative provider efforts to re-form (fundamentally change) the existing health care scenario.

REFERENCES

[1.] Funk and Wagnall New Comprehensive International Dictionary of the English Language, Vol. 2. Newark, N.J.: Publishers International Press, 1982, p. 1274.

[2.] President Bill Clinton. Addressing a joint session of Congress, Sept. 22, 1993.

[3.] Thompson, R. Health Care Reform as Social Change. Tampa, Fla.: American College of Physician Executives, 1993, p. 73.

[4.] "Hospitals Close in on Final Merger Plan." St. Petersburg Times, June 17,1994, p. E1.

[5.] The Minimum Standard for Hospitals. Chicago, Ill.: American College of Surgeons, 1919.

[6.] "AMA to Doctor the Way It Figures Physician Incomes." St. Petersburg Times, June 17,1994, p. A1.

Richard E. Thompson, MD, is President of Thompson, Mohr, and Associates, a health care consulting firm in Dunedin, Fla. He is the author of Keys to Winning Physician Support (ACPE, 1991) The Medical Staff Leader's Practical Guide (Opus Communications, 1992), and Health Care Reform as Social Change (ACPE, 1993).