Mirror, mirror on the wall: reflections from failure to establish a truly uniform national health care policy.

Health care is a profound issue requiring simultaneous attention to questions of ethics, economics, national values, and international influence. So, the latest failed attempt(1) to reform health care policy offers several profound lessons. Indeed, the "great health care reform debate" revealed no less than the true nature of our political system, the values of corporate America, the motivation and goals of individuals, the influence of aggressive reporting in the media, the economic worth of good health in terms of national productivity, and the price of living in a society in which money is the only motivation. The outcome is lack of trust in our most basic services and institutions.

Painful as these revelations may be, the perspective they provide can be the difference between success and failure of physician executives and their organizations in today's dynamic health care environment.

There are also some pervasive myths about America's health care system that need shattering. Consider the following:

The claim that "the U.S. has the best health

care system in the world" is an indeserved,

self-congratulatory falsehood.

The U.S. does have the best medical technology in the world, along with physicians and allied practitioners capable of using this technology to achieve miraculous treatment results. However, the system for providing either high-tech, intensive care or low-tech care (such as daily antihypertensive pills) is characterized by inconsistency. This inconsistency breeds both economic insecurity and a justifiable lack of confidence in clinical care. Unfortunately, the system is inconsistent on

One of the Clintons' many mistakes was putting the cart before the horse. Expanding entitlement to reduce the number of uninsured people should not have been the first step. The first step is fixing a system that is not consistently providing dependable and affordable medical care, even to the wealthy. By focusing first on expanding entitlement, the Clintons ensured opposition from the well-insured.

Oft-quoted statistics ($850 billion annually spent on health care, $160 billion spent on administrative costs, one out of six U.S. citizens under the age of 65 under-insured,(2) and 70 percent of U.S. citizens dissatisfied with some aspect of health care(3)) can be challenged, and do not reveal the true problem with the current health care system. The true problem is that the existing system is characterized by wasteful bureaucracy within medical centers and health care organizations, as well as in local, state, and federal government.

The bottom line is that "managed competition," profit-taking model of the 1980s warmed over, does not change a system that has so far been characterized by costly financial, legal, and political maneuvering rather than by genuine interest in providing dependable, affordable medical care.

The existing system is a patient-provider obstacle course that encourages profit-taking, while simultaneously ratcheting down revenues to providers and imposing high overhead costs and numerous hassles upon those seeking to satisfy inspectors and survey teams from regulatory agencies. It also creates inconsistent dependability from the viewpoint of patients, payers, and providers. Only those with little vision would defend this system as either the best in the world, or the best that political and industry leaders can design and successfully implement.

The biggest issue in the health care

debate is not really money; it is trust.

The expressed objection to the so-called "single-payer" model is distrust of a government infested by professional politicians pursuing their own interests. The expressed objection to the "managed competition" model is distrust of big business, including new health care conglomerates.

The so-called "private sector" is not trusted by the public because, in the 1980s, hospitals and doctors were encouraged by federal policy to emphasize profit-taking at a time when it was accepted business practice.

The 1980s American business ethic was dramatically expressed by J.R. Ewing in the last episode of the television series "Dallas." J.R., the wealthy, sleazy business tycoon was asked his secret to success. J.R. replied, "Secret? Heck, there's no secret. Once you give up integrity, everything else is a piece of cake."

Unfortunately, the public's lack of trust in the profit-taking health care model has been justifiable in some instances. Much was made of using market forces to contain costs by "changing provider incentives." But changed incentives to some providers mean less incentive to put the patient's interests first.

Here are some examples:

A memo from a cardiologist to his hospital's chief executive asked that chest pain patients being admitted by emergency physicians go immediately to the coronary care unit. Admission and treatment were being delayed until after a battery of routine diagnostic tests could be performed to maximize reimbursement under DRGs.

A vice president of marketing bragged, "Our ability to market ourselves now definitely outstrips our ability to deliver services." She won, I guess, the competition between marketing and operations (no pun intended).

After a talk on the legal dangers of overpromising in advertising, a board chair said to her CEO, "I told you we should have actually bought and installed the laser and trained somebody to use it before we ran the ad!"

The legal system now distrusts health care leaders. Once, doctors and hospitals were treated like national treasures and enjoyed special exemptions from antitrust laws. But that "learned professionals" special treatment has been lost, because "credentialing" in the profit-taking model is used to maximize revenue and profit, not to protect patients.

Meanwhile, mergers and acquisitions in the health care field are closely scrutinized by the Justice Department to be sure these transactions are for the public good, not just to take better advantage of the profit-taking system.

The health care business is no exception to the dramatic turnaround of the last few years, from a "money flow" business configuration that made the U.S. strong and individuals secure, to a "money drain" configuration that makes America weak and creates distrust.

The spectacle of professional politicians

of both parties using Washington

as a power base is not the people's

government envisioned by our forefathers.

As part of an effective strategy to recapture the White House in 1996, the 104th Congress will probably pass health care legislation, over President Clinton's veto if necessary. But the law will not reform the existing health care model. Rather, Congress will only tweak a profit-taking health care model. This model is characteristic of the 1990s interpretation of constitutional government, which is government of 15 percent of the people, by 15 percent of the people, and for 15 percent of the people.

This country's wise founding fathers could not foresee a government captured by professional politicians and special interests, so self-serving that all Congressional efforts are flawed for two major reasons:

Politicians are easily swayed.

Candidates now pay more attention to polls than to people. That's good strategy in the age of mass communication. But when a successful candidate becomes an officeholder, he or she is expected to act to solve problems in ways that may sometimes be unpopular, because the results of a good decision are not instantaneous.

Legislating efficiency isn't among

Congresses' considerations.

Once elected, professional politicians can't cut back on either government jobs or public services without jeopardizing their "political base." So, government just keeps getting bigger and bigger.

Those who suggest "reinventing

America" do not go far enough.

it may be time to reinvent Americans,

beginning with you and me.

At the heart of problems with health care, we find the fact that Americans, young and old, have forgotten the relationship between personal values" and economic value." Once again, we have met the enemy, and he is us.

Values beget motivation. Motivation begets an establishment of priorities. Priorities determine actions. Actions breed results, or consequences. This process in business executives determines success or failure of a country's businesses. And success or failure of businesses, large and small, act in sum total to create the state of a nation's economy. Thus, national economic security (or lack of it) is a result of individual values of the nation's leaders in business and government, and of the values and expectations of individuals who make up "the public."

When providing dependable goods and services is the object of business, the result is usually profit. When profit becomes the object of business, and the notion of fair trade is not a respected value, the result is usually disappointment. And for several years in the U.S., common business battlecries have been, "Who says life has to be fair?" and "How to get yours (and his and hers, too)."

To those who want to see private sector health care survive and thrive, reflections in the mirror of the great health care reform debate are disturbingly reminiscent of the old Chinese proverb, "If we do not change our direction, then we are very likely to end up exactly where we are headed."

References

[1.] Thompson, R. Flawed Federal Policies," Healthcare Reform as Social Change. Tampa, Fla.:American College of Physician Executives, 1993, pp. 53-4. [2.] lbid, pp. 5-6. [3.] Starr, P. The Logic of Healthcare Reform. Knoxville, Tenn.: Whittle Books, 1992. [4.] Van Doren, C. The Great Rehearsal: The Story of Making and Ratifying of the Constitution of the United States. New York, N.Y.: Penguin Books, 1976.