Today’s Washington Post has an article by Minnesota senator Tim Pawlenty on the effective design of national health care reform, entitled “To Fix Health Care, Follow the States”. He argues that the federal government should model its initiatives after successful state-based systems that link outcomes to value:
In Minnesota, our state employee health-care plan has demonstrated incredible results by linking outcomes to value. State employees in Minnesota can choose any clinic available to them in the health-care network they’ve selected. However, individuals who use more costly and less-efficient clinics are required to pay more out-of-pocket.
Not surprisingly, informed health-care consumers vote wisely with their feet and their wallets. Employees overwhelmingly selected providers who deliver higher quality and lower costs as a result of getting things right the first time. The payoff is straightforward: For two of the past five years, we’ve had zero percent premium increases in the state employee insurance plan.
Minnesota has also implemented an innovative program called QCARE, for Quality Care and Rewarding Excellence. QCARE identifies quality measures, sets aggressive outcome targets for providers, makes comparable measures transparent to the public and changes the payment system to reward quality rather than quantity. We must stop paying based on the number of procedures and start paying based on results.
Pawlenty also notes that healthcare reform should not focus solely on access to health care, but also the cost and quality of the service – that is, the value that is delivered. The Malcolm Baldrige National Quality Award (MBNQA) Criteria for Performance Excellence provides a framework that has been tailored over 20 years by a huge collaboration of experts to help business, industry and the government better solve this kind of “wicked problem”. The Minnesota solution sounds like it has applied concepts very similar – if not identical – to those presented by the Baldrige Criteria.
When will the government employ the successful problem-solving frameworks it has developed itself (e.g. MBNQA) to solve its most pressing problems?
Health-care reform is bogged down because none of the bills before Congress deals with the staggering waste of the current system, estimated to be $700 billion to $1 trillion annually. The waste flows from a culture of health care in which every incentive is to do more — that’s how doctors make money and that’s how they protect themselves from lawsuits.
The article goes on to talk about “defensive medicine,” the practice of ordering tons of diagnostic tests to refine a diagnosis or a treatment plan for the purpose of avoiding malpractice suits. Howard suggests that physicians are cultured into this way of doing business as a defense against potential risks and potential malpractice cases – he even mentions one case where a doctor reacted to a lawsuit by changing his behavior in favor of defensive medicine. A solution, however, is possible:
Containing costs, as Rep. Jim Cooper (D-Tenn.) noted on “Face the Nation” recently, requires overhauling the culture of health-care delivery. Incentives need to be realigned. That requires a legal framework that, instead of encouraging waste, encourages doctors to focus on what’s really needed. One pillar in a new legal framework is a system of justice that is trusted to reliably distinguish between good care and bad care. Reliable justice would protect doctors against unreasonable claims and would expeditiously compensate injured patients. The key is reliability.
The culture of a system – in this case the U.S. health care system – influences the behavior of individuals within the system. This behavior can be waste-producing. When it is, we need to look towards the cultural influences or the structure of the incentives that drive that behavior, and examine ways to address the root cause(s).
It reminds me of the requirements gathering phase of a software development project. Stakeholders spend hours trying to hash out what functions and behavior they expect from their software, and how reliable they want it to be. It is always a challenge to avoid designing the system (that is, how it will look or act) when the essence of what you need to know is what the system needs to do.
I see evidence in the growing national healthcare debate that many people have opinions on the design of the system (e.g. who gets coverage, how pre-existing conditions are handled, how much it costs, who pays), whereas most citizens and Congressmen aren’t even touching the requirements for a successful system (e.g. what scenarios it should support, what behaviors it should provide incentives for, or its reliability/requirements for how much waste the system can and should generate).
In my opinion, one requirement for a successful health care system is that it provides incentives for you to remain healthy and stay out of doctors’ offices and hospitals. A tax credit for a health Body Mass Index (BMI), or maybe lower interest rates? I’d go for that… it would even stimulate me to boost the economy a little more by buying rollerblades or something.
Today is Monday, November 3rd. Election Day, when the U.S. picks its 44th President, is less than 24 hours away. And as of Saturday night, just 72 hours before the polls close, 27 MILLION early votes and absentee ballots had already been placed. This represents almost 13% of the total population that’s eligible to vote this year, and 22% of all the people who voted in 2004. (The numbers are from Michael McDonald’s dataset; he is an associate professor specializing in voting behaviors. The VEP column in his table represents the total number of eligible voters over 18 and not in prison, on probation or on parole. )
Remember, long ago (or maybe more recently) in statistics class, when you learned that you could learn a lot about the properties of a population by taking a random sample? Having approximately 20% of the vote already in from a sample expected to be between 120 and 150 million is extremely significant – remember, these are actual votes, and not someone’s report of what they may or may not vote “for real”. Assuming that systematic errors have not played a large part in early voting behavior, the winner is already determined, and we just don’t know it yet.
“We go around in a circle and suppose, but the answer lies in the middle and knows.” –Robert Frost
However, ignoring systematics is indeed a significant assumption, one that’s discussed by Peter Norvig, Director of Research at Google, in his excellent explanation of the accuracy of polls. Which is why the campaigns are rightly pushing EVERYONE to get out there and vote – to mitigate the impact of systematic errors. (After all, you don’t want to stop voting if the other side keeps voting.) So if you are reading this and you haven’t voted yet, DO IT! Go vote!
I see three potential scenarios:
Breakthrough: the decision has already been made, is accurately reflected in the actual sample of early votes, and the votes placed on Tuesday won’t change the pattern at all. The additional votes amount to nothing (other than beating down or insuring against systematic error).
Breakdown: a flood of voters overwhelm the capacity of the voting stations, the voting machines just can’t handle it, and the polls close before everyone can get through the door and get an error-free ballot submitted. I think there might be social unrest if this is the case.
Breakout: a single demographic (or two) comes out in droves to vote on Tuesday, breaking out of wherever they’ve been hiding, and shifting the balance of the race in a huge upset. Certainly a possibility.
Whatever happens, the 2008 Election reflects a mythical struggle between structure, order, hierarchy, stability, and tradition on one side; revolution, dynamism, community, collaboration, and exploration on the other. One potential leader clearly has more experience on one side of the coin, and the other potential leader is stronger in the opposite area. Each candidate has plenty of experience on the side of the coin he’s promoting. The difference will be how the voter determines which standard the candidate’s experience should be measured against!
Why am I interested in all this? First, because polling is measurement, and quality assurance requires effective measurement. But more importantly, because the themes of this election parallel the struggle that many organizations face with quality and innovation – getting the job done reliably is paramount, and experience is important, but we cannot lose sight of the way we need to reinvent ourselves and our companies to continue being competitive. Accepting the wilder side, where structures are not sacrosanct and community is more productive than hierarchy, is hard to swallow.