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Feb 25 2010

My Reactions to Health Summit at the White House

I watched an hour or two of the Health Care Reform Summit at the White House today.   My overwhelming reaction to it was how much effort was being expended on just a tiny part of the whole equation.  First of all, it should be called Health Insurance Reform, for it has little to do with the health process at all.  Second, it treats health care as an industry, as if it were a factory taking in sick people and producing well people.  All that we need to do is figure out faster/better/cheaper ways to run the assembly line, and make room for more people to get on it.  It is firmly locked in to the notion that health care is something the system does to the person, patients are “consumers” and doctors are “providers.”  We have transactionalized health care – defining disease/billing codes that shape doctor behavior.  If someone cures their depression by taking up running on the beach, they generate no transactions, incur no medical costs, and improve their health in many other ways.  If they get an antidepressant and go back to sit on a couch to wait for their depression to clear, this generates many transactions, incurs potential side effects, and may diminish their health in other ways.  Unfortunately, our health care system only recognizes the latter… things that don’t get transactions don’t get recognized.  Things that cause health transformations (such as running on the beach) are lost below the radar of the disease industrial complex.

Addiction is one of the great health problems of our time, and Alcoholics Anonymous is the premier organization for treating it.  I recently had dinner with a man celebrating his first year of sobriety, and he was glowing about AA, and has turned his life around.  He is an enthusiastic mentor for 5 others.  AA generates no medical records, no master patient index, and incurs no costs.  The more members it gathers, the more members it can support – members help themselves stay sober by helping others stay sober.  AA in San Francisco has over 700 active groups meeting weekly, yet is has only a tiny staff of 10 to organize it.

So, here is one of our most pernicious health care problems that is being solved virtually cost-free in a self-organizing, self-propagating manner.  It is a transformational approach to health – utterly outside of the transactional provider/consumer model that dominates all health care reform discussion.

The 600 pound gorilla in our health care system is ourselves.  Obesity, smoking, drugs, alcohol, and sedentary lifestyle drive a huge portion of our health care costs… and these are personal life-style issues, not things that “providers” do to “consumers.”

People don’t necessarily “consume” health care when they get healthier.  AA members help others when they become sober – its “baked in” to their 12 step process.  People can get healthier, and in so doing, make other people become healthier.  The fact that your immune system fought off TB today makes everyone else around you a little healthier.

AA attributes their success in part to the fact that that they were underfunded when they got started:

Mr. Rockefeller decided to turn down the request for the money requested by Frank Amos. He reiterated, “I am afraid that money will spoil this thing”… Both Bill and Dr. Bob could access this account and funds could be withdrawn as needed. Rockefeller warned them that despite his help, the movement must become “self-supporting” in order to eventually become a success.

Jonas Salk (in Anatomy of Reality, Columbia University Press, NY, 1983, p. 122) spoke of the need for health care reform to be framed as “Creating an Epidemic of Health.  Only a few are needed to visualize and to initiate a process that would become self-organizing, self-propelling, and self-propagating, as is characteristic of evolutionary processes.”  AA could be viewed as an example of the kind of transformational, “viral” models of health that Salk was talking about.

Are there other self-organizing, self-propelling, and self-propagating models of health out there?  I don’t know.  But I do know that the transaction health industry would not be the place to look for them.  Pharmas are not going to fund products that decrease their dependency on them.  Nephrologists who are sitting on dialysis “gold mines,” despite stated good intentions, would worry about the financial ramifications of a treatment that diminished the need for dialysis.  A approach based exclusively on the notion of health as something the system does to the consumer would not see much virtue in their “consumers” running off and doing things independently of them.

This dependency relationship is exactly what Rockefeller saw when he refused to fund the local chapters of AA… and yet it is the glue that our system is based on.

Vvaleo group at Airlie Conference Center 1999I participated in a health care reform effort called Valeo about 10 years ago.  It was an effort to apply Dee Hock’s theory of “Chaordic” organization to health care reform, coupled with David Cooperrider’s “Appreciative Inquiry”   We ended up in a summit meeting of about 180 stakeholders from the entire health care field.  My Duh! moment from this event was that gathering all the stakeholders in a perversely incentivized system and asking them to self-organize into a more efficient system is not a recipe for success.  Asking some to jump off the gravy train so that others can ride more comfortably is not going to attract many volunteers.

I don’t recall any political stakeholders in the group – certainly nothing like I saw today at the White House.

Health insurance reform is but the tip of a very large iceberg of reform.  Given the enduring complexity of the problem, I have to wonder whether its humanly possible to come up with an effective solution.  Perhaps we need to declare a “complexity crisis” and rethink ways of minimizing complexity, rather than fixing problems.  Maybe adding 2700 pages of legislation to 125,000 pages is not going to create a workable system.  If so, how much is too much?  If we got to 1 million pages of legislation, would we have solved the crisis?  Or would it be an indicator of intractable complexity?

Here are some thoughts towards simplifying health care:

1.  Decouple the employer relationship from the health care system.  Employers don’t buy our car insurance, why should they buy our health insurance?  This would remove a huge load of issues relating to insurance portability, privacy, unemployment, big- vs small business, and taxes.

2.  Give up on the notion that we have a “system.”  It is just too big and too diverse to think of it in the factory model – that there is One Correct Way to push things down the assembly line.  Rather, we should frame things as a Health “Space” – much in the way that the web was designed as a “space for information to exist” rather than a “system for retrieving information.”

3.  Start with a communications-oriented approach rather than a records-oriented approach.  The problem is that we have a failure to communicate, not that we haven’t standardized, organized, and shared our file cabinets in the proper way.  One form of communication is the medical record,  but not the only one.

4.  Start with the transformational notion of health.  Health is something we all do, and are primarily responsible for it ourselves.  Providers are the edge, people are the center.  Let’s discover all kinds of new approaches to this, to communities of health, to buddy-systems, and the like.  Patients Like Me is a great example of this kind of thinking.

5.  Free up telemedicine.  While its nice to have the super hi res, high bandwidth hi-tech telemedicine systems I’ve seen pitched for decades now, the fact is that a lot of good can come from a simple cell phone photo or video.  There are lots of legal (and some would say ethical) issues to be dealt with, but I think that this should be a basic notion for any future system of health.  We need to design from a state of connectivity.

So, my advice to President Obama: make whatever simple changes that can be agreed upon today, but declare a complexity crisis and move to a new model specifically designed to be a simpler, more adaptive, and more resilient health care system focusing on the transformational rather than the transactional nature of health.

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Feb 27 2009

Some background on the Valeo Initiative (Vvaleo)

In the late 1990’s I was involved with a group called Vvaleo formed by Dee Hock (founder of Visa International and proponent of “Chaordic” organizations) Rob Kolodner (then of the VA), David Cooperrider (CASE, founder of Appreciative Inquiry), Tom Garthwaite (head of VA health care), Heather Wood Ion (then CEO of Visiting Nurses Association of Orange County), Don Lindberg (National Library of Medicine) and others.

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Heather Wood Ion and I were seeking to apply Jonas Salk’s ideas about creating an Epidemic of Health (this was the last paper he edited before he died.)  Reframing health care to the positive – creating a viral expansion of positive, health-inducing and supporting ideas, activities, technologies, and support structures is a fundamentally different framework than seeking out what’s wrong and how to fix it.  This was my first exposure to David Cooperrider’s notion of Appreciative Inquiry (Thanks David), and it really rang trRob Kolodner at initial Vvaleo meetingue to my thinking about what I called “benegnosis” (a way of understanding by what is positive) in contrast to “malgnosis” (a way of understanding by what is failing). The Vvaleo group had a few interesting meetings and support from the VA as well as the Fetzer Institute.  David also invited me to the Images and Voices of Hope meeting at Peace Village in Haines Falls, NY.

We developed an Appreciative Inquiry Living Dialog to Support Health Care to support the ideas.  The idea petered out in time (a story in itself – coming soon).  But I think it is a good framework upon which to rethink health care reform ideas, and to lift our thinking above the “disease industrial complex” which is so prevalent in today’s climate.  I think that this also has a lot of relationship to the National Health Information Network, an effort now headed by Valeo founder Rob Kolodner.  After 30 years of tilting windmills with Rob in the VA VistA (then DHCP), then Vvaleo, and now the National Health Information Network, I think he is in a unique position to understand the role of Information technology and how it can lead, rather than follow, organizational reform.

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