Thursday, April 23, 2015

The Success Dilemma In Healthcare (Part 1)

There has been a LOT of clamoring in social media about licensed healthcare providers and their licensed and/or unlicensed care extenders; believe you me, it's not just the physical therapy world that has been talking about this. Care extension has been at the center of a rather heated, uncomfortable, and disuniting talk for MANY healthcare circles including that of physicians, PAs, NPs, RNs, LVNs, CNAs, rad techs, diet techs, nutritionists..... need I go on?

So, after reviewing the true spirit of the discussions, debates, yellings, and social media japs as of late, I've come across this post (which has been in sitting in my blog queue for some time) and realized.... THIS is the center of our problem.

PS. Yeah... this may be a tiny bit of a rant; but I do offer real solutions with plenty of background.

PPS. I've split this post up into Parts 1 & 2. Part 1 as the situation analysis & Part 2 as the solution. Enjoy!

The Success Dilemma In Healthcare

In once sentence, here is our problem: "We're still trying to make a better horse and buggy when we should actually be working on a horseless carriage."

A reference to the oft quoted to Henry Ford, though perhaps not so accurately attributed in this case.

I feel as an industry, and certainly an economic construct, healthcare as we know it has topped out. It has been spinning its wheels in its own Success Dilemma; the vicious repetition of what worked in the past in hopes it continues to work for the future. This particular dilemma is not unique to any one industry. It happened to the horse and buggy when replaced with the horseless carriage. It happened to radios when they went from tube to transistors. It happened to Blockbuster when it got paved over by digital streaming, NetFlix, and the like. It happened and will continue to happen when sticking to whatever once made success, ultimately creates the rigidity that causes its failure.

As for healthcare, let's all be honest for just one moment.

Just even for a moment...

EVERYONE is talking about care extenders. And, why? It isn't for the greater good. It isn't for better efficiency or even the brainstorming of "innovative" care models.

Because, again, we're being honest right now, right? This talk has been around since commerce has been around: "If someone can do something for cheaper..."

I'll come right out & say it even if no one else will: IT'S ABOUT THE MONEY!

Extenders are cheaper by the hour than for whomever's care they extend; therefore, by being less costly upon a business based on human labor and time, it makes the margins better to substitute as such. Yet, We've TRIED this already. What has happened? Healthcare is STILL way too expensive and beyond sustainable for any local, regional, or national economy. And, it is unsustainable for all areas of practice.

The problem is SYSTEMIC. And guess what? Our consumers are absolutely sick (ha ha) of our internal bickerings -- they want applicable solutions TO THEM, not you clinic, business, firm, or organization.

Yet still, what have we all been yammering about? Finding new ways, crafting new laws, enabling new policies, and trying to sway professional opinions amongst our colleagues in such a way that doing things "differently" in the name of cost savings or what have you is then a good thing. Now, there are times when it is certainly necessary. When the automatic blood pressure cuff came out, did you really need a physician or nurse to do duplicate this manually as a health screening? NO! This  and many more types of care elements in this vein exists throughout the continuum of healthcare.

However, this isn't where our problem is. This, again, is a Success Dilemma. We're trying to do the same thing over and over again (definition of insanity); because it has once worked, it has been working, and we can only expect it to work again.

The problem is, everyone is doing it. Everywhere, in health systems, healthcare companies, private practice, for profit multi-center firms... everyone is focusing on better margins. As margins have been falling with lower earnings (due to various factors, including declining reimbursement rates), dismal growth is being reported; that's a bad thing when considering the shareholders. Since firms don't want investors to start dumping their shares, the knee jerk reaction for any company when costs are squashing margins comes to play. Reimbursements went down, so what did we do?

We billed more and paid our people less. When that didn't work, we downsized. When that didn't work, we started using cheaper labor that could hopefully substitute for quantity and quality. We hoped all of our management decision wouldn't affect quality, or, that no one would notice. We hoped that as our little management tricks served to inflate our earnings, improve margins, and hopefully restore growth, that quality care would not suffer. But, it didn't work and it doesn't work. Quality ALWAYS suffers.

And, this is where we fail... this is where the Success Dilemma destroys us. So, what's the answer? Well, it's nothing organic nor is it new. Nope. It's absolutely intentional. When success fails, disruption occurs.

Industry disruptions have historically happened when characteristics of products (or services) offer inherently novel combinations of traits which allow people to go about their day in a way never done before. I need to stress here that it isn't about performance features; making something fast faster isn't disruptive per se -- this just makes all the other competitor shift their understanding of the status quo (ie. "Henry Ford's" faster horse + faster buggy vs. horseless carriage).

Disruptive innovation creates entirely new markets because of the RESULTS of their products; entirely new ways of thinking; entirely new lifestyles; and entirely new sets of human behaviors.

If what you're trying to do is same thing but faster and/or more efficiently, it isn't anything innovative at all. It certainly isn't "different." If you go down this road long enough, you'll find the same "solution" humanity has always found when things can't go any faster.... you take SHORTCUTS.

So, what's my recommendation, you ask?

1. First, I suggest we take a look at what healthcare was and has become. During its inception, healthcare was really the practice of healing arts when it came to the human experience. Be it physician or surgeon (yes, they were considered different in a time before), sage, shaman, healer, priest, witch, whatever... the human experience looked to experts for their knowledge as well as their information and understanding of the human body. As science began to take hold for the human experience, societies started to notice certain reliabilities and consistencies and gravitated to what was termed as the practice of "medicine."

Nevertheless, the skill sets involved all circulated around one thing: Information. As various perspectives on the human experience and health evolved, healthcare eventually became a business model with many disciplines to create a care team, typically headed up by a chief physician and governed by an administrator.

As costs started to present themselves insurmountable, we tried different things. A gatekeeper model, a maintenance model, preferred provider, wellness... you name it. The problem is, the whole time we were still rationing and distributing knowledge in the form of access to care, prescription of pharmaceuticals, and scheduling of procedures. We failed addressed the one thing that could help us.


Since information is practically free now, it is no longer valuable as it stands alone. And, while certainly, the information isn't always accurate as framed on any given website due to generalization or what not, consumers don't care. They already have their information, what they are now seeking is value. As such, my first recommendation is that we get honest with ourselves, our consumers, and all of our stakeholders.

Healthcare has spun out of control in so far that it is no longer a viable business model in and of itself. And trust me, that is HARD for me to say. I spent a lot of time, blood, sweat, tears, and money getting my degrees and training to be licensed to do what I do. I pay good money to maintain my license to have the privilege to provide care for others.

Still, it isn't enough. Honesty declares that the monster we've helped create by ALL the current practices we have participated in... has failed.

We, have failed.

2. Arriving here, my second recommendation becomes a little more obvious. Healthcare is a social burden. As such, solutions must be forged together. All this talk about extenders, cost savings, and blah blah blah... it only divides us. It never unites us.

Unity is what we need. Unity within the professions; unity amongst the professions.

This is part of the big picture I've been talking about.

The solution I recommend has to do with social responsibility as form of economic sustainability and competitive strategy. I base this off of what I'm observing in the grumblings, debates, and opinions in the healthcare marketplace at large. I also base this on the many business studies that have proven a properly leveraged corporate social responsibility (CSR) as that which adds significant value, and sustainable value at that, for consumers. As such, I think it is fair to say: Healthcare is facing a crisis in social responsibility.

The IRON LAW of Social Responsibility:
The iron law of responsibility says that in the long run, those who do not use power in ways that society considers responsible will tend to lose it.

So I ask you, are our healthcare systems using its power responsibly? I would offer the answer is "No." If we were, we wouldn't be in this pickle. We wouldn't be arguing amongst ourselves while all of our consumers, shareholders, and stakeholders are at our throats in one form or another.

So again, my second recommendation is UNITY. We can't do this if we're divided. We can't solve this if we're bickering over the most minute of things which do NOT cause to help the big picture. This means that each profession needs to humble themselves and stop thinking about their supply side perspectives. Sure, physicians do more than prescribe. Sure, pharmacists do more than dispense. Sure, nurses do more than attend. Sure, rehab therapists do more than massage or exercise. Sure, technicians of all sorts do more than press buttons, wave wands, or take blood. Yes. Yes. Sure. Sure. All of it is correct.

But, the fact of the matter is this, all this bickering is going to take the power away from both provider and consumer... and place it completely into a third arbitrary party. At that point, no one gets a say. Don't think so? Just ask those struggling with new contracts; it is so. And, it is terrifying.

3(a). As such, this is my third recommendation: pursue Value Based Healthcare. What?! This isn't anything new, you say? Well... it isn't. People have talked about it. But, people have never AGREED on it. There are 101 definitions to what value based healthcare is and should look like.

This is what I'd like to suggest: Let's examine value from the perspective of the healthcare consumer.

A quote (likely a paraphrase) from one of my business professors goes something like this: "What companies need to do is to develop products by understanding circumstances in which they are used by customers... " It is here that I believe value can be found for how we can provide healthcare.

We, all of us, as internal stakeholders and a community of healthcare professionals need to look at our consumers and external stakeholders and ask ourselves what their circumstances are to which the need arises that they demand (want/need) healthcare services. For it is in those circumstances we find the first seeds of value.

Therefore, I will share again my taken formula for value in healthcare:

As such, let's work from the bottom up. Healthcare consumers want two things: (1) to stay as healthy as possible for as long as possible, and, (2) when health concerns inevitably arise, to have immediate access to expertise and care.

With this in mind, I ask the rhetorical: Is a 4 minute office visit by a physician educating you that you have a flu and don't need antibiotics valuable to its cost? Or, is it better that a message be sent by a patient, screened by a provider, and response given through a digital patient portal?

Is making that same 4 minute office visit to discuss your back pain really all that valuable? Especially when the result is "do these nonspecific print out stretches," take "these pills," and "come see me in 4-6 weeks if you don't feel better" truly valuable?

Even worse, when after those 6 weeks, you get referred to a physical therapist only to wait for another week or two to get scheduled? Or, would it have been better to register a digital health concern of a musculoskeletal nature and get immediately referred to your physical therapist?

The way things have always been is not driving a Value Based Healthcare System. It is neither good business, nor is it socially responsible. So I continue this vein to ask you the following:

How it is even remotely socially responsible that I regularly hear customers complain...
  • a doctor's visit wasn't worth a copay or time
  • that a PTA did more than the PT ever did
  • when an aide provided ultrasound (and it was billed for)
  • that the CNA is the "real" nurse
  • when the OT seemed to just be following what the PT was saying
  • any ungodly wait time for healthcare services
  • that an MRI was used to both fear monger and justify medical necessity for a surgery (and PT was never consulted)
  • a PT "walks a patient" (noncardiac) for 1000ft and doesn't d/c services in a hospital
  • patients get the imaging run around until they receive a referral to a physical therapist months later
  • prescription drugs are ordered brand name and not generic when possible
  • I mean... the list goes ON!.... FOREVER
The answer is obvious: It isn't. It isn't responsible. It isn't ethical. It isn't right.

The situation is clearing wrong. It is no where near functional, efficient, good for providers, good for consumers, nor right for society. Value Based Healthcare sounds like a great idea; but, does it have any backing? Does the framework even have theoretical grounds for building? What about the "evidence?"

Please continue reading and find my solution for breaking out of the Success Dilemma in Healthcare... AND, an entirely new paradigm of healthcare here at:

The Success Dilemma In Healthcare (Part 2)

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