Barriers To Change: The View From Berlin

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For the past two years, Health Affairs has published blog posts arising from the Center for Healthcare Management’s forums, held in Berlin. These events are unlike a typical conference — more conversation than presentation, and more participation by various actors in the health care sector than discussion of a single topic. An excellent summary of the entire event can be found here.

Why Is Change So Slow?

The same question bedeviled the attendees as challenges all who are interested in improvement in the health sector: If the distance between the value we obtain from our health care investment and what we receive for that investment is so apparent, why is the system so resistant to change?

In remarks at the forum, Sherry Glied, Dean of the NYU Wagner School of Public Service, suggested three barriers: focus, politics, and inertia. Her blog post presents some of her thoughts regarding focus. In essence, the concentration of high medical costs among a very small segment of the population makes risk avoidance a viable business model when compared to the difficult work of actually redesigning how health care is delivered so it is more efficient. While she acknowledges steps that have been taken to reduce the rewards for avoiding risk, she argues that additional steps are needed to help shift the focus.

Bearing Risk As A Motivation For Change

Bruce Fried had a more optimistic perspective on risk, arguing that the evolution of payment toward value-based methods, while very complex for health care organizations to handle, is the largest driver of change in the health care system today. Fried describes this view.

http://healthaffairs.org/blog/wp-content/uploads/Fried-edit.mp3

Frank Maddux discussed that very challenge for an organization transitioning from providing dialysis to caring for the entire person with kidney disease.

http://healthaffairs.org/blog/wp-content/uploads/Maddux-edit.mp3

Other participants in the forum examined the problem of lack of focus from a different perspective. Many attendees were from organizations that have made significant efforts to improve care, only to find that the business model doesn’t support the changes they have put into place. No matter how much policymakers and payers say they want the delivery system to focus on improvement, it’s hard to do so when their payment policies don’t align with their words.

The Role of Politics

Glied’s second point was about politics — a particularly interesting topic at a global forum where the political systems and imperatives were so variable among the attendees. Yet, the theme of politics as an impediment to change was always there. For example, Peter Homberg described how the regulatory regime in Germany causes delays in introduction of pharmaceuticals due to that country’s pricing policies.

http://healthaffairs.org/blog/wp-content/uploads/Homberg-edit.mp3

Liz Fowler noted that the move toward value may be global, but how value is defined varies substantially around the world.

http://healthaffairs.org/blog/wp-content/uploads/Fowler-edit.mp3

No matter the country, those who are delivering care have a stake in continuing to do things pretty much the same way. Whether it is through protecting existing payment streams or challenging regulations that implement a change, the health care sector seems able to use the political process to impede the pace of delivery system change.

The Problem of Inertia

And then there is inertia. From one perspective, inertia is simply the sum of a lack of focus and entrenched politics. In this view, inertia is the embodiment of resistance to change. But Martine Bellanger suggested another view of inertia: as the source of unhappiness in health care. Unhappiness by workers, trapped in organizations, burdened by rules and regulations, saps the energy needed to effect real change.

http://healthaffairs.org/blog/wp-content/uploads/Bellanger-edit.mp3

A Problem of Management?

If politicians say they want better value, payment policies are shifting toward value, and health professionals want to provide value, why are we moving so slowly? Perhaps because we rely so heavily on management as the mechanism for translating these incentives into action. Consider the growth of physicians and administrators in the US from 1970 to 2009, shown here.

Returning to Sherry Glied’s remarks and suggestions, it strikes the external spectator that the system might have created its own slack by subscribing to complex management approaches, refining and implementing incentives without much evidence of added patient value. As clinicians view themselves as subject to management controls, they lose their sense of purpose.

In the end, change occurs because motivated and creative people push themselves and their organizations to do something different from what is expected of them. Policies and politics lag change; they don’t lead it. The challenge for health care is to liberate and energize those with the vision and resources to make improvements and hope that their leadership will change the context for the rest of the system’s actors, who will follow, hopefully happily, as their view of what is possible is reshaped by the vision of the leaders.

It remains to be seen whether proper and purposeful management will be aligned with medical care of the 21st century. The system’s ability to exist and persist as it is seems to be the most powerful force opposing change.

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