Why not shoot for what we really want, which is good health?
Daniel Patrick Moynihan once said: "If you've been in government a long time, as I have been, then the most exciting thing you encounter in government is competence. Why is this exciting? Because it's rare." When I read the quote, even today, I can hear the late New York senator’s voice booming, his last word full with extra punctuation.
Today I'm excited for the government. Health care reform should bring nutrition to a starving Indian health system. And, if the next test for health care reform is execution, then the government might be on the right course. President Obama used his authority to give Dr. Donald Berwick a recess appointment to head the Centers for Medicaid and Medicare Services.
This is a choice that exceeds Moynihan's rareness of competency. Berwick represents the ideal, the one person you think could help the government, the people and the medical profession come together and a coalesce around the idea of excellent health care.
Last December at the Institute for Healthcare Improvement conference, I watched hundreds of professionals cheer on Berwick as they would a rock star. This is a doctor who's willing to talk about what's really important to people. "Health care has no intrinsic value at all. None, Health does. Joy does. Peace does," he said in December. "The best hospital bed is empty. The best CT scan is the one we don't need. The best doctor's visit is the one we don't need."
Imagine that. Doctors we don't need.
That notion is far removed from the politics of health care reform. The debate in Washington is about the role of government or insurance. It's not about capturing bliss.
Our current system is not designed to empty hospital beds. Our reward system — dare I say, the very foundation of free enterprise — works best when hospital beds are full, CT scanners are humming, and doctor visits are available on demand. That's even true in government and the Indian Health Service; the appropriations process does not pay for those patients not requiring treatment. Yet that very idea, a paradox, is what could lower health care costs for all.
Berwick said it's our version of the Tragedy of the Commons. The 1968 article in Science by Garrett Hardin described a pasture open to all that works reasonably well until "a day of reckoning, that is, the day when the long-desired goal of social stability becomes a reality. At this point, the inherent logic of the commons remorselessly generates tragedy." The commons no longer works because each of us seeks the best deal for him or herself.
"Name any stakeholder — hospital, physician, nurse, insurer, pharmaceutical manufacturer, supplier, even patients’ group — every single one of them says, 'Oh, we need change! We need change!' But, when it comes to specifics, every single one of them demands to be kept whole or made better off," Berwick said. "So everybody draws on the Commons, the herds grow, and the Commons fails. If you don't increase your herd, you're a chump. And, who wants to be a chump?"
Let’s make being a chump a good thing. The fact is the spirit of cooperation is already driving down medical costs in places as diverse as Anchorage, with the Southcentral Foundation and Alaska Native Medical Center, and Cedar Rapids, Iowa. Indeed, the great thing about the Indian Health System is a head start in this regard. There is a long history of consultation — doctors and government officials working together with tribal leaders — for common solutions (and with little money). The Indian Health Service invented a prevention bundle — a series of tests — that look at many aspects of a patient's life that helps identity and then treat problems ranging from spousal abuse to depression.
"I challenge us to end the Tragedy of the Commons in health care. I challenge us to prove Garrett Hardin wrong," Berwick said. "It isn't easy. Positive collective action, even in small communities, and especially in health care, is fragile. It could all just fall apart. But, it can work. I know it can work because, sometimes, some places, it does work."
Forget health care reform. Let's shoot for what we really, really want. But if we seek bliss, that means we must get folks working together.
Material for this column was originally published in December and March.