Among the many unexpected benefits of COVID19 is the opportunity to take a step back and reflect one’s life, career, and impact. Over the past two decades, I’ve had the privilege of trying to lead change in healthcare through several different lenses including academia, government, the pharmaceutical industry, the health insurance industry, and clinical medicine. While my work has spanned a number of sectors, the task has always been the same: to try to drive systemic improvement in healthcare delivery. The work has been hard and humbling, teaching me a set of unsettling lessons that I share in case they benefit others trying to make healthcare better:
1. Things are the way they are because someone wants them to be that way.
When I started out in healthcare, I always thought there was a degree of un-eveness in quality and cost in healthcare that was a function of information asymmetry. The explanatory model was painfully naive and arrogant: if only we could show people a better way to do things then they would. The natural implication is that we just needed to validate and spread the “right way” to do things and everything would get better for everyone. As I landed in the driver seat of trying to create change in organizations, I encountered resistance like I had never imagined. The resistance didn’t come from people who didn’t understand or didn’t have the capacity to understand. But instead it often came from people who didn’t want to understand. Their lack of curiosity about new ways to do things usually arose from inertia or, more often, an entrenched interest (financial or otherwise) in maintaining the status quo. Lots of good, obvious ideas in healthcare die because someone (usually a very powerful someone or someones) wants things to stay exactly the way they are.
2. It’s easier to write and talk about fixing things than it is to actually fix them.
Early in my career, I developed a habit—one that I persists with this post—of trying to solve problems by writing about them. This approach stems clearly from my early origins in academic medicine where the number of lines on your CV is often a measure of one’s merit. Writing (and talking) is such an important first step because it prompts the necessary exchange of ideas that enriches ones thinking about a problem. But early in my career, I convinced myself that writing about a problem was in fact doing something about it. My best papers would end with some great punchline like “policy-makers should” or “physician leaders should,” believing that an imaginary set of policy-makers and practitioners were waiting to read and react to what I had to say.
Then I began to work in policy and management and realized that many of my papers and ideas were painfully naive, oftentimes ignoring the complex implementation challenges that executing on most ideas involved. When he was at the Centers for Medicare and Medicaid Services (CMS), my colleague Rahul Rajkumar (now Chief Medical Officer of Blue Cross Blue Shield North Carolina) made a habit of contacting researchers who made bold recommendations in the pages of top journals and inviting them to work with him in the federal government to bring their ideas to life. As you might imagine, few took him up on his offer.
3. Engaging multiple perspectives doesn’t mean that all perspectives matter equally.
Healthcare is fundamentally a human endeavor affecting the lives of the people who use healthcare services and products. It is also how many people make their livings. It is also governed by policies and informed by perspectives on ethics. Many approach this complexity by saying that we have to balance clinical, business, policy, and ethical perspectives. Balance, however, is the wrong framework. In many situations, one perspective can (and necessarily must) dominate the other perspectives.
My experience has been that organizations can get flat-footed in key moments because they don’t engage the diversity of perspectives and get overly focused on a business or clinical or policy imperative. The best healthcare organizations and leaders recognize and engage these inherent tensions and lean firmly towards the imperative that fits the moment and situation, not split the proverbial baby.
4. Using your own experiences is often a poor way to design healthcare.
In so many boardrooms in America, decision-makers lead and make decisions by “putting themselves in the shoes of the customer” and directing a path. This might work in the footwear industry, but it is a mostly flawed approach in healthcare where most decision-makers (though a broad generalization) are far healthier than their most significant consumers. Everyone (because they are human) is a healthcare consumer. But the most frequent users of healthcare are sick, frail, vulnerable and have a different set of needs and requirements from healthcare than the leaders and executives who are in the drivers seat to shape the industry.
I have sat in so many rooms where leaders say things like “When I go to the doctor for my physical…” and proceed to make decisions and shape strategies and priorities based on their own experiences and needs. I’ve made this mistake many times myself. But many frequent users of healthcare face a serious, life-threatening illness or have multiple chronic diseases with complex social circumstances. While many in positions of influence may have had brushes with these situations—only a small fraction (fortunately for them) have actually lived them for prolonged periods. The art of designing around the consumer in healthcare is therefore very humbling—and usually an exercise in understanding others more than reflecting on ourselves.
5. Outsiders are worshiped in healthcare and kicked on their way out.
The healthcare industry has a long history of deifying individuals and companies that promise to bring fresh, outside of industry perspective to solve big problems. When I was in business school, one of the hottest companies recruiting on campus was Revolution Health, AOL Founder Steve Case’s $250m foray into healthcare. The pitch was compelling: we will bring industry outsiders to bring a fresh perpective to solve thorny problems that have been unsolved by the usual suspects. This is a seductive story that has been repeated several time since—notably Google’s first foray into healthcare and, most recently, Haven’s founding by JP Morgan, Amazon, and Berkshire Hathaway. The same can be said of individuals as they can be of companies. After a short bit of time, the bloom always seems to fall off the rose—and countless post-mortems are written.
Revolution never amounted to much and Google’s first entry into healthcare is a famed disaster. The story of Haven is still evolving. And countless non-industry executives have veered into healthcare with big plans to bring “fresh thinking” only to retreat in 18-24 months. I’m a firm believer that we do need fresh thinking, but we also need more patience as new entrants figure their way about the industry.
Measuring the success of Haven—or any other such effort or individual—over a 2-year time period is inadequate. Outsider organizations and leaders for their part might also do better to start on their journeys with more humility about the enormity of the task ahead. Healthcare is an atypically complex and networked industry, relying on a dizzying set of entrenched and interconnected relationships. While the need to disrupt incumbent ways of operating is undeniable, we often must rely on the incumbents to meet real patient needs in the present. It is indeed hard to both depend on incumbents today and be working to put them out of business tomorrow.
6. Your corner of the world isn’t the only one that matters. Patience pays.
Many who try to lead change in the healthcare industry find themselves disenchanted or disappointed when their single “great idea to change the world” is met with deaf ears by a potential partner. They take it as a sign that the potential partner ” just don’t get it” or that buyers of services don’t have the right orientation. My experience with healthcare startups that sell into industry is that the loneliness of that work sometimes breeds an innocent self-centeredness that ignores the fact that their customers have lots of priorities and opportunities for improvement—and limited bandwidth with which to execute on it. This can be tremendously frustrating for entrepreneurs, but it’s also reality. Slow and steady seems to win the race and those who stick with their message and remain undeterred by the ever-changing priorities always seem to find a way.
Early in my career, I worked with Lloyd Myers, CEO of CECity, who had the brilliant idea that continuing medical education should be linked to performance improvement. He started beating that drum in the early 2000s and stared at many blank faces as evangelized that message. He stuck with it, and when the healthcare industry adopted more real-time performance improvement through various certification programs, he was there to capitalize on it. Myers later sold CECity to Premier, Inc to enable its foray into the growing space.
7. Shared savings isn’t always the answer. Not everyone wants to share.
For the past two decades, there has been a consistent push around shared-savings or gainsharing as a model for commercializing solutions to improve care and reduce costs. A vendor will offer to deploy a solution for free or a discount in exchange for some portion of the savings that they create. Sounds like a good deal, right? It’s a pitch I’ve heard (and made) on countless occasions and certainly lowers the barrier to making a complex sale.
But it’s not the slam-dunk many have come to think it is for a simple reason. What I’m working with two different organizations on two different interventions on a shared-savings framework? What do I do then? How do I decide who was responsible for creating the savings? In most cases, organizations are doing a lot of different things to improve their results. Shared savings makes sense when there is a single intervention being deployed to improve care, but can be a challenging business model when organizations have multiple efforts underway to drive results.
Measurement and adjudication of value-creation is often more challenging than anyone acknowledges upfront and many vendors use “sleights of hand” to claim value creation rather than using true rigorous methodologies. The challenge of teasing out correlation from causation is much harder than it sounds.
8. There are very few new ideas, just people who haven’t seen them before.
In an industry that touts “innovation” as much as it does, I’m blown away by how little real innovation there is—that is, if you are aware of the history. So many ideas that are sold as “new,” “innovative,” or “different” have been executed upon in the past, but somehow failed to scale or make it into the history books, enabling someone new to sell old as new. Earlier in my career, I might tell one of my mentors about something new that I was excited about—and they would recount a story about how they (or someone they knew) tried something similar in a prior decade.
Perhaps most remarkable is the push toward using artificial intelligence to make diagnoses. Pretty new and innovative, right? That’s what I thought until I was introduced to the work of the legendary physician Lawrence Weed. Weed founded a company in 1982 (!) to build computer-based algorithms to improve the quality of diagnosis of conditions in the emergency room. Methodologies may change, but many of our best ideas to improve care have actually been around for a long time.
9. When human life and business collides, the rules should be different, but they aren’t always.
Many of us expect that when human life and business collide, organizations apply operating frameworks that are different from non-healthcare businesses. A dangerous thing has happened in American healthcare enterprise, however, which is that many organizations have deified high-level business principles—not patient patient—as their de facto “true north.” Many organizations will reflectively recite “no mission, no margin” to justify decisions and center their profit motive. While this orientation certainly has its place, it does not have its place in all situations involving human life, patient care, and meeting human need. Sometimes, the human imperative overrides the business imperative.
Unfortunately, many healthcare organizations suffer from goal mesmerization, a concept that business ethicists use to describe when an organization adopts a singular goal that crowds out all competing priorities. Meeting a quarterly target or organizational goal can momentarily become more important than it should be, forcing individuals to make unsavory tradeoffs that they may later regret.
10. Everything takes longer than it should.
Changing healthcare can be excruciatingly slow. Most healthcare organizations have a complex organizational structure that leads to a highly-matrixed, consensus-based decision-making process that make even the easiest decisions feel like they are acts of Congress. Committees will review ideas and send them back for more review and then send them back for more analysis and then send them back for more review. Many gray hairs have been turned gray waiting for straightforward ideas to gain approval and acceptance.
The primary job of leaders in healthcare organizations is to make things go faster and create the kind of urgency and momentum to lead to real meaningful change and improvement. This directive doesn’t mean leaders need to sacrifice the quality of decisions or rush. It simply means that simple decisions should be made simply—and complex decisions should be engaged as such. Too many organizations treat all decisions equally, not adjusting process for the associated complexity.
With lives at stake, some argue that decisions should not be made with haste—that the slow pace of change is deliberate and necessary given the stakes. I frequently argue the opposite: with lives at stake, we shouldn’t drag our feet on decisions that we know make a clear difference to patients.
11. The most important asset in most organizations isn’t “intellectual property.” It’s the people.
Healthcare organizations get very fond of their intellectual property. For clinical organizations, it can be their clinical or business models. For pharmaceutical organizations, it can be the chemical structures of their molecules. When I take a close look at what actually creates value in most organizations—the single fundamental driver of performance—the answer is usually a person or set of people, not the so-called intellectual property. The best organizations in healthcare value their people over just about everything else and have thoughtful strategies around people development and retention. The worst ones treat them like commodities to be traded and swapped in and out.
12. As in life, who you know maybe just as important as what you know.
Another reality for those trying to change healthcare is that healthcare is a relationship industry, and often times the relationship matters more to getting something done than the quality of the product or service. Conversation over beer and steak dinners (I write this as a vegetarian who doesn’t drink very much) often have more to do with whether something happens than whether you are delivering a superior product. This was very unsettling to me early on in my career, but I balanced my perspective as I’ve become aware of how significant trust is in business relationships where human lives are stake. Relationships do matter and and are one way to mitigate risk—but must be approached cautiously, as too often the relationship supercedes a careful and critical analysis of an organization’s true capabilities and needs.
This list of lessons is by no means comprehensive or exhaustive—and is certain to grow longer over time. One thing I’ve learned for certain is that the work of changing healthcare is harder than it looks, but nonetheless worthy of our very best efforts. With greater awareness of some of the challenges inherent in the task, my hope is that our collective odds of success will be fractionally better. Godspeed.