I often wonder where the fight is more contentious: the one raging inside, or the one outside the healthcare system?
The way that we talk about healthcare almost everywhere is remarkably zero-sum; it seems none of the stakeholders can conceive of the future of the system in a way that serves everyone’s interest. Instead, change, progress, and priorities all are framed in terms of who benefits, and who is compromised.
Outside of healthcare, the big line in the sand is political affiliation; inside the system, it is a web of payments, perspectives, and professional roles. Even defining problems, much less conceiving of solutions, is inhibited by silos and silo mentalities.
The politics of access
The newsmakers in Washington are preoccupied not even with the care side of health, but with insurance. The ACA was a massive tome in part because on top of all the financial rule making it did, the law found time to focus on actual access beyond insurance coverage. That is, “access” understood as literally, physically encountering medical professionals, not “access” in terms of getting an insurance plan of varying quality or cost.
This was achieved by putting more legal (and yes, financial) support behind nurse practitioners and other non-physician caregivers taking on primary caregiving roles, and by calling attention to critical-access hospitals and the plight of America’s rural and remote communities. Arguably, the ACA also incentivized clinics and systems to leverage telemedicine technologies to expand access to patients — in order to reduce readmissions and deliver care and attention, if not physically, at least directly to the patients seeking it.
But this definition of access is not the one most commonly used in policy debates and townhalls. The better recognized legacy of the ACA is not how it expanded access, but how it expanded coverage. Naturally, it follows that the most vociferous critics and opponents of the ACA (or at least, of its nominal authors) are mostly concerned with changing the rules on insurance coverage.
That’s the argument occurring outside of the care system. Inside, a whole other war is being waged.
Siloed problems, siloed solutions
By comparison, politics looks almost simple: with battle lines drawn along a polar spectrum, people are mostly satisfied aligning themselves with one side or the other.
Healthcare is a mangled network of silos, each with its own interests and challenges. Is ICD-10 a function of diagnostic reporting or billing? Is interoperability lagging because of developers, providers, or regulators? Is EHR functionality limited more by the user interface, or the users themselves? Should leadership positions be staffed by business experts or clinical professionals?
The 2016 election was characterized in part by the phenomenon of people losing Facebook “friends” based on the political opinions they espoused on their accounts. Say the wrong thing, or even agree with the wrong person, and you alienate everyone from family to casual acquaintances.
You can achieve something similar by suggesting to a physician that, say, an MBA is as robust a qualification for hospital leadership as an MD. The subject is just that sore. Pick a different target — someone working in hospital IT, a nurse facing another round of changes to shift-length regulations, the coding specialist trying to ensure both accuracy and maximized reimbursement — and you can get similar results by adjusting your commentary.
The healthcare industry is siloed from the political conversations and regulations seeking to change it; at the same time, every stakeholder and user group that healthcare comprises is insulated from one another, both in function and even how they define their primary complaint.
Cohorts or cronies?
The one thing that seems to hold true in politics and in healthcare is that before anyone can share ideas, they need to state their affiliations. Which group you belong to matters more than your pragmatism. Before you can speak to the importance of any single issue, you reveal yourself to be “us” or “them,” part of a community or outside of it. No idea is more powerful than the identity of the person or group presenting it.
Aligning groups along common interests and the problems they hope to address can be effective. Unfortunately, it can also further isolate the silos that need to be broken down to achieve progress. The reason all our conversations are so contentious, whether they are political or professional, seems to be that, in both realms, we’ve grown accustomed to talking past one another because of our focus on a proprietary definition of the problem.
Political leadership redefines the problem being solved with every iteration of legislation it produces. The ACA promised “affordable” care, and created incentives and penalties to get patients, providers, and, most importantly, insurers to participate. Under the Trump administration, “pre-existing conditions” are the talking point of preeminent importance. More penalties and incentives are in the works to create the appearance of people self-selecting whether the system serves or sidelines them.
Meanwhile, those directly engaged with formulating and delivering care fight battles over influence, autonomy, communication, working hours, and how to both define and measure “quality” in the context of healthcare. If you are part of the pack of insiders with respect to any conversation, be they doctors, lawyers, adjusters, or programmers, you get the benefit of the doubt: you “get it” enough to talk shop.
When team membership takes over our ability to engage in discourse, civility is the first casualty, progress the close second. It all feels eerily similar to the final act of Animal Farm: the vitriol of politics and the business of healthcare have caused gridlock – where the term “cooperation” has been completely abandoned, and each side continues to prop the other side up with equal resistance.
Like a classic fool, I don’t let any of this convince me that we won’t work out a way to integrate technology seamlessly within our care systems, or to get people into the system when and where ever they need. I just doubt whether the next major step forward will come from those ostensibly committed to working on these goals, or from someone laudably removed from the sausage-making process enough to see clearly.
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