Ownership in Healthcare
By: John Corsino
Tags: Leadership, Systems Thinking, Healthcare, Health

In healthcare, we enjoy unequaled opportunity to create special relationships with our work. Few enter these professions for practical reasons alone, and fewer still survive rigorous training without genuine belief in what they might accomplish. And cliched though they may be, the many mission statements which purport the ‘art of caring’ do convey something real and meaningful.

But to even the naïve, enough time spent around healthcare forces a certain perspective. A machinelike structure becomes difficult to overlook — one engineered to squeeze out dedication and compassion in favor of the calculated administration of services.

There are new deficiencies in this system all the time, but the old ones haven’t gone anywhere. Compassion, after all, produces no billable service units. And as businesspeople hand down goals, facilities focused on shorter-term success (which many must become to remain competitive in a climate of acquisition) game those metrics by reorganizing the ways they care for sick people. Providers feel powerless to contend with the increasingly conglomerate system that surrounds them.

And they’re not totally wrong. But part of this is our responsibility: we’ve relinquished ownership of this system and it’s direction. This barely-recognizable behemoth mutated to serve interests far beyond health itself leaves us struggling to empower our patients to effect meaningful change, to find the time to get at the real roots of their maladies, and to do work that we can proudly sign our names to, that we imagined we might be doing.

A craftsman maintains a direct and personal relationship to his work. As a result, the quality of his product is supreme, unthreatened by assembly lines. But in this iteration of healthcare, providers are not craftsmen. Care is fragmented. Each provider must focus on what he can be reimbursed for, regardless of the scope of his training and of what might help his patient most.

In the name of cost-efficiency, the most relational work there could be is growing dispassionate and impersonal. Providers are shortchanged on the privilege to help the person in front of them. Clinics are engineered to maximize profitability and score highly on metrics that distract from real quality of care.

The deleterious effect of this focus on the wrong goals is not easily overstated. Productivity, not quality, has become the measure of a provider’s worth, and it should be no surprise in that paradigm when some quickly refill opioid scripts instead of beginning a long and difficult process which they don’t have time (and insurers won’t pay) for.

It should be no surprise either when patients, who walk into our clinics from a culture of rampant consumerism, view their bodies as products and demand effortless solutions to their complaints. They, like providers, feel powerless to contend with the system around them. They perceive such limited capacity to impact their own health, and instead of empowering them to overcome that view, we perpetuate it through our own compulsive focus on customer satisfaction and passive engagement.

But insurers pay for office visits, for procedures, for medicines — not for healthy food, or for being active, or to quit smoking. This is the proximate cause of care provision different than what is best for patients, and it exists because of the cultivated dependency on reimbursement dollars faced by hospitals and clinics today.

Engaged patients who take ownership of their health aren’t just much cheaper to take care of, they’re rewarded with longer lives of higher quality. But a hospital makes more money from a patient who hands over ownership of his health in favor of passive procedures which cost many times more than effortful but effective alternatives. Behavior change, the highest-value focus there could be in terms of outcomes produced relative to their cost, is paradoxically one that will never generate a dollar of revenue for a hospital system.

Problems like these are pervasive in a self-defeating complex that undermines providers’ opportunities to effect change by overwhelming them with patients, dictating what types of care can happen and when, and producing incentives that clash with right practice. While these decisions might benefit the balance sheet of one facility, to our patients, providers, and system altogether, they are deadly.

If we wrote an equation to predict burnout, we would divide the total impact of the work we do by its volume. Right now, everywhere, volume is too high and opportunity for impact far too low. To fragment care as if it occurs on an assembly line takes away not just the responsibility but the satisfaction of and sense of ownership to help people, replacing them with feelings that we are partitioned from one another and must not deviate focus from our assigned tasks towards care in gestalt. It produces a system of technicians and obfuscates responsibility.

As quality slips in a system that pressures services different from the things that patients need most, providers’ effectiveness is limited by a kind of inaction on our own part. We consign ourselves to do our best within the system as it is and accept that its faults are too large and complicated to erase. But this system exists to enable people who take care of patients, not to direct us.

The privilege to help take care of people demands commitment. Clinicians, even very good ones, who complete visits, bill units, and consider their work finished, are enablers of this system. The providers who will solve these problems will be those who, beyond their clinical responsibilities, engage with the rules of a damaged system and change those rules to support what is right and sustainable for patients.

The myth of healthcare is that altruism is exclusive from competitiveness. The hospital that will thrive in tomorrow’s healthcare is the one that identifies synergies between things as they are now and things as they should be, dedicates resources to those areas of overlap, and works towards reorganizing the system around it to better serve patients.

The fragmented nature of care produced by fixation not on ownership of good work but instead on compliance with orders and rules is far-reaching and influences quality, cost, and satisfaction to a great degree. It’s backwards: the system exists to support providers and patients, not to direct them. We’re more focused on administering services than empowering patients to achieve health because services, not wellness, are what generate revenue. But the goals of all parties can and should be aligned.

We have in healthcare an incredible advantage, and one that will help us through a time where another industry might flounder: people are drawn to this line of work by purpose, sincere and unwavering. We all share in the responsibility to change the rules of this system to enable what we know is right, and it will be providers — not administrators or policymakers — that solve these problems.