Error: Unable to create directory /home/demockra/public_html/wp-content/uploads/2010/09. Is its parent directory writable by the server? Health Care Reform: A Lesson From the Big 3

US health care reform is the biggest domestic issue facing America today, and action is needed to fix it. But as I was reading about Chrysler’s bankruptcy the other day, it got me thinking about the similarities and differences between the auto industry and the health care industry. As the rhetoric and furor over health care reform gets more and more heated, it might help the debate if we step back and take a look at the failed auto industry and try to learn some lessons about what to do and what not do when reform is needed.

To use an oxymoron, American health care is sick. As many reports have stated, Americans spend twice as much on health care as similar western countries. Half of this cost is paid thanks to the American taxpayer (or the American taxpayer’s children and grandchildren, thanks to budget deficits). But even with all that spending, objective impartial statistics rank America’s health care near the bottom when compared with those same western countries. (See Demockracy article from February 16, 2009, “Health Care in America – A Time for Change” for a full discussion of this issue.) However, even with the groundswell of support from many different corners, this is not a problem which will be fixed at the flip of political switch. This is a problem which has been forty years in the making and will probably be forty years in the fixing.

So, as we watch the plight of the Big 3 automakers, I can’t help but compare their plight to the current situation of the health care industry and compare the position of the auto companies of 1960s to the health care providers of today. For many, many years, the Big 3 automakers were the most celebrated and profitable companies in the world. CEOs, executives, shareholders, unions, and car salesmen all got rich and fat on the profits from the US auto industry. They were the “Masters of the Universe” in the mid 20th century. A national infrastructure was built to support the industry. “What’s good for General Motors is good for America” was the oft-quoted refrain.

GM, Ford, and Chrysler made cars that were the shiniest, biggest, boldest, and the envy of the world. Even if you didn’t need or want rear fins or white side wall tires or big V-8 engines,  you got them because it was the American way to do things. Cars got bigger, more expensive, and more inefficient, and the industry run by the three big oligarchs with almost no other meaningful competition slowly lost touch with the consumer.

And then in the 1970s the car industry had a hiccup. The Japanese (and others) devised a cheaper, more sensible way to make cars which fit the needs of the consumer. These cars were cheaper and on objective criteria, better (sound familiar to an industry we know?). Detroit of course tried to react in the 1970s and 1980s. The industry went through thirty years of pain – a government bailout here, a merger there, a few concessions from the unions. They pared down their product lines to sell mostly SUVs and big cars (cars which people really didn’t need, but old habits die hard). Salesman and marketing programs claimed that the quality statistics comparing the Japanese cars were flawed, and anyway, who wants to drive a small little Japanese car (“I don’t care what the statistics say, the American made car is better”).  And now thirty years later, the Big 3 are on the critical list. Their infrastructures were just too cumbersome to change in the radical ways that were necessary to survive. Chrysler has now died, and GM and Ford are gasping their last breath. It is sort of ironic that one of the biggest problems of the auto industry is the escalating health care costs of the labor force that simply cannot be reduced under the current system.

Saying all that, and even with the Big 3 in their current sad state, I don’t think I know one American who is not a lot happier with the car they drive now compared to what they drove thirty years ago (OK, maybe we need to exclude owners of ’57 Chevys or ’64 Mustangs). All of the trauma and gut-wrenching decisions and layoffs and closures, although obviously difficult for those directly involved, were part of the process required to allow the American consumer to buy the product that was best for him.

So the similarities to the health care industries today and the auto industry of thirty years ago are obvious. The health care infrastructure is bloated and inefficient – it is providing products and services which are too big, expensive, and inefficient to many US citizens. It is more expensive and has less quality than other countries’ health care systems. A huge and complex national infrastructure has been built to support the entire industry. CEOs, executives, and shareholders, along with many powerful physician specialties, are all getting rich on the profits of the health care industry. These constituents do not want to stop the gravy train – but stop it will and stop it must – someday. In the long run, the American consumer will force the change – and it will most likely lead to trauma in the industry. It might take thirty years or longer – but the health care industry will change. In fact, I will make a bold and a rather pessimistic prediction: We will know that health care is “fixed” when one or more of the health care giants of today go bankrupt. The trauma that is necessary to change the system will almost certainly lead to the bankruptcy of a major player in the industry. Just like the Big 3, one or several major health care players will not be able to adapt to changes in the industry, and the result will be predictable. The somewhat tricky issue here is that the bankruptcy that occurs could well be the US Government, which foots nearly 50% of the health care bill in the U.S. – the bankruptcy in the health care industry which occurs might be US.

CHANGING HEALTH CARE IS DIFFERENT – IT’S HARDER

Although there are similarities in the predicaments of the auto and health care industries, there are three major differences worth noting, none of which are going to make reform any easier.

First, there is limited foreign competition to replace and offer alternatives to an inefficient industry. Health care, especially in- patient and primary health care is almost inherently a domestic industry. Japan, India, or China cannot easily begin a strategy of exporting health care to America and provide a competitive hammer to the industry. But this trend can be hard to predict.  If a consultant would have advised the CEOs of the Big 3 in 1960 that they would be brought to their knees by Japanese companies exporting two ton cars from Japan across the Pacific Ocean, he would have been laughed out of the board room. In the high technology world of internet, ipods, blackberrys, and instant data transmission, it is not inconceivable that a cheaper, more efficient health care model could be imported into the US and provide consumers with an alternative. If this does happen, you can be sure the first persons to cry foul will be the doctors, US health care companies, and their lobbyists who, predictably, will complain about low quality, “non-approved” health care, cheaper replacements, job losses, un-American competition, etc. – the mantra that car companies have moaned about for years.

Second, the US government does not just regulate or support the health care industry – it is the health care industry – as mentioned before, approximately 50% of health care spending is through Medicare, Medicaid, and other government programs. Moreover, the rules, regulations, and reimbursement programs developed and administered by the government are incredibly complicated when compared to other private industries. So when we speak of infrastructures that need to change, we are not speaking of a board room in Detroit; we are speaking of the mother of all infrastructures – the US Government. Needless to say, changing the direction of this US battleship will not be an easy task.

Third, the health care industry by its very nature involves life and death situations. The auto industry had to deal with issues like increasing miles per gallon, faster times for 0-60 mph, and how many grocery bags could fit in the trunk. Health care involves more serious issues – which cancer drug is likely to cure a sick child, kidney transplants, strokes, and heart attacks. Health care is emotional and stressful. To affect change within this emotional environment will be much more difficult given the potential side effects if a particular policy is in error.

If anything, then, these three major differences of the health care industry, as compared to the auto industry, will make change harder not easier. The lack of  foreign competition to drive changes and to lower costs, the gargantuan bureaucracy of the US government, and the emotional issues involved all are roadblocks to change. Change will not be easy.

LESSONS TO BE LEARNED

It has been said that he who fails to learn from history will be destined to repeat it. So what can the health care industry learn from the plight of the auto industry?  In my opinion,  there are several important things.

First, what is required to fix the health care system is major surgery. The cost structure and system is fatally flawed. The auto companies cost structure was fatally flawed thirty years ago. Tweaks here and there allowed thirty years of survival for the Big 3, but they did not fix the problem. The health care companies, the insurance companies, and the US government cannot keep forcing their “SUV” solutions when what the consumer needs is a reliable, efficient, quality health care system. If rich people want to pay for big SUVs, then let them, but the average person needs good and efficient, not excessive and gaudy.

We will need to accept that this major surgery to the health care system will be painful and it will take a long time. There will be winners and losers. Jobs will be lost, salaries may be lowered, and mistakes will be made. And given the emotion and seriousness of health care, the mistakes may lead to serious consequences. Let us be prepared for these mistakes and issues. These issues that change brings about cannot reduce our desire and drive to change the system for the better. And as we are going through these painful changes, let’s not let lawyers and tort laws allow even more money to be sucked out of the system by legal confrontation. Tort reform is needed to limit damages and to let providers make the decisions necessary to cut the waste out of the system without worrying about multimillion dollar lawsuits that ultimately just add more costs to an already inefficient system.

Second, good old fashioned competition will ultimately serve the needs of the health care consumer best. Whatever the system looks like in twenty years, it must be a competitive system where individual consumers choose what is best for them. This does not mean that government cannot be involved, but government needs to develop and nurture a system which promotes competition. However, it must be noted that just introducing competition into a system which is broken is not just a cure all. The private and public health care system does have competition now, but it takes place at the wrong levels and on the wrong things. This dysfunctional competition does not focus on delivering value for money to customers, but instead motivates providers to capture more revenue, shift costs to the deep pocket, and restrict services to those who cannot pay. The competition is more about profit and revenues and less about providing value to the patient. Flawed model – flawed competition. The industry needs to develop new business models that reward quality and efficiency, not simply a fee-for-service mentality. Reform should focus on creating a system whereby providers compete directly on the six overarching “Aims for Improvement” (as identified by the Institute of Medicine) for health care. These aims are:

• Safe: Avoid injuries to patients from the care that is intended to help them.
• Effective: Match care to science; avoid overuse of ineffective care and under-use of effective care.
• Patient-Centered: Honor the individual and respect choice.
• Timely: Reduce waiting for both patients and those who give care.
• Efficient: Reduce waste.
• Equitable: Close racial and ethnic gaps in health status.

If competition is refocused along these parameters rather than just on profit and revenue, then the competition will bring value to the customer. The book Redefining Health Care: Creating Value Based Competition on Results by Michael Porter and Elizabeth Teisburg is an excellent treatise on how competition can be implemented into health care systems to drive the most efficient solutions to the consumer.

Regarding competition, it would be interesting, indeed, if a foreign competitor could begin importing health care services into the US.  I have traveled and lived extensively overseas and experienced health care in many foreign countries.  I can testify that many, many overseas providers would be more than willing to provide health care to US citizens at a fraction of the cost that is paid in the US (and this is from persons living in Western Europe – the opportunities from a low cost country like India or China must be staggering). And remember, before you get protectionist, these other countries’ health care statistics are better than ours – don’t be fooled like the automakers who claimed that your 1972 Ford Galaxy is really better than the Toyota Corolla.

Finally, the leaders of the health care industry, public and private, must focus on what Detroit did not – the needs of the consumer – what does the average citizen want and how much will he pay for it.  In too many cases, the health care industry has lost touch with its customer – the patient.  Instead, the dysfunctional system we have now has redefined the customer as the payer, which usually is Medicare, Medicaid, or a large insurance company. As a simple illustration of this, let’s assume there are two viable, equally effective procedures available to cure a patient: Medicare pays $100 for Procedure A and $1000 for Procedure B. Guess which procedure will be recommended by the Provider – the Provider will choose the one giving him more revenue (assuming more revenue generally leads to more profit). The patient won’t argue, he just wants the best treatment, and there will be an implied view that the more expensive treatment is the “better” treatment. No one is worse off except the government, and they have lots of money – right? This is a simple example, but this is how it works. There are scores of accountants, lawyers, and clinicians who are employed not to provide better care to patients, but to maximize revenue from the “customer” (Medicare, Medicaid, et al.).

The current system and structures are designed to maximize revenue and profit from the intermediaries – they are not focusing on the needs of the customer. The average person does not need the “Cadillac” of health care; the average person does not need the Mayo Clinic. The average person does not need a multimillion dollar tort settlement. The average person needs and wants good, reliable, quality health care at a reasonable cost. The average consumer knows in his heart that health care bills are too large, but that there are currently no viable alternatives for the average citizen. (There are no inexpensive imports he can turn to!) The industry leaders cannot let their existing infrastructures, inefficient practices of the past, or bloated costs and salaries be the drivers of the decision-making process. The industry cannot survive with a “if we build it, they will come” attitude. The health care industry must give the consumers what they want.

Other countries have health care systems (public and/or private) that give the same or better health care results to its citizens for about half the cost of the US. The Big 3 automakers did not survive such inefficiencies, and neither will the health care industry. Change must come or the health care industry will ultimately face the same crisis as the Big 3. Change is imperative; failure is not an option.

Error: Unable to create directory /home/demockra/public_html/wp-content/uploads/2010/09. Is its parent directory writable by the server? Copernicus and the Search for God

I started my search with hope, but in the end there was nothing, but that’s OK. My search spanned many years, many books, and many miles traveled. It is a journey made in some way by all of humankind, an effort to correlate religious belief within the parameters of authenticated history and science. While I was never a regular Church goer, after a brush with cancer, I decided to explore the options.

Just as man has developed over the centuries, so have religions evolved and developed to mirror man’s progress. In the very beginnings were the worship of the sun, natural phenomena, and the spirits of the animals. With the establishment of city states, so came the idea of King/Gods to give strength and courage to their soldiers in battle, by convincing them that the sacrifice, even of their lives, would be rewarded by their God/Kings. [This theory is explained by Jared Diamond in his best seller Guns, Germs and Steel.] The Gods were depicted as enhanced versions of themselves, living in improved versions of our cities, suspended above us in the sky.

From those early beginnings, education, philosophy, and the sciences emerged. With more knowledge of the known world, the old City Gods seemed primitive, and all encompassing religions with one God became the norm. The first of these monotheist religions that grew around the Indus valley in India was Hinduism. The beginnings of Hinduism in India occurred around 2,000 B.C.E. Much of its beliefs were imported with the Dravidians, who entered India from the North already with many of the basic beliefs of what was to become Hinduism. It retained the old Gods at a base level, but assumed the belief that at a higher level, God was one, but man was too lowly to comprehend the higher complexities. Buddhism, which in many ways is more of a philosophy, was then born with the Buddha in 563 B.C.E . Many devout Hindus claim to this day that Buddhism is really just an offshoot of Hinduism.

The area where all our western monotheisms or one-God beliefs started was the Middle East. There Judaism, Christianity, and Islam all arose with very similar and overlapping histories. Jerusalem is of course central to all of those faiths. It is intriguing that some of the main beliefs of our Abrahamic faiths are taken directly from the pre-Abrahamic Gods.

Validation of the Faith

For as far back as faith has been around, humankind has attempted to validate that faith through the scientific philosophical approach. [Here I am indebted to Karen Armstrong for her amazing book, A History of God.] Thousands have sought over the ages to prove the existence of God. Indeed, probably all of us have at some point. The Greeks were probably the earliest recognizable true philosophers. They rejected mythological answers to solve the basics questions of heaven and earth. Probably the most intense and prolonged questioning occurred in Iberia during the 700 years it was under Arab rule, while Europe was still deeply mired in the Medieval mud. It was there that the sharpest religious minds from Judaism and Islam cooperated closely to try to reach a proof, any proof. From all of this evolved the most elaborate theories, doctrines, and suppositions, all as improvable as the original question. The mystic approach, where students look deeply within their own being, has proven more successful to its adherents. Christian Mystics, Muslim Sufis, and Hindu Sadhus have all turned their focus inward through a variety of modes of contemplation. Sufis whirl in concentric circles; Sadhus contemplate, often in poses for hours or days on end in positions that would be extremely uncomfortable for most of us for even a few seconds. Some Monks go without speaking for years on end in an attempt to hear the small inner voice. Even hippies have tried this approach, perhaps the easy way with Mescaline, LSD, Magic Mushrooms, and other mediums. Unfortunately, these approaches probably reveal more about the complexity of the human neurology than the nature of God.

Religious opinions change almost on a daily basis in an attempt to remain pertinent to societies own changes. For right or wrong, it has been essential to keeping stability in many societies by helping keep a promise of a better life after death for those who live indigent livelihoods and as a mechanism for keeping a people united under a common tribal identity against a common enemy with supposed lesser beliefs.

Should Have Religion Died in 1543?

In 1543 Copernicus’s seminal work, De revolutionibus orbium coelestium (On the Revolutions of the Celestial Spheres), posited that the heavens did not revolve around the earth, but the other way around. Arab and Indian scholars had of course knew that for centuries, but this was the first time it was proven to the Christian world. Before this, everything was about us and our planet. Our earth was the center of the universe, all things revolved around us, and, of course, our God overlooked us, judged us, rewarded us, and helped us out in times of trouble. After 1543 we were an immeasurably tiny part of billions of galaxies that extend outward for millions of light years.

The End of My Journey

So is this the end of this journey that I strangely found very satisfying?  The question then is what drives us to religion, and how it is sometimes used to manipulate us. It is a truism that all of us, from the age where we first have a brush with death, be it the death of a relative, friend, or pet, feel the need for a power that makes it alright. The need for religion makes talented salesmen of religion rich, powerful, and influential in every society around the globe. In areas where religion is strongest, it is essential that our leaders adhere to the true faith. Barack Obama would have stood no chance of election if he had declared himself agnostic, yet reading his autobiographical book Dreams From My Father suggests that he valued the works of the church in their help to the poor in Chicago and the dedication of some of the ministers. However, nowhere is there any statement of his own faith. Although I have no doubt that is he a Christian, the fact that he doesn’t seem to wear it on his sleeve, but rather seems to live it through shared values is probably one of his greatest strengths.

Once we accept that belief can transcend evidence, we are programmed to accept without question what those good Christian, Muslim, Jewish, and Hindu leaders tell us. That is why religion has caused so many conflicts over the ages. Today, of course, medieval tortures have been reinvented to use on those lured into battle by their own deluded religious teachers and leaders.

Religion in one form or another has been with us from the beginning of time and will probably be with us until the end. Einstein himself believed in no formal religion, but thought that their must be some master equation which could be used to harmonize all things. It was this equation which he saw as God’s design. He did not believe that humankind played any role, above being a tiny part in “the equation.” Alas Quantum mechanics, whose theories Einstein opposed vehemently throughout the latter part of his life, with its basis being a lack of any order, has moved physics further from any such unifying equation.

The final question then must be: Has mankind benefited from religion, or has all of it been a chain around our necks. Clearly, as mentioned before, it has been a necessity for stability in many societies. Without this stability, the conditions for economic growth and progress may not have been sufficient. Also, it has been a solace to many in times of great stress or sorrow. It has helped countless people through times of intolerable hardship, famine, plague, and wars. Religion left alone and not seized upon by power hungry individuals, states, or countries, can and has been a power for good. I look on the Dalai Llama, Mahatma Gandhi, and the Aga Khan as shining lights in that respect.

Unfortunately, where religions have evolved into powerful advocacy groups on their own behalf, with their leaders’ power-hungry egos inflated by their own sense of gravitas, they inevitably do more to divide and deride than to resolve, pacify, and heal. Religion will continue to hold sway for many more millennia, so it essential for us to understand in an historical rational way the damage that can be caused by the lack of separation between state and religion. In the end, that was the main lesson of my personal journey.

Error: Unable to create directory /home/demockra/public_html/wp-content/uploads/2010/09. Is its parent directory writable by the server? Journalism: The End or the Beginning?