Viewing America’s health care system microcosmically - a ‘good news’ vignette

A few months ago I switched my health care insurance from a “one stop” Health Maintenance Organization, Kaiser Permanente, to “Care First” a more traditional insurance provider. Care First offered greater flexibility, which I needed, but the switch was not made without trepidation. Friends who were Care First clients warned of opaque, legalistic documentation, difficult-to-negotiate procedures and bureaucratic, indifferent staff. These warnings were amply confirmed. Staff members of the outstanding internist I located and the fine surgeon that he recommended informed me, when I made my first inquiries, that problems with Care First had lead them to disaffiliate as “preferred providers.” One had a poster communicating this information prominently displayed for viewing by potential clients. Waiting-room anecdotes advised me never to trust information from Care First customer service staff received over the phone - to insist on written communications, via email, for anything of importance and, even then, to be prepared for interminably protracted negotiations in which I would be treated as an adversary.

But once I accepted the reality that dealing with Care First would require all the skills I had learned as scion of a family of lawyers, plus years of negotiating experience with developing-nation and academic bureaucracies, things began to improve. Yes, health care would be more expensive and battles with my “insurers” would have to be fought. But I have discovered health care professionals - from modestly compensated office and hospital staff to physicians - who genuinely care about serving patients in a manner that is only skilled and efficient but compassionate.

My experience with Washington DC’s Sibley Hospital, completing an in-and-out abdominal surgical procedure provides the case in point that has motivated me to write. Once my surgical appointment had been made - and my surgeon’s organization (Foxhall Surgical Associates) would make another good news vignette - I received two follow up calls from hospital staff just as promised. The voicemail message from the appointments nurse was among the most cheerful and courteous I have ever received - I told her so. When I arrived at the hospital I was immediately impressed with the efficient congeniality of staff members greeting me and pride they expressed in Sibley. Everyone with whom I met seemed to have been employed there for twenty years or more.

Waiting times at each stage of a fairly complex check-in process, with many documents to sign, were brief. There was no sullenness or resentment when I asked to read documents before I signed them. When I called attention to a small inaccuracy, the response was immediate, forthcoming and apologetic. Staff members wore name tags, with first and last names prominently displayed in easily read block letters. They seemed pleased when I introduced myself, asked their names and used them in our interactions. When I asked how long they had worked at Sibley all seemed to have time to share a professional experience and a bit of personal information. When an emergency delayed my procedure, a nurse provided an immediate explanation and asked what she could do to ease my waiting. In my six-plus hours at Sibley, meeting with numerous staff - professional and non professional - every single one communicated congeniality, professionalism, efficiency, pride on their work and pride and their organization.

In leading two very different programs at American University, each for a decade, I always emphasized the importance of generating “Good Karma.” I defined this has the ability to have every individual who has any interaction with our organizations come away feeling good about the organizations and themselves. Good Karma, I always emphasized, accumulates (Buddhists believe this) and is infectious. Good Karma, I believe is the most important leadership/management principle that should guide customer service organizations. In hospitals, when customers (patients) often feel at their most vulnerable and disempowered, communicating Good Karma is particularly important and, sadly, all too rarely encountered. The good news vignette I have experienced - and shared - suggests that Sibley Hospital’s leader/managers have discovered the secret of delivering efficient, high-quality health care that embodies Good Karma. It is a secret that should be shared, They have my deep gratitude - and my deep respect

Why ‘free markets’ often are not really free. The ‘systems trap’ of success to the successful.

I am reading a powerful and evocative short book, entitled Systems Thinking. It was authored by the late Donella Meadows, a close friend and collaborator of many years. It was edited by Dana’s former research assistant, Diana Wright and published posthumously after her death.

The current debate over health brings to mind a ‘systems trap’ Dana identifies (one of several) that she calls ‘Success to the Successful - Competitive Exclusion.’ Dana writes: (p. 127,128)

‘Using accumulated wealth, privilege, special access or inside information to create more wealthy, privilege, access or information are examples of [this archetype]’ This system trap is found whenever the winners of a competition receive, as part of the reward, the means to compete even more effectively in the future. That’s a reinforcing feedback loop, which rapidly divides a system into winners who go on winning and losers who go on losing.” The business executives about whom I wrote last evening are among the beneficiaries of this trap. Here are some other examples:

In most societies the poorest children receive the words education in the worst schools, if they are able to go to school at all. With few marketable skills, they qualify for only low paying jobs, perpetuating their poverty.

People with low income and few assets are not able to borrow from most banks. Therefore, either then can’t invest in capital improvements, or they must go to local moneylenders who charge exorbitant rates. Even when when interest rates are reasonable the poor pay them and the rich collect them.

land is held so unevenly in many parts of the world that most farmers are tenants on someone else’s land. They must pay part of their crops to the landowner for the privilege of working the land and so never are able to by lland of their own. The landowner uses the income from tenants to buy more land.

Dana does not write about health care, but it seems pretty clear that many those who are the leading charge against health care reform, using their wealth and position are not numbered among the 47 million Americans who lack health insurance, a national disgrace. This includes of course, many - not all - members of Congress. No member of Congress, of course, lacks health insurance coverage. That would be unthinkable. Like many - not all - high-level business executives they view themselves as members of a high caste elite, that is not governed by the circumstances, nor constrained by the moral precepts with which ordinary folk (the low caste and untouchables) must deal.

AN ADDITONAL THOUGHT: This blog later evoked a reflection on how to write in a way that will change people’s minds. This is something I discuss in my ‘International Development’ course. It is a challenge that reformers and spiritual leaders face. The blog I wrote was a reflection of outrage and anger, but if its goal was to transform those whom I targeted as complicit in injustice, it almost certainly did not achieve its goal. The great spiritual leaders often write that such transformations must begin with connection, forgiveness and empathy. Among leaders now living, Nelson Mandela may exemplify this best.

'We thought it would disrupt people's commute too much."

This monday evening, shortly before 5:30, A Washington Metropolitan Transit Authority Train crashed into a second train, parked at the station. Nine passengers were killed and many more injured. What caused the crash is still under investigation, but some facts seem clear. The computerized system that was supposed to control the train failed. The driver attempted to stop the train manually using the emergency braking system. That, too, failed. The cars on the train causing the crash were the oldest in the system. In 2006, the National Transportation Safety Board had recommended that they be removed from service. The Board has the authority to recommend, but no enforcement authority. According to news stories, the head of the Washington Area Metropolitan Transit Authority declined to follow the recommendation. There were no funds available to replace the aging cars, he is reported to have said and removing them from service without replacement would be ‘too disruptive.‘ Unplanned disruption has now occurred, of course. For those who have lost their lives their families the ‘disruption’ has been catastrophic.

The crash occurred at a time when, just a few miles from the crash site, legislation to limit global warming and legislation to reform the America’s dysfunctional health care system are being debated in the halls of Congress. The proposals being offered have their flaws, no doubt, but the objections of opponents sound much like those with which the head of the Metropolitan Transit Authority responded to the NTSB in 2006. Fighting global warming will be ‘too disruptive’ of the economy. Addressing societal and economic problems created by more that 40 million uninsured Americans; by the most costly least effective health care system in the industrialized world disrupt our system of private health care. Not too long ago, the same voices were speaking out against and effectively lobbying against more rigorous regulatory oversight of America’s financial system. No doubt those arguments, too, attempted to stoke fears of ‘disruption.’

‘Crashes’ that are a consequence of global warming and a dysfunctional political culture in Washington lie ahead, and not too far in our future. They will be disruptive.

No ‘20 minutes per patient’ rule - another reason I like being a professor

After more than twenty years with my health maintenance organization, Kaiser Permanente I was finally able to find a ‘personal physician’ who did not either leave the organization or get transferred after one or two visits. She recognizes me as an individual and has some contextual knowledge of my medical history. She is congenial, professional and seems to enjoy her work. This is a breakthrough. I was coming to believe that the concept of “your doctor” existed only in slick TV commercials of drug companies, Kaiser Permanente marketing brochures, rural hamlets large enough to sustain one or two physicians, and negative ads funded by private insurers opposing government intervention on behalf American’s 40 plus million citizens without health insurance.

At my last visit, I asked her if there was a time specified by Kaiser management for each patient visit. ‘Twenty minutes,’ she said. ‘It used to be only fifteen, but we were able to lobby with management to increase it to twenty. This works very well for patients who are in relatively good health such as yourself. For older patients with multiple health problems and/or who have difficulty communicating, it can be difficult. Then we sometimes get behind schedule.”

This set me to thinking about one of the perquisites that sets the profession of university professor apart from most others - discretion. As economic pressures mount and calls for ‘assessment’ from voices outside academic institutions grow louder, the number of institutions who are able to offer professors significant discretion is shrinking. But at American University, at least for faculty teaching within its nationally ranked programs, considerable discretion is still the norm.

It is not that faculty members don’t put in long hours. I advise young faculty whom I counsel in my role as Director, Center for Teaching Excellence that they should plan on a 70 hour work week, or more, if they expect to successfully compete for tenure. In other words, the demands on their time will be at least as great as for aspiring top-tier young professionals in law, medicine, accounting, and financial services.

But there can be a difference between how professors and those other professionals spend their time. In other postings, I have written about the discretion we have to choose the research questions we investigate. Here I want to reflect on the discretion we have to spend relatively unconstrained ‘face time’ with our students. This is particularly true with MA and Doctoral students, but it extends to undergraduates as well - and even to students who have completed their degrees. If a student stops by my apartment for help with an academic or personal problem, or simply to discuss an issue of mutual interest, I can take the time to be with them. If a former student stops by to seek a letter of recommendation or to discuss professional options, I can make myself available to help. I can show a student’s parents from Asia, visiting America for the first time, the beauty of rural northwestern Virginia where my wife and I have our home. I can take time to help a gifted undergraduate who is struggling to negotiate AU’s sometimes complex and unforgiving bureaucracy. None of these instances are hypothetical, they - and many more - transpired within the last two weeks. On no occasion did I have to enter the time spent on a spreadsheet or prepare an invoice detailing ‘billable hours.’

Whether or not the discretion my generation of professors have been privileged to enjoy will survive the growing commodification of higher education I cannot say. In large degree it will depend on whether or not those of us who have been granted this privilege are seen to be using it wisely, with integrity, professionalism and effectiveness. It will depend whether the current generation of students - future parents, political leaders, boards of trustees and university managers remember instances when a professor took time to connect with them, listen to their concerns and offer compassionate professional guidance that made a difference in their lives.

"We have introduced a new automated system to improve our services."

Saturday morning is a time for catching up on personal chores that have be deferred during a busy week. This week the chore list was greater because I had been away for a month and my work-day (normally 8 AM to about 8 PM) efficiency was reduced by jet lag.

One chore - renewing a prescription I receive from my ‘health care provider,’ Kaiser Permanente called to mind a contemporary social-economic pathology I find particularly aggravating. Kaiser has had an automated prescription renewal system for several years. The layers of insulation between the system and an intelligent human being have become ever more difficult to penetrate. However the skills that serve me well as American University’s academic information technology director have helped me to penetrate its intricacies with reasonable success.

On my next to last renewal attempt, a more complex menu of options began with an announcement, “we have introduced a new automated system to improve our services.” The particulars, I discovered, were these: Prescriptions would now be filed by the ‘Kaiser Automated Prescription Refill Center.” Prescription numbers would change (one should always have a writing instrument at hand to take note of changes and instructions). The procedures were more complex. The refill time would now be 7 to 10 days rather than 5 to 7 days. “Improve our services?” For whom, I asked myself?

I am not picking on Kaiser Permanente. The problem is endemic. Some time ago, American University introduced an automated room scheduling system for events. The time for a response to be given to requests immediately increased from less than 24 hours to three days - the target - or much more.

As opposed to the ‘improve our services’ announcements that are customary when automated systems are introduced, I propose the following.

‘We have introduced a new automated system. Its purpose is to cut costs by reducing the size, competence and compensation level of our work force. Once the glitches are worked out we do expect to provide a minimally adequate level of service, though of lower quality than previously. We appreciate your patience and forbearance. If you choose not to be patient and forbear, we recommend that you find another provider. Press “7” for a menu of instructions on how to do so.”