This weekend I dug into Jonathan Haidt’s The Righteous Mind: Why Good People are Divided by Politics and Religion and the recent issue of Time featuring Steven Brill’s “Why Medical Bills are Killing Us.” I am definitely processing the Haidt book as a marathon—it’s packed with mind-musings—but here’s my first 50-yard dash of thought.
Both are must reads—even the Time article—it even comes recommended by Jon Stewart of The Daily Show! To recap, Brill follows the medical bills of several Americans, tracing the inflated costs set by hospital “chargemasters” while we average Americans with insurance, or Medicare, or various flavors of Medicaid, or are uninsured, or more likely under-insured, learn after the fact that the costs connected to our procedures, doctor’s visits, lab tests, and drugs are all negotiable. He concludes that we “are powerless buyers in a seller’s market where the only sure thing is the profit of the sellers.”
He does offer some solutions such as cutting prescription medications costs and basically de-coupling common incentive practices that tie diagnosis to outpatient clinics, medical device companies, and laboratories owned by the same people diagnosing, but they underwhelm me. Reading each of his healthcare billing case studies I see not only sob stories but individualism run amok where the incentive for individual practitioners and healthcare management lies solely in not getting sued and not making waves, and for some, making money. Inspired by Haidt, who addresses “plausibility deniability,” (the experiment that showed that people are less likely to cheat if they have to lie directly to do so), I couldn’t help but think that one quick solution to try would be to require that at least two practitioners verbalize to each other answers to these questions: Is this bill fair? Does this bill make sense to you? To wax deontological, would we want to apply this bill to everyone we serve, including me?
We need some basic team accountability.
As I read the Brill article I realized that my experience in healthcare has been a bit warped—I’m a hospice junkie. Instead of the traditional fee-for-service payment system, hospice is an outlier that is paid a per diem and must manage the costs related to the terminal diagnosis including medications, visits, emergency hospital visits, transportation, medical equipment, dying stuff and so on. Our team of doctors, nurses, social workers, chaplains, nurse aides, and billing clerks, as well as the entire accounting department, talked about cost ALL THE TIME. And our team talked about cost with families before they made any care decisions. On page one of our “Welcome to hospice…” brochure we began: “Most families entering hospice have two main concerns: 1) I can’t believe I am going to die and 2) How am I going to pay for all this?
As our team worked with a family, countless team decisions would arise concerning the frequency of visits, the type of prescription medication to be ordered, the piece of equipment needed, the lab test required…In our team meetings, everyone became adept at figuring out how to make a case for what you believed was the best course of action. Over time, you learned who was the most creative in a pinch, who had a sixth sense about families when a drug diversion was suspected, and that human beings on their own turf (in other words the patients and families we visited in their homes) are inherently tattlers who will rat you out in a heartbeat. If you are cranky, complain about other team members, don’t follow protocol to a tee, are late, make promises you can’t keep, and so on…every patient and family will tattle on you…to EVERYONE. Side effect: Your other team members will not like you and when you are inevitably called out at 2am with an emergency and need back-up, your back-up won’t trust nor like you.
Now, I know I probably sound naïve, as if hospice walks on water (it does not) and I must admit here, that as a pastor moving into healthcare management, I genuinely believed that individuals want to be just, loving, and good for the sake of being just, loving and good. But working in healthcare management taught me the lesson that Haidt makes early on, drawing upon Plato’s Republic where Glaucon wonders if people really want to be just or simply appear just. Haidt makes the case that
“people care a great deal more about appearance and reputation than about reality…Glaucon is the guy who got it right—the guy who realized that the most important principle for designing an ethical society is to make sure that everyone’s reputation is on the line all the time, so that bad behavior will always bring about bad consequences.”
Haidt reminded me of the rocky road I walked to learn that incentivizing individual morality (as a pastor) versus communal morality (as a COO) entailed different tasks. Our CFO, who believed that the best form of trust was a good control, helped me realized that my job as a leader was tri-fold: 1) to make our ideals as transparent as possible, so that those who do NOT want to be excellent, honest, compassionate, aggressively charitable, and part of a team of diverse and highly accountable professionals can leave, 2) create policies and procedures that form an environment in which living the ideals will most likely occur, and 3) enforce systems of accountability where the money you make is directly tied to living the values. We already had a mission (what we do) and a vision (what we hope to do in a perfect world) but what we needed were values, which we stressed were not defined by how you felt you were living them but defined by how people described you living them. In other words, I don’t care if you say that you are loving or excellent, I care if your team members and the patients and families you serve say that you are. We want a good reputation.
If we truly want to address healthcare costs, we need to begin asking whose reputation is on the line? What values are we espousing and are we tying those values to the money made? And if our fear of mortality and blind hope that nothing catastrophic will befall us is motivating us to deflect these types of macro questions, then we’re going to keep getting the bills we’re getting. The good news is that almost all of the medical professionals I’ve known want to do what is best for patients and for society as a whole; they just need an environment that values that quality and calls them out when not espousing it.