Thursday, September 1, 2016

Solving Healthcare Problems 101, Part I

As a promised follow up from my previous post, it's time for a smarter way to think about solving health care woes.

I'd bet my bottom dollar that if you convened a meeting of doctors, nurses, politicians, administrators, members of the public, pundits, and researchers - from just about any corner of the globe - they'd agree on at least one thing: health care needs fixing. Some things need fixing more urgently than others - lack of clean water, Zika virus, maternal-fetal HIV transmission - but there's never a shortage of fires to put out.

In the developed world, you'd think that the problems would be comparatively minor, given the billions upon billions of dollars available for health care in advanced economies. And indeed, disputes over doctors' incomes, concerns around bureaucratic overreach, and nurses with scary tattoos are pretty trivial in the global grand scheme of things. But there are still intractable problems - hospital overcrowding on both sides of the Atlantic, cost pressures,  increasing system demand by an aging population - that never seem to get any better.


Because all too often someone in power commits to a poorly conceived solution before coming to a solid understanding of the problem. Or worse, someone in a position of authority gets excited about a minor (or even non-existent) problem, and diverts critical resources from less sexy but more essential issues. Or worse still, the true nature of the problem is willfully ignored for political or ideological reasons, apart from cost.

For all the hot air bandied about around "innovation" as the solution to health care woes, we seem to forget that at its core, health care is a social program that largely serves the elderly, disabled, and poor. The diseases that health care is meant to combat have their roots in peoples' genes and social conditions, and don't really care what business school flavor of the month ideas are applied to their treatment. Moreover, any health care system - government-run or private - is an insanely complex institution. It can take years to successfully implement meaningful long-term change, never mind evaluating, disseminating, and duplicating the results. By that point this year's TED-talk-inspired innovative approach will be as old as the hills and passe.

On the flipside, it means that we have time to think about festering health care problems - think, not just study - before squandering valuable time and untold millions (or billions?) of dollars. How should we think about a public policy problem, then? By asking some very basic questions that seem to elude too many policymakers.

For the purpose of the discussion, I'm going to assume that whatever health-care system we're talking about - a hospital, local primary care network, provincial/state authority - is properly governed, with leadership at least somewhat invested in making things better. Applying principles of sound decision-making to the recent or current U.S. Congress, for example, would be as instructive as farting into the wind.

1. Is there a problem? How often do you read a headline like, "Ourtownville has longest ER waits in the County" or "OECD ranks Sokovia 16th for nurses per capita"? Politicians and pundits love to fret over ratios and relative performance metrics, but who cares? It's not the Olympic games. What's the reward for being #1 in an arbitrary government service parameter? Keynote PowerPoint talk at a conference? I'll take a decent cup of coffee and cookie, thanks.

We see this in education all the time. Does it matter if South Korea's youth has higher average math scores than France's? Why? The absolute number might be a problem - say, the number of kids in a school board that aren't numerate - but chasing international rankings leads to policy fiascos like "discovery math".

If you're going to tackle a problem, you have to make sure there actually is a problem.

2. What is the problem? As is the case with medical disorders, public policy challenges have symptoms (ER overcrowding) and diagnoses (lack of long-term care capacity). Likewise, symptoms can be superficial and minor (delays to treatment for low-acuity patients in the ER) or severe and potentially crippling (lack of ICU beds). Sometimes, you can get away with treating a bunch of symptoms rather than the underlying problem - that's basically what doctors call "supportive care" - but with the billions at stake in large health care systems, it's far smarter to come to the right diagnosis before drawing conclusions.

3. What's the cause - the real cause - of the problem? If you have the right people asking the right questions, it's not hard to figure out what needs to be fixed. It's silly to worry about how quickly a porter can move an ER patient to a ward bed to improve patient flow, when the ward is full of people needing nursing home placement instead of a hospital.

There's value in knowing the answer to this question even if the real cause can't be remedied. Prescription drug misuse is a severe, systemic problem - you can train doctors and pharmacists to be smarter, even change laws around drug use, but nobody can "cure" the urban decay, poverty, and child abuse that predispose to addiction. By acknowledging that nobody has all the answers, at least you can identify where you should and should not focus your energies.

4. Does the prospective solution address a real cause of a real problem? If the answer to any part of this question is no, and the problem can be remedied by concrete policies - building capacity, reallocating funds, expanding or cutting programs - but isn't, it's at best a band-aid and at worst a complete waste of time and money.

5. What are the likely risks of the proposed solution? Every policy decision will have unintended consequences. Some can be foreseen, others cannot. It's not hard to figure out the obvious ones, and these should be actively brainstormed and aggressively solicited from stakeholders. Once you've accounted for the most likely possible downsides to a policy, the decision becomes a much more solid one.

I'm not sure why, but governments have an irksome habit of engaging potential stakeholders before determining a preferred course of action. Why worry about what the beverage industry thinks about obesity before you've decided on a "sugar tax" as a policy response? Isn't the conflict of interest glaringly obvious?

Unless the problems are genuinely systemic, none of this is terribly complicated. But time and again leaders and politicians go full-steam ahead to implement the most embryonic of policy ideas, with the results being anything but demonstrably positive.

Next time: tapping the right people to formulate policy

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