Thursday, September 8, 2016

Solving Healthcare Problems 101, Part III

So you've found the right people and come up with a foolproof plan. Now what?

Hopefully I've made the case that, as with many other public services, thinking about healthcare can be straightforward, though by no means easy. Sometimes the hardest part is agreeing on the exact problem you want to fix - improving quality or improve efficiency, reduce mistakes or reduce costs. Other times it's brainstorming concrete actions to improve upon long-festering, systemic problems - getting doctors into rural communities, reducing prescription drug abuse, and so on.

No matter the goal, nothing good will come of a strategy or action plan without proper execution. Even with detailed, properly managed implementation of small projects, there will be snags, cost overruns and screw-ups. Someone's kid inadvertently erases key documents on a USB stick, and the author's on holidays without telephone or internet. Unseasonably heavy rains delay pouring the foundation for the new building. The room for the new servers has inadequate cooling. Some of these hiccups are predictable, and can be accounted for by adding slack to the budget or timetable. Others are "unknown unknowns", and it's impossible to foresee the problems coming to pass.

Nevertheless, there are ways to approach implementation of a healthcare policy to mitigate unwanted headaches.

Think about implementation from day one. Brainstorming ideas costs nothing. Forging ahead with expensive ideas such as, say, labyrinthine energy schemes can be disastrous for everyone involved. If you've asked and answered as many questions as you can dream up around how the world will look if your plans work haven't dreamed up enough questions.

Assume nothing will go as you want it to. Budget for an increase in interest rates. Don't count on doctors signing on to the new hospital funding formula. Ask yourself if the plan will work if half of your nursing staff goes on parental leave in the next year.

Start with where you are now, not where you want to be. There's a tendency to treat public policy like business strategy - set a Big Hairy Audacious Goal, and retool everything you do to get there. That's what Jack Welch did for GE, right? Winning! Or like a chess game played by a Grandmaster - think ten, even twenty moves ahead, and work backwards to fill in the details.

Wrong. It's a terrible approach for public institutions. For one thing, large bureaucracies are not replete with creative thinkers and dynamic leaders. Some Ministries have absolutely sclerotic institutional cultures. Moreover, the complexity involved with drastic overhauls of a public service make backwards planning almost impossible...too many balls in the air, too many things to go wrong along the way. Most importantly, the downstream effects of a major public service overhaul will invariably hurt the vulnerable more than anyone. You want to "streamline" Children's Aid? If done poorly you risk opening more cracks for kids to fall through.

This is one of the major reasons the Affordable Care Act (Obamacare) seems so needlessly complex, even accounting for the "sausage-making" and dysfunction in the U.S. Congress. To take the employer-based system of health insurance immediately into a single-payer model (as Bernie Sanders campaigned on) would have thrown many thousands of people out of work, and wreaked havoc on the way doctors practice in too quick a period of time to ensure patient care wasn't compromised.

The better way to think of health care (or any other public service) is like a species undergoing evolution. Change only happens in one direction, and sometimes you have to accept "legacy" problems that preclude things from working the way you'd like. Humans still have tailbones and an appendix. We need neither, but we're stuck with them.

As a more salient example, Ontario's Public Health services are organized by municipality - operations, funding, and governance are all under the auspices of city or county governments. While it might seem ideal to put public health under the regional health authority umbrellas of the LHINs, the legal, jurisdictional, and administrative snags would take years to untangle. Sure, there are missed opportunities for better integration, but overcoming the hurdles is almost certainly more trouble than it's worth.

Limit interdependence where possible. If a cascade of interdependent events is necessary to achieve your goal, you don't have a plan but rather a house of cards. The only people that routinely try to pull off convoluted plans are movie and cartoon villains.

Let's say you have a policy objective of getting more nurse practitioners (NPs) into rural areas. You decide on three steps to make it happen: 1) expand the university programs that train NPs, 2) build Community Health Centres (CHCs) in the target communities, and 3) recruit doctors into an on-call pool to provide backup to the NPs. All sensible ideas, right? Yes, except that let's see what happens if one of these steps hits major roadblocks.

If you don't have enough qualified faculty to train NPs, the expanded programs won't be accredited. You're building CHCs and paying doctors for no reason.

If you don't build CHCs, you've created a glut of NPs that might not find work, and your rural communities are no better off.

If you don't put physician backup in place, there's a limit to what those NPs can do in those rural communities. You might have spent a lot of money without seeing the anticipated benefits.

When do overly complex, interdependent plans actually work? Oceans movies and episodes of The A-Team. Not a good approach for fixing healthcare.

Give ownership to the people behind the plan. I could go on (and have gone on) for days about Ontario's ludicrous strategy to reform primary care. Of the many, many problems with that plan, here's one we don't talk about. It came out of a single discussion paper, devoid of careful implementation details, and not one of its authors is leading its execution. Ask a group of experts to plot out a primary care framework that will affect thousands of doctors and millions of residents, but give them no hand in seeing it through? Governments do this all the time. Need your budget deficit slashed? Medical education overhauled? Call in the expert, then cut them loose.

There are reasons to give policy architects a key role in policy implementation. It improves the chances that the plan will be executed with conviction. More importantly, along with the credit someone can take responsibility for the results.

Be on the lookout for the sunk-cost fallacy. However much work or even money went into its development, a policy is an intangible, inanimate object. If some part of it - or even all of it - is no longer working or no longer needed, scrap it. There's no sense in throwing good money after bad, nor doubling down on a bad bet.

Health care is a messy human endeavor, people working with people, for people. No policy or plan will ever be perfect or fix all problems for everybody. Be thoughtful, methodical, observant, curious, realistic, and humble when you try to tinker with it, and you might just make it better in the end.


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