OK: People are motivated by money. Check. people want to get ahead. Check again.
This idea has recently (last 20 or thirty years it seems: Recent in geologic time) has been taken almost as a point of religious belief about its basic truthiness. This faith has few tenets, the main one being that Greed is the underlying engine of capitalism. Capitalism is how you take advantage of peoples basic drives (be they basic power / money lust type of greed or just wanting to get ahead so that one can be a better caregiver for their family) to power innovation and so forth.
If you pay people more for good, profitable results, what happens when the people making the big money can not achieve those ends via innovation, either because :
- It is taking too long to develop the new innovation, or
- Taking too many resources to develop or
- The people doing the actual deciding just aren't as smart as they should be?
- What happens if the people we chose to lead us in these hospitals are like the way we often pick presidents here in the states, where studies show that the taller, more attractive, better hair, etc, the more likely they are to be elected. Sure, we sometimes get lucky, like this last time, but the two times before that we picked an evil clown (and yes, it is possible that all clowns are evil).
- What happens when the path of least resistance is not innovation but exploitation?
If we only pay better for better results, and how we measure those results is profitability... how does that make the heath care system better? If the path of least resistance to profitability in health care is to deny peoples health care claims, and make them work harder in order to file claims, how is health care improved? If you can keep nurses underpaid and exploited, and import doctors and nurses from other countries who will take less money, how is health care being improved by being for-profit?
What about people that work for free? If the hospital actively uses volunteer help such as the famous Candy Stripers and they are for profit, how can they feel good about not giving any of the profit they made by leveraging the cheapest of all possibel labor: Free? In fact, isn't it bit odd (in an exploitative sense) to ask for people to volunteer in a for-profit hospital? Isn't that like saying to them "I want to make good money on this, but you should do this out of the kindness of your own heart."
For-Profit medicine can work out all sorts of ways. Some would tell you that the modern hospital buys the latest gear so that they can compete with the hospital down the street, driving innovation and so forth. That same logic says that in hard times like now, even if there is a new gizmo that will save lives, that it will be subject to Profit and Loss (P&L) logic, not "Will it save lives if we get one" logic. Even the general idea that going ahead and buying the new gear now, in the down time, might actually help get struggling companies through the hard time will met with no compassion when it is a P&L decision. It is easy to imagine the statement: "It is hard, but we have a responsibility to our stockholders. They expect us to profit, not to make decisions with altruistic motives."
Not saying I have heard that, or read it, just that it is easy to see how such a statement could be made, and would be accepted as "well yes: Its just business". In fact, how many times have you heard the phrase "Nothing personal: Its just business" as if that makes any act, from disadvantageous to outright evil OK?
P&L logic attempts to put a price on human life, and then say once someone has exceeded that cost that they should be allowed to suffer or die. At the same time, there are all sorts of debates going on about whether or not it is OK for someone to determine when they no longer wish to continue this lives struggle. The answer sometimes comes back that as long as they have insurance, they should be forced to continue to live. One argument against government health care is probably that the government, being so big that the decisions for prolonging life get even more complicated because the government potentially has a lot more money to spend on heroic measures, no matter what the poor person hooked up to all the machines may think about it. This problem was recently solved when Bush's buddies drained all the money out of pretty much everything. Gee, thanks guys. Solved that little problem.
There is a reason the small local hospitals are dying out and the large regional hospitals are jumping into existence. It has nothing to do with convenience or quality of care, and everything to do with the reason why airlines always fly you through their regional hubs, even if they have to take you out of the way to get there.
Measure for Results
Having "said" all of those things, I do actually believe that there is a place in health care for for-profit business. I just think that the compensation plan has to be set up correctly. You can not pay people for health care results: For qualitative improvements in life. You can have the only results be the fiscal bottom line in health care. That way lies the dark side.
Businesses talk all the time about tying pay to performance, but the metric is always the easy bottom line one. We are going to have to dig deeper. Find a different metric. We have to incent the behavior that we want, and we have to find a way to measure "Health" and "Care" so that it is not an oxymoron. Honest. People really will by and large do what you pay them to do.
Leave me alone. Incent is too a word. Go away word police.
There are ways to measure decreases in:
- Loss of life once care is received
- Infant death rates
- Non-accidental death at a given age rates
- ... and increases in quality of life. One I care about is not how long I live so much as how long I live independently. If I am still crawling out of bathroom windows, I'm good to go.
Those measurements have to be at the very core of the compensation program. You can measure the time it takes from the time someone enters the ER to the time they see a Nurse, a Doctor, and then are discharged, and you can *then* measure how happy the patient was that they received quality care, and that their particular problem was solved. Be careful there! The key metric is not how fast they were pumped though and discharged, but how fast they were seen and really cared for! The length of stay metric only counts when looked at *in context*.
You need to have metrics to know if you are being efficient, but how fast does not measure quality of care. You can assume there is a relationship between time spent in the ER and how happy they will be with the care, but it is not congruent. Fast does not equal better. Take triage for example. In the case of someone who is in the ER with a serious but non-critical (say a broken leg) condition that is stuck in a hall for hours. This is fine to some degree if there is a real bubble in the caseload, and that during this bubble there are worse cases to be seen to. If it happens all the time then there is not enough staff for the workload, it is not a bubble, and profit be damned, staff up.
One of things that has many people on the right worried about changing the health care system is that by insuring everyone that the profit motive will be gone, and that this will drain innovation out of the system as well. It is easy to see in some countries that bureaucracy can be a real problem. Of course, many on the right do not believe that any government can be built that is efficient or internally motivated to do the right thing (yet they keep running for office).
The answer to this is actually the same one as for the health care companies and insurance companies: Measure for and reward the result that you want. People like the money. Give them some when they figure out better ways to do things: When they figure out how to cut red tape, and increase efficiency, give them a piece of the action. Even the "lifers" that, according to legend, gravitate to the safe government positions, will not mind having a chance to make more money, and given the tenure of many, there are probably ideas floating about just waiting to be rewarded rather than punished.
Be careful though: Reward systems are just as often dis-incentive systems as they are incentive systems. A badly designed incentive system is worse than no incentive system at all. Here comes that problem again: we need competent people designing this thing, not placeholders or crooks.
If you want to see how not to set up a measurement system, see the so-called "No Child Left Behind" stuff. That manages to measure just about everything wrong, and to motivate things like teaching the test rather than learning the material.
Be careful for how the system can be gamed. It will be gamed. There are people who take deep pleasure in finding ways to make the system give them money without them giving the desire result. We call these people "Scum", but they exist in large numbers. See your Inbox SPAM for details.
Example: I knew a guy who set up a system where he measured people on their code defects. The instrumentation point was how many cases of a certain type were opened up after code was released. Developers, QA, and managers were rewarded for low defect rates. The game was simple: Don't let any problems be officially opened: put everything on paper, and solve the problems on the down-low.
As such people exist, the reward system will have to be balanced with a punitive side. The reward can not be worth the risk, or it will be gamed. It will still be gamed. Some just love a challenge, but not the challenge of playing it straight. That it appears is too boring, and not risky enough. I am told some people jump out of perfectly good airplanes for fun too.
The things that work against "pure" capitalism, and keep it from actually working the way it is supposed to:
- Those that game the system because they love a challenge
- Those that rig the system because they are mediocre
- Invalid metrics
I think I have made my point. But just in case I have been unclear, have a look at the recent stock market meltdown (This is being written in 2008....). Look at guys like Bernie Madoff and his 50 Billion USD Ponzi scheme. Like any Ponzi scheme, the early investors did OK. It was the last ones in before it fell apart that were left holding the bag.
This same thing can happen anywhere. Anytime. Not only do you measure for the results that you want, you have to be sure you are measuring for the results that you do NOT want.
