A friend and I were discussing a plan to overhaul Maine’s school system, reducing the number of districts from more than 400 to 26. Even though we’re both skeptical of the promised $291 million savings, I like the plan, while my friend hates it.
What’s this got to do with healthcare finance? My view of systemic change might be termed “revolutionary,” while my friend’s is “evolutionary.” He thinks it impossible to produce meaningful changes in large complex systems without buy-in from all stakeholders. I think it unrealistic to believe meaningful changes will occur from within a system, especially if it requires the consent of stakeholders.
Since I think the evolutionary view is currently in vogue, I’ll make my case for the revolutionary side.
A stable system occurs when all stakeholders suddenly find themselves holding positions worth defending. This doesn’t mean that every player’s in an optimal position, but rather that there’s at least a bird in the hand (even if there are two in the bush) for every participant.
In healthcare, stakeholders include patients, providers, payers and the government. Of course, it’s far more complex than that – there are a variety of patients, pushing a variety of agendas; there are different kinds of providers, from different sectors, serving different patient types; there are a multitude of payers, some private, some public.
As research in political science and economics shows, groups form alliances to protect their interests. The result is an irrational commitment to the status quo. But it is also inefficient from a systems perspective – the “big picture” is more than the sum of interests.
History teaches that inefficient but stable systems can change, but only when new circumstances – a new and powerful stakeholder, for example, or technical innovation – upsets the status quo.
Consumerism has been touted as just such a disruptive force. My own hunch is that while consumerism itself may not overhaul our healthcare system, reactions to it – such as AOL founder Steve Case’s latest effort, Revolution Health – can change the stakeholder equations. When Case starts making a ton of money helping consumers save money, the status quo won’t seem so, well, static.