Why Not, Indeed

Recently in The Washington Post, author Daniel Pink initiated a series of columns he and WaPo are calling “Why Not?” He believes “American imagination needs an imagination shot.” As he describes the plan for the columns: “In each installment, I’ll offer a single idea — bold, surprising, maybe a bit jarring — for improving our country, our organizations or our lives.”

Sometimes you just have to ask "why not?" Credit: Bing Image Creator

I love it. I’m all in. I’m a “why not?” guy from way back, particularly when it comes to health care.

Mr. Pink describes three core values (in the interest of space, I’m excerpting his descriptions):

• Curiosity over certainty. The world is uncertain. Curiosity and intellectual humility are the most effective solvents for unsticking society’s gears.
• Openness over cynicism: Cynicism is easy but hollow; openness is difficult but rich.
• Conversation over conversion: The ultimate dream? That you’ll read what I’ve written and say, “Wait, I’ve got an even better idea,” and then share it.

Again, kudos. One might even say “move fast and break things,” but the bloom has come off that particular rose, so one might just say “take chances” or “think different.” Maybe even “dream big.”

Around the same time I saw Mr. Pink’s column I happened to be reading Adam Nagourney’s The Times: How the Newspaper of Record Survived Scandal, Scorn, and the Transformation of Journalism. In the early 1990’s The Times (and the rest of the world) was struggling to figure out if and how the Internet was going to change things. Mr., Nagourney reports how publisher Arthur Sulzberger (Jr) realized the impact would be profound:

One doesn’t have to be a rocket scientist to recognize that ink on wood delivered by trucks is a time consuming and expensive process.

I.e., contrary to what many people at The Times, and many of its readers, thought at the time, the newspaper wasn’t the physical object they were used to; it was the information it delivers. That may seem obvious now but was not at all then.  

Which brings me to health care. Contrary to what many people working in healthcare, and many people getting care from it, might think, healthcare is not doctors, hospitals, prescriptions, and insurance companies. Those are simply the ink on wood delivered by trucks that we’re used to, to use the metaphor.

And it doesn’t take a rocket science to recognize that what we call health care today is a time consuming and expensive process – not to mention often frustrating and ineffective.

Why not do better?

I also thought about health care when reading Mr. Nagourney’s book when he described the conflict between the journalism side of the company versus the business side: was the newspaper about the articles it published, with the advertising just there to support them, or was it really an advertising platform that needed the content the journalists created to bring eyeballs to it? In healthcare, is it about helping patients with their health, or is it a way to provide income to the people and organizations involved in their care?

I.e., is it about the mission or the margins?

That's the dilemma. Credit: Bing Image Creator

If you think that’s too cynical, I’ll point to Matthew Holt’s great article in The Health Care Blog arguing that many hospitals systems are now essentially hedge funds that happen to provide some care, while also creating scads of rich executives. Or to how an actual hedge fund is buying a hospital. Or to how, indeed, private equity firms are buying up health care organizations of all types, even though many experts warn the main impact is to raise costs and adversely impact care. Or to how Medicare Advantage plans may be better at delivering insurer profits than quality care.

I could go on and on, but it seems clear to me that healthcare has lost its way, mistaking how it does things from what it is supposed to be for. If healthcare has become more about making a small number of people rich than about making a lot of people healthier, then I say let’s blow it up and start from first principles.

There’s a “Why Not?”

Mr. Holt’s “Why Not?” is to take a measly $38b from the $300b he estimates those hospitals are sitting on, and invest it in primary care, such as the Federally Qualified Health Centers (FQHCs). Primary care needs the money; the hospitals/hedge funds, not so much. Amen to that.

A couple years ago I proposed an even wilder idea: let’s give every physician $2 million – maybe even $2.5 million – annually. We say we value them, so let’s reward them accordingly. The caveat: from that they’d have to pay for all of their patients’ health care needs – referrals, prescriptions, hospital stays, etc. I posited that they’d negotiate much better deals with their compatriots than we seem to be able to do. Lots of details to be worked out, but it falls into the “Why Not?” category.

Here's another audacious Why Not: it’s fairly well known that CEO to worker pay ratios have skyrocketed from a modest 20-1 in the 1960’s to something like 344-1 now. There’s no evidence I’ve seen that the ratios are any better in healthcare. Since no profession in healthcare is more respected and relied on than nurses, I propose – maybe making it a condition for receiving any federal funds -- that no healthcare organization should have an executive compensation  to nurse compensation ratio that exceeds 20 (and I do mean compensation rather than salary, to avoid the bonus/stock shenanigans that executives have relied on). 

If that sounds low, I’d pity the executive who wants to argue with straight face that he/she is more than twenty times more important than nurses. I bet they couldn’t find many patients who’d agree, or any nurses.

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If you work in healthcare, you should ask yourself: is what I do the ink, the wood, or the delivery truck, or is it truly integral to what healthcare should be in 2024?  If you think your job should be more about health and less about the business of health, why not make it so?

And the rest of us should be asking ourselves: is the healthcare we get still the equivalent of a print newspaper? We don’t have to be rocket scientists to recognize that, in 2024, we should be expecting something better – cheaper, faster, more interactive, more personal, and much more impactful.

Why not, indeed?