Friday, February 15, 2008

Collaborating to Control Health Care Costs

In the losing battle to contain health care cost increases, employers and insurers are getting some black eyes.

In previous posts I discussed (a) employer experiments with penalties for poor employee health habits and (b) Blue Cross of California's stab at enlisting physicians in detecting enrollee fraud. Both efforts are in retreat.

Blue Cross had asked physicians to review the accuracy of insurance applications from their patients. This practice is allowed by California law. But physicians were outraged at being asked to "rat" on their patients. Blue Cross backed down, and acknowledged that it "was creating a misimpression and causing some members and providers undue concern."

With regard to employer incentives, Clarian Health Partners, an Indiana hospital system with 13,000 employees, had set standards for tobacco use, weight, blood pressure, blood glucose, and cholesterol. They proposed that employees who did not meet the targets and were not working toward them would pay $5 per risk toward their health insurance premium per pay period. Employees revolted. Like Blue Cross, Clarian backed down.

I don't agree with the California Medical Association in faulting Blue Cross or with the Clarian employees in faulting Clarian. Blue Cross and Clarian are trying to make cost-containing moves in a profoundly broken system. As a result, like drowning swimmers they thrash about and raise havoc with those they interact with.

Until a clone of former Oregon Governon John Kitzhaber appears on the national political scene, we can't expect the kind of educative leadership our body politic needs. (See the speech I proposed ten years ago for the Vermont Governor.) In the absence of top down leadership, we have to rely on bottom-up collaboration. Blue Cross should sit down with the California Medical Association and say - "OK guys - we really messed up. Let's learn from our mistakes and work together to get a better grip on costs..." Clarian should do the same with its employees.

Liberal outrage against "unethical insurers and employers" and conservative outrage against "entitled, cost-unconscious employees" make for lively journalism and elevated pulse. But the psychiatrist in me sees these unproductive battles as efforts to avoid acknowledging a painful fact - we need to set limits in health care. Family therapists know that family fights don't end until the family acknowledges the real source of pain. When that happens, families can get down to work on making things better.

We need to learn to use the "family arguments" between insurers and physicians and between employers and employees as pathways towards ground-level collaboration. In families, when parents crump out - the way our political leaders have been doing for years - the kids have to do the work!


GhostOfTyrone said...

Hi Jim,

I agree with you 100%. It's unfortunate that both Blue Cross and Clarian are backing down. It's frustrating to see different parties continually prodding at this, the broken machine that is our healthcare system, all from different angles and most with negligible, if any , results.

And by the way, whether intended or not, your post would make for an absolutely excellent speech to address this issue.

eric said...

Jim--Leadership is important. And, as you suggest, it's not leadership that tells people what to do, but leadership that gets people talking to each other about the real issues. This is described nicely by Ronald Heifetz in Leadership Without Easy Answers. In chapter 4 on "Mobilizing Adaptive Work," he describes how William Ruckelshaus led the EPA in 1983 to mobilize all parties in Tacoma, Washington to talk about the risks and benefits of continued copper smelting, taking into account the arsenic there. Instead, Ruckelshaus could have easily handed down an edict and left it to the parties to fight it out in court. --Eric

Jim Sabin said...

Hi Ian and Eric -

Thanks for your comments and suggestions.

Both of you are moving the issue of leadership forward. Ian, I hadn't thought of the post as the basis for a speech, but I have been thinking about these issues in the context of the presidential campaign. No candidate is going to run on a "Let's Start Rationing Now" platform. But I do believe that candidates could (a) start educating us about what is really required to get a grip on costs - particularly, that prevention and reduced administrative charges, as important as they are, aren't enough, and (b) do it in a way that emphasized their leadership capacities as a potential future president. Eric - thanks for the Ronald Heifetz reference. I've put in for the book at my local library!