Author: Shawn Whatley

Scouts pick pro athletes in high school. Agents pick winning manuscripts. Even backyard gardeners pick weeds out of a sea of identical shoots.

Experts in all fields identify winners and losers.  Why is it so hard with government programs?  Every year we hear about new programs or structures that promise to fix healthcare like Local Health Integration Networks, Health Links, and Health Care Connect.

Each wave of politicians feels the need to create a splash of new programs that cost more than anticipated and deliver less than hoped. How can we choose great government programs without it feeling like playing the Ontario Pick 3 lottery?

Les Vertesi, in his book Broken Promises, wrote that government programs fail because they:

1. Assume a new and large bureaucracy.
2. Assume people will do as told.
3. Ignore unit value and only focus on total cost (usually large).
4. Avoid mentioning incentives.
5. Forget about customers, or treat them like widgets on an assembly line instead of agents with choice.

How to pick a winning government program

Using Vertesi’s comments, we can draft a tool to help us sift out winning government programs. All programs should:

A) Add no new bureaucracy.

Great businesses find ways to build new programs that use existing management. Unless politicians are vigilant, even circumspect, bureaucracy bloats and spawns. We need money for patient care, not more paper-data-regulation-reporting. At the very least, new bureaucracy should eat up a tiny part of the budget.

B) Assume individual freedom.

People break rules. Rules get misunderstood. New programs should build these assumptions into their design. We do not live in a 1950s, rule following society. Leverage rebellion into the design. Inspire rule-breaking to benefit patient care.

C) Report costs per patient.

For example, how much does it cost to deliver a baby? Does the cost change if a midwife delivers versus a physician? Reporting annual earnings of midwives alongside doctors creates a festival of envy. It does nothing for patients. Instead of talking about program costs, government should share unit costs.

D) Align clear incentives.

Every schoolboy knows that people respond to incentives. And every schoolgirl knows that money is only one of many incentives. Failed programs pretend incentives do not work. They tack them on as an afterthought or align them in opposite directions.

For example, outpatient chronic care programs often pay doctors for each patient seen. They pay nurses whether they see patients or not. And they pay hospitals less for seeing more patients (hospitals often close outpatient clinics to save money).

Soldiers follow orders, but civilians need aligned incentives.

E) Consider people, not things.

Vertesi suggests we have soup kitchen healthcare. A small group of people makes the soup and decides how much everyone else gets. The rest of us line up for our fair share. But some people cannot eat soup. Patients come with needs that often defy tick-boxes. They choose to seek care where it works for them, and then they decide whether or not to follow instructions.

Progressive

Our current government lusts for change.

• The Price-Baker report tells us to think of patients like children in a school district. They should enroll with their local clinic, no choice allowed.
• The New Graduate Entry Program limits new doctors to earning less than some nurses, after overhead, with rigid productivity rules.
• In the next few weeks, we expect a promised ‘white paper’ from the government on healthcare reform. Will it add bureaucracy and cost? Will it discuss incentives, patient choice and unit cost?

Government could ask doctors and nurses about basic criteria that every new program must address; like a surgical checklist, except for government.

Asking frontline providers about new plans before implementation might increase the chance of picking a winning government program. But then, they’d have to ask.

 

Trust fund babies enjoy income for life, and almost no worries about appearance, job performance or promotion. If they avoid felony, regular cheques never stop.

A job in healthcare offers something similar: an unending supply of sick people, solid incomes and some respect. If you get even a few years’ seniority, a healthcare job lasts your whole working life, regardless of performance.

How to get fired in healthcare

Let’s look at bureaucrats, hospital administrators, unionized employees and doctors.

Bureaucrats

985 federal public servants were fired between 2000-2005. There were 210,000 public servants, 260,00 if we include separate agencies (What Is Government Good At?, p. 196-7).

That means 0.07% of federal public servants got fired for misconduct, or released for incompetence and incapacity, per year.

Maybe the fired employees did something really bad. Or perhaps the other 99.93% were really high performers. Or most likely, bureaucrats do not get fired.

Observation suggests bureaucrats in healthcare do not get fired either.

Granted, layoffs can come unexpectedly. In 2012, 19,200 federal employees were cut (7.3%). But overall, even former Prime Minister Stephen Harper increased the number of public servants by 30,000 during office. Still a pretty secure profession.

Challenge: Name 3 healthcare bureaucrats who lost their jobs for underperformance or a failed program.

Administrators

Hospital administrators usually get promoted from nursing or other allied health professions. They work hard and earn better incomes in management. By avoiding obvious errors, they get decades of solid earnings with job security.

Hospitals started to put 10–15% of administrators’ pay at risk against performance targets. This guarantees targets are modest at best. Why risk job security for 15%?

Only physician administrators can afford to take on real risks. When doctors assume part-time leadership roles, they can push for serious change, secure with their clinical jobs to fall back on.

Challenge: Name 3 hospital administrators fired for low performance.

Bonus: Name 3 that were promoted despite sub-stellar output.

Unionized Employees

Hospital leaders spend at least half their time, if not more, dealing with union leaders’ opinions about process, union member grievances and collective bargaining issues.

Unless they try hard, union members do not get fired.

True, workers risk being laid off during the first few years on the job. Collective bargaining often forces hospitals to hand out raises by firing junior staff. But after a few years of seniority, unionized employees are set for life.

Challenge: Name 3 unionized employees who lost their jobs for performance issues such as low productivity or bad attitude.

Doctors

Parents tell their children to study hard, get into medical school and they’ll never have to worry again. There will always be sick people, and doctors will never be out of work.

Actually, doctors can lose their jobs.

Doctors take on personal debt, so they can work in the public system. Beyond several hundred thousand dollars of school debt, most doctors finance new practices. If they expand a clinic, they get a second mortgage or dip into RRSPs.

Doctors must work hard to cover overhead, or they go out of business. Outside of academics and salaried positions, doctors shoulder the same pressure to produce as every other small business. If they survive, their gross billings become part of average billings the media loves so much, a case of survivor bias.

To be fair, many docs work in niche markets and survive while being rude to patients. This is wrong. In an open system without rationing and turf protection, all doctors would have to serve, or go out of business.

Some doctors commit a felony and lose their licence. But only a few leave this way. Far more close their clinics or change jobs due to business pressure.

Challenge: Name 3 doctors who had to close their clinic, change jobs or quit. (If you need help, check out this infographic.)

Reward for Success vs. Pain of Failure

Everyone champions accountability for doctors these days. But no one tries to make bureaucrats, administrators or unionized employees accountable. Never mind patients.

Hernan Cortes burned his ships in 1519. His sailors knew they had to conquer the Aztec empire or die trying. People never move forward if they see no reward for doing so; less risk in staying put.

As long as…

• bureaucrats never lose their jobs for underperformance and do not get bonuses for success,
• unionized employees get paid no matter how slowly they move and get raises regardless of performance,
• and administrators get promoted just for avoiding mistakes,

…medicare will continue to lag.

Either we put everyone’s job at risk based on performance, or we put all doctors on salary like everyone else. As small medical businesses die off, maybe doctors should work towards the job-security-regardless-of-performance that everyone else in healthcare enjoys?

Physician autonomy is fading into history. Doctors might want to consider trading up for the security everyone else enjoys.

 

Steven Paikin, from TVO’s The Agenda, wrote a great blog. Every stakeholder seems to have a powerful organization, except patients. Who speaks for patients?

This is more important than any content I have right now. Here’s Mr. Paikin’s post in full (or click the link to his site).

When will Ontario’s Health care system finally focus on the patient?

by Steve Paikin

The people of Ontario spend $50 billion a year on the province’s healthcare system, and that’s only through their taxes. For many, of course, there are user fees, co-payments, drug costs and private insurance premiums on top of that.

You’d think all that money going to doctors, nurses, hospital workers and administrators would ensure we get the best care, and that the patient experience would be at the centre of that focus.

Think again.

There’s a growing realization that in spite of the huge dollars spent on treating sickness in Ontario, the patient actually isn’t at the centre of everything. And that’s becoming increasingly unacceptable given how much we’re spending and how unsatisfactory too many patient outcomes are.

Recently, The Walrus magazine convened its annual Health Leadership Dinner, at which several dozen of the leading figures in Ontario health care attend to debate the biggest issues of the day. The dinner operates under a form of the Chatham House Rule, meaning what’s said can be repeated, but not attributed to the speaker. I’ve moderated that discussion for several consecutive years now, and I can tell you, those rules do encourage a very free-wheeling, honest discussion. Over the years, several ministers of health, deputy ministers of health, assistant deputy ministers of health, along with numerous stakeholders in the system have been in attendance.

(Full disclosure: my wife founded and chairs the dinner; she’s a volunteer director on the foundation board of The Walrus).

The portrait of Ontario’s health care system that emerges is unsettling. “The fatal flaw in the system is a lack of integration of care and services,” one observer noted.

That observer’s check list looks like this:

• Too many vital services are not covered by the Ontario Health Insurance Plan.
• The system operates in silos.
• It’s not remotely ready for the demographic changes that are coming.
• Stakeholders operate as if the system is theirs, rather than the patient’s — for example, patients still need to pay to get photocopies of their own health records.
• The system is still burdened by 1960s architecture that often makes putting in new state-of-the-art equipment difficult.
• Patients need a “Sherpa” to navigate their way through the system.

“The Ontario health care system isn’t in crisis,” this observer said. “It’s in stasis.”

Furthermore, patient input into making improvements is treated as secondary and frequently met with suspicion, according to another critic.

“When we meet with the ministry, we’re forced to sign confidentiality agreements,” this critic says. “The public doesn’t know what goes on because all the meetings happen behind closed doors. There’s a lack of respect. Pundits and experts are there, but people who represent actual patients are evicted. The government tries to intimidate us.”

Not only that, everyone who works in the health care system has a special interest group representing them:

• Doctors have the Ontario Medical Association.
• Nurses have the Ontario Nurses’ Association and the Registered Nurses’ Association of Ontario.
• The Ontario Hospital Association represents the hospitals.
• The Canadian Union of Public Employees and other unions represent other workers in the system.
• Administrators get a seat at the table through Local Health Integration Networks and hospital CEOs.
• The Ontario Long Term Care Association represents those who run facilities for those who can no longer live in their own homes.
• Home Care Ontario represents those organizations that provide home care.
• The Ministry of Health and Long-Term Care has ample numbers of bureaucrats setting policy.
• And, of course, the government steers the ship via the minister of health and an associate minister of health, not to mention the premier’s office and the president of the Treasury Board, who must approve all spending.

Who, on this long list, is supposed to represent the patient? Theoretically, of course, they all do. But too often, some critics say, the patient’s interests take a back seat to those of the stakeholders: The “players” in the health care system want things from government; government, in turn, tries to placate those stakeholders to the extent it can. As the $50-billion pie is divided among the players, who represents the end user so his or her say can be taken into account?

Are things changing? Hard to say. Representatives from the Ministry of Health told the dinner that patients are invited to discussion tables to participate in policy-making sessions. (Critics say their presence is mere tokenism).  However, the Ontario Government will also hire a “patients’ ombudsman” sometime in the spring — a new watchdog whose sole responsibility will be pursuing patients’ complaints with the healthcare system.

While most people I’ve talked to are encouraged by that development, they also note that’s a “downstream” solution. In other words, the harm has already happened once a complaint is laid. How can the province change the way it does things to ensure problems don’t happen in the first place — in other words, find an “upstream” solution?

One idea that emerged at the Walrus dinner: perhaps the government needs to create an assistant deputy minister for the patient and caregiver experience — someone whose job it would be to filter every new policy change through the eyes of the patient. Under the Liberals, there are 16 assistant deputy ministers in charge of several different sectors such as health system information, drug policy, communications, corporate services, human resources, negotiations, strategic planning, long-term-care homes, accountability and performance, and quality and funding.  But there is no one that high up on the ministry organizational chart whose sole mission is the patient experience.

One former university president in attendance at the dinner said it wasn’t until he created a “provost in charge of the student experience” that the yardsticks really got moved at his institution.

Is it time to create an assistant deputy minister for the “patient experience?” And if it isn’t, how will the patient’s voice genuinely be heard in an increasingly complex and expensive system?