How to pick a winning Government Program

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.