Watching Culture Change

January 16, 2013 at 3:01 PM Leave a comment

I do a fair amount of work in payment and delivery system reform, in various communities around the country.  I have been speaking to physicians about change coming for over a decade.  If you have done any of this work, you may have had this common experience: that change is hard, and people have to have a really good reason to change the status quo.  I admit it sometimes seemed to me that change would never come. 

But lately I have noticed some of the conversations are different.  I have been in a couple of meetings recently where audience physicians were answering the doubts and objections of other audience physicians. 

“Aren’t all these quality measures arbitrary, and unhelpful in real patient care?” one might pose. 

“No, in my organization, knowing our real performance has helped us improve things for patients.  We’re thankful for this information, and we’re proud of doing better,” another would answer.

“Isn’t this just a race to the lowest price?  Isn’t this just a way to penalize me for investing more in the care I give?”

“No, in fact quality and value rankings have helped weed out the bad performers in my procedure.  The guys looking to make a quick buck are gone, and should be gone.  And, my designation as a center of excellence has brought me new business.”

Say what?  Where did this second group of docs come from?

I’m not sure of the answer, but here are some guesses:

  • From integrated delivery systems.  Many of the docs in this new category come from places that have been able to generate their own internal quality and value reports.  Because these systems often have advanced IT shops and analytics, they are able to generate useful information based on both financial and clinical data.  This definitely is an advantage in the era of Big Data, and is one reason why we have seen and will see more provider consolidation.
  • From specialties that are competing for business nationally.  If your particular niche is a rare and expensive one, you’ve already experienced something many of your peers have not—buyers shopping actively and aggressively for value, holding up your services to the light.  They don’t come to you because you’re down the street, or even in the same state.  They come to you because you are able to offer something predictable, affordable, and professionally excellent.  And what buyers are shopping for is expanding.  They are looking at more services and conditions every day, and shopping for them regionally and nationally.
  • From those who have grieved the loss of unaccountability, and moved on.  If no one can measure whether you’re doing a better or worse job than the next person, it’s hard to penalize anyone for bad performance.  (It’s also hard to reward anyone for good performance.)  This is a real loss for us docs, as we took the lack of shopping by buyers as a tacit endorsement of our judgment and competence.  But truthfully, it probably represented as much an inability to judge quality by any meaningful criteria.  That’s hard to swallow, but those who are succeeding in quality-driven markets have gotten over that loss.

This second group of docs is by no means a majority.  But a decade ago, they were almost nonexistent.  I think we are following the typical innovation diffusion curve: experimenters, followed by early majority, followed by late majority.  I think what I have been seeing recently is the move from experimenters to early majority.  And that, as those familiar with that S-shaped curve know, is the steepest part of the curve.  Here’s hoping.

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