Chapter 1   

Myth #1

We have a system of health care.

I haven’t noticed. Mostly we have a collection of disease cures, or at least treatments, often the more acute the better. Overall, “health care” favors cure over care, acute diseases over chronic ones, and the treatment of diseases in particular over the prevention of illnesses and the promotion of health in general. As for research, development of cure receives much more attention than the investigation of cause.

Calling something a system does not make it a system where it needs to deliver. A system is characterized by natural linkages across its component parts. As we shall discuss later, a cow is a system, since its organs function together naturally. You and I are systems like this, too, at least in how we function physiologically, if not socially. About how much of the field of health care can we say that? What happens when all we individual physiological systems get together in a social context? Even the various medical specialties often have difficulty working with each other, let alone with nursing, community care, and management. As for the inclination to treat diseases instead of preventing them, let alone promoting health, see the box on “Health Promotion over the Cliff.” It is not quite an allegory.

The French word for a surgical operation is intervention. Using the word in English, that is significantly what happens in health care: intermittent and disjointed interventions, whether in primary, secondary, tertiary, or so-called alternative medicine, as well as in public and community health. We need more systemic practices in health care, especially to reconcile the delivery of quantity, quality, and equality.

¹ Abraham Fuks of the McGill Faculty of Medicine has pointed out how medicine has reconceived some of its practices as preventative: “In the case of non-infectious diseases, preventive medicine has been transformed into a search for disease at its preclinical stages. . . . This strategy is reminiscent of the early warning systems of anti-missile defenses” (2009: 5).

Chapter 2 

Myth #2

The system of health care is failing.

If there is one area of agreement in this field, this may be it: these “systems” are failing, all over the world. Users and providers alike complain bitterly about their health care.

At a party in Montreal a few years ago, I got into a conversation with a young radiologist who went on and on about how bad health care was in Quebec. “You did your residency in the United States,” I finally intervened. “How about that?” She threw her hands in the air: “Don’t get me started on the American system!” Sometime later I was in Italy, with people in the field who were likewise putting down their health care. So how does Italy compare with other countries, I asked. Oh, they replied: in the last ranking by the World Health Organization (2000), Italy ranked second best in the world behind France. Is second best still bad?

SUFFERING FROM SUCCESS

Quite the opposite: I believe that second best and much else is actually rather good—as far as it goes. In most places in the developed world, the treatment of disease is succeeding, often rather dramatically. The trouble is that it is doing so expensively, and we don’t want to pay for it. In other words, where it focuses its attention, health care is suffering from success more than from failure.

And where it focuses less attention—in preventing illness in the first place—there have still been remarkable improvements, for example, in vaccines and the promotion of better eating and more exercise. It is just that here the pace of improvement is slower, and the efforts and resources expended are less—and no match for the commercial interests that promote poor eating and sedentary living.

On some of the broadest measures of life expectancy, infant mortality and others, performance in most countries has been steadily improving. A World Health Report in 1999 reviewed “the dramatic decline in mortality in the 20th century.” To take one of its examples, Chilean women in 1998 could expect to live to age 79 on average, which was not only 46 years longer than their predecessors of 1910, but also 25 years longer than women of 1910 whose countries had the 1998 Chilean income level. The report attributed a part of the reduction in mortality to “income growth and improved educational levels—and consequent improvements in food intake and sanitation” but concluded that access “to new knowledge, drugs, and vaccines appears to have been substantially more important” (1999: 2).

Don’t get me wrong about this claim of health care succeeding rather than failing, as did the head of an ICU who attended our International Masters for Health Leadership program (imhl.org). When he heard me say this, he became angry: he had to live with the errors, the distortions, and the other failures of health care. I could not argue with him about any of this, only to reply that I use the word success to mean getting better, not being perfect. Health care has its problems, to be sure, but it has been making remarkable progress where it focuses.

How about being offered this choice: (1) Health care circa 1960: when you feel chest pains, your GP comes to your home, gets you straight into a hospital, where you get attention from many doctors and nurses, who eventually send you back home to rest and hope for the best. You have received state-of-the-art health care. Or (2) health care now: no doctor comes to your house—you may even have to get yourself to a hospital, there to wait in an overcrowded emergency room until you get to cardiac surgery, where a stent is inserted, so that you can be sent home the next day, in rather good shape. You have received rather ordinary 21st-century health care.

Medicine has been particularly brilliant at developing expensive new treatments. Who among us is prepared to forego one of these to save our life? So we live longer, although sometimes more expensively sicker.

But not always: Consider a 90-year-old man in Vancouver who demanded an expensive hip replacement so that he could keep running. He was intent on maintaining his lifestyle, at the expense of the taxpayers of British Columbia. Could they fault him?

Pharmaceutical companies have had their expensive successes, too, except that these have been far too expensive in those countries disinclined to control the exorbitant pricing by this industry. (Bear in mind that these companies depend on state-granted monopolies—namely, patents—to charge what they do. When in the recent past has any country ever granted monopoly rights on necessities of life, such as electrical power or fixed-line telephone services, without seriously controlling prices? Being allowed to charge “what the market will bear” [a term used in Businessweek by Carey and Barrett in 2001] is simply patent nonsense. [See my article by this title, Mintzberg, 2006b.])

MORE FOR LESS?

Of course, while the costs of treatments go up, so too must the budgets to cover them, whether they are paid by taxes, insurance premiums, or personal payments. If we want more, we have to pay more. But in this age of consumptive greed, we want to pay less—or at least not that much more.

For the most part in the field of health care, we are not buying services so much as the possibility of needing services (i.e., insurance). Why, then, should I pay for you, who is sick, while I am healthy and probably invincible at that? In other words, while the ill act as a concerted force for spending more locally, the healthy act as a general lobby for spending less nationally. This is not a happy combination: it makes the field of health care sick.

Reconciling Supply and Demand

Before considering the obvious consequences of this, let me mention two other myths related to this one. The first is that we cannot afford the escalating costs of our health care services. Of course we can: it’s a question of choices, individual and collective—really individual or collective. When we spend on cars and computers, we get instant gratification. How is health insurance, public or private, to compete with that? ¹ It offers no fun! In the case of the United States, while health care costs far exceed those anywhere else, the very rich pay low taxes, and some major corporations hardly any taxes, while many Americans have long suffered for want of basic services.

The other related myth is that the demand for health services is insatiable: provide more and we shall consume more. I don’t know about you, but going to the doctor is not my idea of a good time (although I do like to chat with my particular GP): the waiting room, the needles, the prostate examination—no, thank you. I don’t even cherish being admitted to a hospital. “Medical procedures are not hotcakes. People aren’t going to line up eagerly demanding heart transplants just because someone else is paying” (CHSRF, 2001, citing Robert Evans of the University of British Columbia).

For every hypochondriac, how many other people avoid health services like the plague (so to speak)? Even that 90-year-old in Vancouver was not being unreasonable. Put yourself in his running shoes: this was truly a question of health care. So excessive demand for health care services is not the problem so much as reasonable demand for services that are in short supply, thanks to our collective reluctance to pay for them. (An exception can be noted here for the proclivity to order too many tests, especially in the United States, where there is so much litigation.)

Of course, there is a supply side to this issue. Give some physician the time and the fees for some treatment, and he or she may find lots of illness in need of it. Or give some hospital more beds and it will fill them. Is this a bad thing? Only if the added services are unnecessary or, worse, lead to the diagnosis of conditions that are better left untreated. ²

So what are the consequences of all this? Quite simple: The field of health care is being squeezed on all sides, by governments and markets, demanders and suppliers. As a result, many users are justified in feeling that they are not getting the services they need—not fast enough, not good enough, or just plain not enough.

Pervasive Rationing

Rationing is a taboo word in much of health care. In Canada, governments go to great lengths to avoid mentioning the R word, let alone facing decisions about it. Yet rationing is an intrinsic part of health care, everywhere, all the time—for example, when a night nurse has to decide which of two beeping monitors to attend to first, or a physician has to determine who is to get a kidney that has become available for transplant, or a government or HMO has to specify the age at which people can no longer get some expensive treatment. The only alternative to this rationalizing is that everyone gets everything to cover every possible contingency. That is hardly feasible, at least if you are not Michael Jackson—and look what happened to him. ³

Sometimes medicine strikes back. A surgeon called the executive director of his hospital: “I have a heart. I have a patient. I have an operating room. I have no budget.” What is any manager who has a heart to do? This is rationing reduced to a game of Ping-Pong. Hit the problem back to someone else. Is the “system” failing, or are we failing in how we make choices, or refuse to?

We turn now to what have been the main administrative interventions applied to deal with this ostensible failure of health care: heroic leadership; administrative engineering; categorizing, commodifying, and calculating; increasing competition; and running health care like a business. I shall argue that, in some significant ways, much of this has delivered conspicuous failures.

¹ Perhaps this explains a report on the National Health Service of England website that compared patient satisfaction with public satisfaction. “People who have used the NHS tend to be much more positive than the general public.” They speak from experience, while the latter are more inclined to form their opinions from exposure to the media (Edwards, 2009).

² In a striking article, Atul Gawande (2009a) investigated two poor regions of Texas with rather similar health outcomes that had dramatically different costs: for U.S. Medicare in 2006, $15,000 per enrollee versus $7500. The reason, in his view: “across-the-board overuse of medicine.” Casual decisions about prescriptions and financial benefits to the prescribers may in fact have increased risks. “Many physicians are remarkably oblivious to the financial implications of their decisions,” while for others, “this is a business, after all.” Recent reports on prostate tests and mammograms have suggested that they may be encouraging dysfunctional surgeries. On the other hand, those people who avoid health care services may just be increasing the costs, since problems caught late can be much more expensive to treat.

³ Peter Goldberg (mentioned earlier as head of that ICU in a Montreal hospital), wrote in his final paper in our IMHL Program entitled Rationing in the Public Health System in Canada: The Search for an Ethical Construct:

In thinking about these issues—aided, I must admit by the luxury of time afforded me to do exactly that in the confines of the IMHL—I came to understand that I had become, wittingly or not, an agent of rationing of medical services. While it was clear to me that none of my training or professional experience had prepared me for such a role, it also became clear to me that the public, or certainly those who took the time to consider such issues, would recoil at the arbitrariness with which I had come to occupy such a pivotal role in the allocation of their health care services. Furthermore, and perhaps instructively, I noted that nobody within the public health care system ever mentioned rationing. Nobody ever uttered the “r” word. When spoken of, such euphemisms as allocation of scarce health care resources would be used so as to spare one’s sensibilities—although it was unclear whose sensibilities were to be spared. (2011: 3)