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Friday, 3 September 2010

Harvard Pilgrim's New CEO (and my new Boss)

In February, Eric Schultz was named President and CEO of Harvard Pilgrim Health Care, where I direct the ethics program. Eric is my boss's boss's boss.

This past week Eric reactivated the Let's Talk Health Care blog that his predecessor had launched several years ago. I don't know Eric well yet, but his initial post made me very happy. Here's the key quote - with my highlighting added:
During the past 25 years or so, I worked both in the health insurance and health delivery space. My first dozen years, I worked up the ranks at a national, for profit insurance company. At that point, I believed I had a broad and well-rounded view of the health care system. But thanks to a physician executive who took a chance on me, I stepped into the role as the Administrator of a physician group practice comprised of 25 primary care physicians. It was a humbling experience and an opportunity that many insurance executives should have in order to learn first-hand just how an insurance company can disrupt the physician/patient relationship. Equally important, it was at this group practice where I learned the value of a coordinated clinical care delivery system practicing within a prepaid environment. This group practice also had a unique integrated financial arrangement with a local health plan – where all parties focused more on the needs of the patient and creating efficiency rather than maximizing fee-for- service visits or filling hospital beds. This stuff wasn’t rocket science but did depend on a combined vision and high degree of mutual trust.
In the 1990s, at the height of the backlash against managed care, I did research on the interaction between insurers and providers in my own clinical area - psychiatry. What I saw was a tragedy in the making.

My research involved interviewing mental health providers and the manged care reviewers they interacted with at the other end of 1-800 lines, and observing those interactions directly. What I saw was good people who lacked a real understanding of the ethical responsibilities of the other "side." Providers didn't understand that insurers were managing collective funds on behalf of individuals, employers and public agencies. As a result, they demeaned reviewers as "bean counters" who didn't care about patients. Reviewers didn't experience the distress felt by patients and their families directly. As a result, they demeaned providers as arrogant narcissists who felt entitled to spend collective funds without any accountability.

To be truly patient centered, a health system requires what Eric calls "combined vision and high degree of mutual trust." We need clinicians who understand what their patients need and who can advocate for their patients within the insurance system and, when needs fall outside of what insurance covers, within the wider community. But clinicians must understand that containing costs isn't "bean counting" - it's an ethical responsibility for society. And we need insurers who can manage collective funds in an efficient manner, but who also understand, in Eric's words, "how an insurance company can disrupt the physician/patient relationship."

Tension between those who are directly responsible for patient care and those who are directly responsible for stewardship of collective funds is not peculiar to the United States. I observed the same tension in England between clinicians and the National Health Service. The tension arises from a classical good v good conflict. It is good to care about patients and to seek to do everything possible for them. And it is good to care about containing health care costs so that individuals and society have the wherewithal to address other important areas of life. As important as health care is, individuals and societies have other interests as well!

I agree with Eric that it's important for insurance executives to have a deep understanding of the doctor-patient relationship. But it's equally important for clinicians to have a deep understanding of the impact of soaring health insurance costs on family budgets and the ability of employers to create new jobs. That's why the concept of "accountable care organizations" that take responsibility for both quality of care and efficiency is such a good one.

(For additional background on my new boss see here and here)


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