By Francis M. Miller
The recent allegations of mismanagement within the VA are part of a greater pattern within the health care system. All of the health exchanges had major systems problems this past open enrollment period. And, some systems, such as the Colorado Benefits Management System that processes Medicaid applicants, have had problems for years.
Several common threads run through the tapestry of these system problems.
Our lives are now molded and shaped by systems and technology. There is little we can do without enduring the petty tyranny of systems. Th manager at Staples tells me that cash and check transactions are less than10 percent of his sales. It’s all credit or debit card.
Smart phones and tablets are ubiquitous and rule our lives. As users of these systems, it is often apparent that the nurses and doctors somehow figure out how to deliver high quality care in spite of the system.
The problem is often in the appointment scheduling, billing and administrative side of the shop. Administrative costs in the health care system are nearly 40 percent of total costs. And, these costs extend up and down the food chain.
Doctors, hospitals, insurance companies — every major player in the system has significant administrative costs, delays and problems.
You would think that the No. 1 concern of a business is to book a sale and get paid for it. But, during this year’s open enrollment period it took weeks for insurers to be in a position to accept payment.
Part of this problem rests in the evolution of the technology.
Hardware has evolved at a faster rate than software. Vendors leave application development to the open market and concentrate their capital investments on new hardware, operating systems and peripheral devices such as printers.
Hewlett Packard was once the premier manufacturer of medical monitoring devices. Today, they make 80 percent of their profit from the ink sold to keep printers running.
In 1969, Kaiser-Permanente came to Colorado. Against physician opinion, a contract was negotiated with Saint Joseph Hospital to provide inpatient care. At that time the impacts on SJH’s operations were minor but disruptive. So, Sister Mary Andrew brought in industrial engineers to flow-chart a mesh design that sustains to this day. Both Kaiser and Saint Joe’s had to accommodate each other, but the system was well designed.
Little formal design work is done today. User organizations are either coping by trying to milk old systems or they are installing off-the-shelf software that fails to accommodate the human interface.
I am appalled at the pervasive use of outdated operating systems such as Windows XP and legacy software, some of which ran on old AS 400 IBM mainframes in the1980s.
There is denial by management and policymakers as to the extent of the problem. The fix is almost always a request for millions of dollars, often to be dispensed to the same vendors who were the perpetrators of the problems. CBMS uses Deloitte and Connect for Health Colorado uses CGI.
We all somehow know that changing the administrator at the top of organizations will in and of itself not solve the problem. When a building falls down for lack of proper architectural engineering and construction, it’s time to go back to the drawing boards.
Frank Lloyd Wright claimed that you cannot be a great architect without great clients. The development of systems that interface at multiple levels in large scale organizational hierarchies and transcend numerous boundaries are “big-brain” projects. They necessitate involving highly skilled people and using hardened teams of professionals.
Federal Express, Hertz, UPS and organizations that rely on systems to be “force-multipliers” in their business realize this.
Several years ago, the British government and health system suffered a collapse of its systems. It responded by doing a 180-degree turnaround in its approach. It now uses open systems, transparency and internal teams to achieve its ends.
It is not trying to build systems using the low bidder, or even worse, the most politically connected contractor.
We have crossed the Rubicon and it is not a Jeep. It is a divide between an old way of doing business and the demands of the 21st century. We simply must design our way out of this mediocrity.
The use of agile approaches is well known. Leading technology organizations do it all the time. At the crux of the matter is the hollowed out nature of many of our organizations.
We hire managers without a deep or long track record in systems development and turn them into procurement officers.They let out bids to third parties but the shallowness of their skill sets does not allow them to manage the project.
Yes, there are transcendental skills a good manager can deploy. But, if you do not really understand at a deep level what it takes to build a large scale complex system, you will fail.
We send our military officers to war college. We don’t recruit guys and gals in suits to “manage” war. It takes requisite skills that can only be acquired over time through a combination of experience and education. It takes a commitment.
We have arrived at a moment in history where the system determines our success. Without a blending of high tech systems with the high touch human part of organizations we cannot succeed.
In the good old days, we could buy everyone a calculator or personal computer. Departments could kluge together solutions. And IT managers could conspire with IBM to produce bills and statements.
Today, the system is the organization. When it fails, the organization fails. You can force-feed the VA money all day long and you won’t get the job done. And, you can put wounded warriors in charge of the organization because they have stars on their collar and you will also fail.
In the end, this situation reminds me of Arthur Conan Doyle’s saying: “Genius instantly recognizes genius; mediocrity knows nothing higher than itself.”
If the high-level policymakers are a confederacy of dunces, they will continue to put people like Shinseki in charge, when he clearly did not have the skills to run such a system. And, if we do not think strategically about the role of government run health care systems relative to delivery of services by the private sector, we will also fail.
There is a compelling argument to reframe the VA’s problems and possibly voucherize the system like Medicare.
It can’t be any worse.
Francis M. Miller is the past president of the Colorado Business Coalition for Health and the vice chairman of the Colorado Health Data Commission. He founded the first consumer cooperative for health care called the Alliance and is the current president of Health Smart Co-op. He blogs on www.thethoughtczar.com and is a frequent contributor to Health News Colorado.