Revolution or Evolution?

I always find myself drawn to the “Big Idea.” That was a phrase a fellow consultant and I used when we were working with a troubled health care organization in the late 1990s.

Looking back, the organization had just completed an acquisition that doubled its size and it’s leadership was struggling under heavy operating losses. We were engaged in assisting them with cost control and revenue enhancement. While we looked for efficiency gains in labor, reductions in supplies and pharmaceuticals and improvements in their revenue cycle, we also looked for an idea that would magically transform the organization into a model of efficiency.

That would have been a great accomplishment of course. But, the path to efficiency and effectiveness was a more difficult one. It required an inward focus on improving existing operations, a focus on the core business if you will. In other words, the organization needed evolution not a revolution. Today, that organization, having traveled the more difficult path, is the leader in its market.

In early December, Atul Gawande published an essay in the New Yorker about the incremental nature of the health care reform that has since emerged in separate bills from the House and Senate. Gawande’s essay, “Testing, Testing – The health-care bill has no master plan for curbing costs. Is that a bad thing?,” describes the many pilot projects in the two bills and argues that the incremental, or evolutionary, approach may be a very good thing indeed.

Gawande skillfully compares the current approach to that used by the USDA over the past century, dating to 1903 when the cost of food was 50% of the typical family’s budget, to improve the art and science of farming. Yes, farming.

My nature, both emotional and intellectual, will probably always draw me to the “Big Idea.” If I were King, I would wipe the health care “system” slate clean and start completely anew and the world would be a better place. But, as Gawande points out, there are problems that can be solved with technical solutions and there are those that cannot.

While I tend to believe that health care could be “fixed” with a technical solution if it weren’t for the pernicious ways of today’s political leaders, I have adopted Gawande’s point of view on the matter. Rather than whine about the lack of a comprehensive plan, we as health care leaders need to study the pilot programs outlined in the reform legislation and embrace those that can improve our local organizations and communities.

Whether its comparative effectiveness research, bundled payments, accountable health organizations and so on, matters little. Contributing to a fruitful journey, like that traveled by American agriculture, matters greatly.


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