This morning I read a short article by my favorite journalist, Fareed Zakaria (who I have been reading since long before he was a CNN news celebrity). In the article, Zakaria covers and expresses his general agreement with a policy paper published by the Wilson Center proposing a new “National Strategic Narrative” regarding prosperity and security.
The paper was written by two actively serving military officers, Captain Wayne Porter, USN and Col Mark “Puck” Mykleby, USMC. But they signed the paper “Mr. Y” to communicate their intent for it to be considered as a proposed replacement for a very influencial paper published back in 1947 in Foreign Affairs under the pseudonym “X.” That paper, actually written by George Kennan, was titled “The Sources of Soviet Conduct.” It portrayed the U.S. as the “leader of the free world” and argued for the U.S. to seek “containment” of its adversaries. It provided the narrative that drove national security policy for the subsequent 40 years. In the new paper, “Mr. Y” proposes to update this narrative to reflect a more complex and interdependent world, replacing “containment” with a goal to become the most competitive and influential country. Even though it is written by military officers, the paper advocates for decreased emphasis on military might, increased investments in human capital (including education and health care), and increased focus on domestic prosperity, adherence to internationally-respected American values, and civilian engagement in the international “ecosystem.” It is a readable 14 pages, including a preface by Anne-Marie Slaughter. I recommend it.
How does this relate to health care transformation and the emergence of Accountable Care Organizations (ACOs)?
First, the content of the paper puts health services into the larger framework of prosperity and security. Access to health care is a component of prosperity. Freedom from disease is a component of security, which is defined as a state of mind. This conceptualization reminded me of Don Berwick’s description of the two approaches to improving health care quality: eliminating “bad apples” (the providers at the extreme unfavorable end of the performance distribution) vs. “moving the mean” (focusing on improving health care processes to shift the entire distribution of performance in the favorable direction). It seems that national “security” is eliminating the undesirable tail of the distribution of human well-being, while “prosperity” is shifting the whole distribution in the direction of greater well-being.
Second, the paper points out the importance of entrepreneurialism, competition and free markets to improving prosperity and security. Regardless of your politics about public vs. private financing of health care, I think it is important to recognize that fundamental transformation and continuous improvement in the actual delivery of health care services will require the creative energy of entrepreneurs, the forces of competition and the reform of markets to create the information transparency and level-playing field necessary for free choice and fair competition.
Third, in outlining our fundamental national values, the paper includes an “environment” that provides “plentiful” water and soil and “abundant” fuel, but settles for health services that are just “adequate.” Given our problems with health care spending that greatly exceeds the per capita cost of other economically advanced countries with little measurable increase in health benefits, I understand the authors’ avoidance of adjectives that promote further increases in the quantity of health care. But, I found the word “adequate” to be uninspiring. I would have preferred that they focused on the abundance of health and wellness, and went with the themes of “smart” and “sustainable” that are present throughout the paper to convey the need to use our inventiveness and practicality to get the most health and wellness while avoiding waste and preserving as much of our economic output as possible for other values and pursuits.
Fourth, the paper argues that we need to avoid “labeling” and “binning” in ways that miscommunicate our true intent and that turn off nuanced thinking. The authors give the examples of the harms from using terms like “terrorist” and “jihadist.” Extrapolating from this point to health care, I feel that we are poorly served by much of our terminology and labels, such as “cookbook medicine,” “rationing,” “death panels, ” “kick-backs, ” and even some seemingly positive but nuance-killing terms like “professional autonomy,” “patient advocacy,” “standard of care,” and “evidence based.”
Finally, the idea of creating a “narrative” that can transcend political parties and traditional constituencies to establish a shared vision, underscore shared values, and drive long term policy and societal transformation seems to be very applicable at this point in the history of our health care system.