My native Scotland had a momentous vote in September. Scots were asked a very simple question: "Should Scotland be an independent country … Yes or No?"
Well, you probably know what happened: 85 percent of the electorate, including 16- and 17-year-olds, turned out and voted 55 percent "No" and 45 percent "Yes." I happened to be in Scotland twice in the last few months, once in June in the run-up to the vote, and again in late September, just days after the polls closed. While emotions ran high, it was a largely civil discourse except for a bit of a sectarian skirmish along class and religious lines in Glasgow after the vote (which was not covered much in the U.S. media). Overall, the vote, while an interesting curio to outsiders, was a bit awkward and divisive in the country. It still is.
Yes or No?
The "yes" side had a vision of Scotland as a brave wee country going it nobly alone like a 21st century Braveheart; although practically, it was really an attempt to get an even more generous welfare state supported selfishly by a higher share of North Sea oil revenues. Basically, Norway with whiskey.
"Yes" voters were much more visible across Scotland over the summer, which led the silent majority to be a bit worried that they were going to be taken out of the United Kingdom.
Public opinion polls tightened as the vote neared and showed weird and conflicting preferences among the "yes" voters. For example, they wanted to be independent but preserve the monarchy: "Aye, keep the Queen, get rid of the English." Not so easy.
The same kind of tricky questions came about the currency: Could Scotland keep the pound and not join the Euro group? The best answer to that was Scottish comedian Kevin Bridges' suggestion that the Scots would start a new currency, the smackeroony.
Don't even start talking about how an independent Scotland would disentangle its defense infrastructure; realign medical education, pension and housing subsidies; and deal with the many, many non-Scots in Scotland and the millions of expatriate Scots abroad.
Mercifully, the "no" vote won, but the forces favoring independence are still there, and the British government will still have to deal with the demands of the many Scots who favored more independence. For the record, I canvassed for the Scottish Nationalist Party in the late 1960s as a student, and my local member of parliament was Winny Ewing, only the second SNP member to go to Westminster. I believed then and now that Scotland should have significant devolution of power (and, indeed, it has) over health, education, welfare, housing, transportation and other important domestic policy matters.
But a small, independent Scotland trying to make it alone in an increasingly weak Europe, a continent that, in turn, is competing in a brutally competitive global economy, in a divided and dangerous world, seemed like a stretch to me.
Across the world, in Spain, Canada, Norway and France, and throughout the Middle East, Asia and Africa, there are groups, regions, peoples, tribes and whole countries that see a better future being independent and isolated from the trends around them. In many of these cases, the aggrieved parties see a world that is complex, increasingly globalized and interdependent, and controlled by factors, forces and stakeholders over which they have no influence. They see independence as a pathway to control their own destinies (especially if they can get the oil revenues to support it).
What Has This to Do with American Health Care?
In America, independent doctors and hospitals feel threatened. They see the relentless growth of large regional systems of care coming to dominate the landscape. They see doctors running to hospital-owned practices to huddle for warmth in this uncertain future.
The independents may realize that they are suboptimal in scale for delivering high-quality and cost-effective health care services. They may recognize that they are woefully ill prepared for the move from volume to value. They may even 'fess up that they are completely out of their depth in a world of big players. But even if they have this self-awareness, they often cling to independence because of the very real fear that they will lose control and autonomy. Why?
To preserve the deal they currently have. Like the Scots, many are convinced that if they stay independent, they have the best shot at preserving the deal they have. Most economists and oil experts anticipated that North Sea oil revenues would eventually decline over the decade ahead. Yet, the forces advocating independence assumed they would be able to cut a favorable deal with rival governments and massive global oil companies, even in the face of predicted future declines in production.
The same could be said for independent hospitals, as well as those rural critical access hospitals that believe they still will be able to preserve the deal they have in the face of fiscal pressures to the contrary. Similarly, many of the less-aligned solo physicians simply refuse to deal with payers like Medicare or Medicaid or narrow network exchange plans, and believe they can make it as free agents or concierge doctors. And some of them may be right. But it is unlikely all of them will be OK, and most are likely to be blindsided by larger forces creating consolidation and integration in health care delivery.
For example, when I was advising a national group of ophthalmology leaders, many of them flatly stated they would no longer take Medicare patients because of inadequate reimbursement.
"Which patients typically get eye disease?" I asked naïvely.
"Old people," they told me.
"Well, that should work really well."
Old dog, new tricks. Remaining independent seems attractive because it is assumed that it liberates you from having to change. The Scots who voted "yes" genuinely believed that this was their best hope to preserve and enhance a welfare state and obviate the need for government austerity favored by more conservative English politicians. While there may be legitimate arguments that austerity is overrated and perhaps dangerous as a macroeconomic strategy, remaining independent does not insulate anyone from the global forces of change. Nor does it give you a pass on change.
Uncertainty over the future. You can blame tough times on irresponsible global bankers, or English politicians or Obamacare, and argue that this will blow over and go back to the way it always was. You might even be right once or twice, but you cannot eliminate uncertainty entirely.
We may be gone. Scotland will never lose its cultural identity; it has shown that over centuries. Being independent is not a requirement for maintaining traditions or preserving unique cultural quirks from haggis to the Glasgow accent. But in the case of American health care, there is a legitimate concern that losing independence may threaten the very existence of the organization or its culture. I have seen this deep concern in the faces of board members of critical access hospitals, of sisters as they contemplate turning their missions over to secular leaders, of department chairs of academic medicine contemplating throwing their lots in with the system and giving up some departmental autonomy.
Facing a Vote on Independence
American health care stakeholders will be asked to vote on independence in the years ahead. There are examples everywhere. Faith-based institutions and smaller systems are being brought into larger megasystems like Ascension or Catholic Health Initiatives, and some have been acquired by for-profit actors — witness Daughters of Charity hospitals' recent choice to be acquired by Prime Care.
Similarly, Banner Health's acquisition of the University of Arizona's Health Center in Tucson is an example of a large, independent academic medical center's becoming part of a much larger community-based system.
The Vivity deal announced in Los Angeles is receiving national attention. Six southern California hospital systems, including UCLA, Cedars-Sinai and MemorialCare, have joined with health plan partner Anthem Blue Cross to offer an HMO product to compete with Kaiser.
These are the high-profile examples, but in every state there are scores of hospitals and hundreds, if not thousands, of physician practices that have to ask themselves whether they can and will be independent in the future. And if not independent, then withwhom do they partner, and on what basis?
Advice on Independence
As you confront your own vote on independence, consider the following:
Get real. Hoping things go back to some imagined past golden age is not my idea of a smart strategy. Dude, these are the good old days. Make a realistic assessment of how your market is going to unfold and know that the big dogs in your marketplace (wherever you are) are trying to grow in scale. They will be aggressively managing referrals to keep more business flowing to their team, and they will be stepping up to compete more aggressively on value, both on a fee-for-service and (eventually population health) basis. And many of them have the financial heft or backers to make the necessary investments to win a sustained fight.
Fight for what matters. If you are the chair of an independent rural hospital that is the largest employer for miles around and the anchor of your community, you probably worry about the future of your community if your institution were to disappear. But maybe the real fight is to ensure that there is a continued high-quality presence in the community, that services and facilities are repurposed and transformed with the help of committed partners to serve your community better. And that future may be better realized with partners rather than as an independent institution.
Vote with your head, not your heart. My fear with the Scottish independence vote was that a majority of Scots would get weary of hearing whining, nasal speeches by ineffectual, condescending English politicians, then get drunk the night before and vote "yes": "We'll show you English (expletive deleted)." Similarly, you who are leaders of independent institutions in American health care need to be clear-headed and honest about what is the best solution for the stakeholders and communities you serve. And don't get carried away with a romantic notion of independence that may be unrealistic and unattainable.