You follow movies? That is, not just watching them but thinking about how they are built, looking at the structure? In classic movie structure there is a moment near the end of the first act. We’ve established the situation, met our hero, witnessed some good action where he or she can display amazing talents but what also may be a fatal weakness.
Then comes the moment: Some grizzled veteran or stern authority brings the hero up short. Think of "Casino Royale," that scene where Daniel Craig’s Bond (after those brutal opening scenes) is back in London and is confronted by Judi Dench’s M. Or Obi-Wan Kenobi challenging Luke: “You must learn the Force.” Or that moment in the classic Westerns when the tired, angry old sheriff rips off his badge and throws it on the desk, leaving the whole problem to the young upstart deputy. But before he stomps out the door, he turns and says to the young upstart, “You know what your problem is, kid?”
And then he tells him what the problem is: not just the kid’s problem, but the problem at the core of the whole movie. He just lays it out, plain as day.
In health care, this is that moment. We are near the end of the first act of whatever you want to call this vast change we are going through.
And where are we? Across America, the cry of the age is “Volume to value.” At conferences, we all stand hand over heart and pledge allegiance to the Institute of Health Improvement’s Triple Aim of providing a better care experience, improving the health of populations and reducing per capita costs of health care.
But in each market, some major players are throwing their muscle into winning against the competition by defeating the Triple Aim, by increasing their volume, raising their prices, doing more wasteful overtreatment, and taking on little or no risk for the health of populations. At least in the short term, the predatory strategies of these players are making it more difficult for the rest of us to survive and serve.
I’m not going to name names here. You know who you are. Even worse for you in the long run is that your customers and potential customers are coming to know who you are, and their strength in the market is increasing every year.
Nap time is over, folks. It’s time to put this discussion in the open.
First Question: Will They Succeed in Defeating the Movement?
These predatory systems are certainly making the movement from volume to value more difficult. Will they succeed in stopping it?
An insight from systems thinking about traffic might be instructive. One way to study traffic is to model it with automata: Create little software bots that mimic the motions and decisions of cars and drivers and set them loose on virtual freeways and streets. If you make them all the same, say, all moving at the speed limit when they can, at a certain traffic density, they always gridlock. If you make some of them different, if you introduce, for instance, a few slow-moving trucks onto your virtual freeway, the traffic actually moves better as it constantly rearranges itself to get around them.
Similarly, such predatory systems may slow the rest of us down and be a problem for us, but over the longer term, they may well spur faster changes in rival systems and in the customer base that will lead to more rapid and complete change.
Second Question: Will Their Strategy Succeed and Last for Them?
Whether they will succeed really depends on the strength of the other forces in the system — in this case, the forces pushing for lower cost at the same or higher quality.
These forces include employers, other large purchasers such as pension plans, health plans constructing narrow networks, competing health care providers, out-of-region and virtual competitors, new market entrants and individual consumers pushed into narrow network plans with high deductibles and co-pays.
Note who owns the largest “lever and a place to stand” in this concatenation: employers and other large purchasers. They have the direct incentive, the market power and increasingly the information to try new strategies.
Competing structures including, especially, multispecialty physician groups, are also important in many markets. Why? Because doctors are truly scared. That fear is driving many of them into the arms of hospitals and hospital-based integrated health networks. But the fear is driving others into building their own larger structures and creating specialized accountable care organizations and ACO-like arrangements through them. Increasingly they are seeking direct arrangements with self-funded employers, as with Boeing in the St. Louis, Seattle and Chicago areas.
The cost crunch driving this price-sensitive behavior will increase as income inequality grows and as more boomers retire. The possibility of “entitlement reform,” which unbundles Medicare into a defined-contribution program, is slim; but if it happens, it will only increase the cost crunch and put more of the decision-making power into the hands of the individual consumer.
The pressure will grow also as buyers become more aware that in health care price is truly not a marker for quality, only for market dominance. The prices in health care are not justifiable even in terms of the supply chain, as similar institutions in the same or similar markets often have wildly different price structures. In any market, under conditions of full transparency about quality, prices for substitutable products might vary by 50 percent or even 100 percent, not by 500 percent or 1000 percent as they commonly do in health care.
Payer and purchaser techniques such as reference pricing, bundled products and medical tourism are capable of picking apart a market and exposing health care providers to market forces based on price and quality whether or not those providers wish to be exposed.
Third Question: Does Size Matter?
CEOs of these expanding market dominators will tell you that it’s a defensive strategy: They know that the big crunch is coming, and they are bulking up to own as much of the market as possible as a reserve against that future.