Sunday, March 15, 2015

Paradox and Focus

I have just spent two days at the Conference Board’s 15th Annual Employee Healthcare Conference.  The speakers were the leaders in an evolving world of employee health benefits whose goal is to improve the world of healthcare and healthcare benefits that large employers make accessible to their employees.  These speakers were both representatives of the companies that serve (and sell to) employer’s health benefit programs and the representatives of the corporations who are responsible for managing the funds available for health for their employees and the employee’s families. 

As I listened I was often struck by the specific lens through which the speakers were offering their solutions.  There were physicians who developed and put forth programs on their specific areas of expertise.  This ranged from offering physician services over the Internet in a telemedicine mode to offering high level academic medical type services as second opinions to offering a specific program for a specific condition or set of conditions such as diabetes, heart disease, and others.  There were the business leaders of these companies, with their sales focus, who tried to show how their solutions would save the employers money while potentially improving care and helping the employees be healthier and more productive.  And finally there were the employer health benefits people whose lens was the budget that they must meet while also meeting the commitment they have to their employees.  Their goal is often the hardest as they must find a way to lower costs and bring tools to bear to also improve productivity, and increase the employee’s sense of attachment to their company to help recruitment and retention.  All who spoke were well meaning, earnest people who truly believed that what they were doing would be helpful and useful to all concerned.  However it struck me that depending upon their particular lens, they were sometimes speaking different languages and had trouble bridging the gap between their own fields of vision. 

I have spent a good part of my career as a translator between those different worlds.  As a physician consultant for a large international benefits consulting company, I helped traverse the difference between the business world of cost charts, analytics related to claims payments, and the black and white of insurance contracts, with the medical world of pathology, randomized studies, and the shades of grey of actually treating patients.  I often had to deal with physicians who believed that health is everything and costs and contracts are mere distractions, and therefore must be made secondary to the medical issues.  I dealt with business people who truly believed that to be responsible stewards of the health dollars that were available they had to divorce themselves from the tragedy that specific people with specific illnesses had to deal with and make policies and procedures that protected the bulk of the people for whom they were responsible.  As I tried to chart a course that addressed all these issues, I often found my skill as a translator challenged as it seemed like I was bringing a third language to the cacophony of voices. 

This week, all this came to mind as I sat down with a group of journalists while at the meeting to discuss what we at Accolade were doing and how that was saving money and helping people.  At Accolade, we founded the company with neither that primary financial or medical lens, but rather the real world challenges of a person trying to find their way to the best care possible for themselves and their families.  As we built the company, we realized that our system of each family having their own health assistant could potentially help the problem as long as the health assistant had a laser focus on neither the medical nor the financial alone but rather on the person and family’s needs and wants.  When you focus on a person, you must know and address the financial and the medical but it always must be from their point of view, knowing their priorities and the real life barriers they need to overcome.  We developed our system and the curriculum for our Accolade Health Assistants and made sure as we built all of our training and supervisory programs that we never had saving money or directing medical care as primary goals for our health assistants.  Instead, we set primary goals of gaining trust, forming relationships and assisting those in need get the care they need in the context of the real world in which each and every one of them live.  We believed that by doing so we would end up saving money.  That belief, eight years later, has proven true.

I described this to the journalists who looked askance and could not understand why our health assistants did not have a primary goal of saving money, as they believed that focus would be more effective.  They did not totally understand our desire not to be directive in telling people what they should do.  They spoke a different language than the one I was speaking when I talked of the focus on trust and the paradox inherent in lowering costs and improving care based on building trust. A key component of trust is that there must be no hidden agendas.  A hidden agenda of saving cost for your employer could potentially destroy a relationship before it is even started.  This would lead to lower savings.  Another key component of trust is mutual respect.  Telling someone that they are wrong, or their doctor is wrong, about what should be done also destroys trust.  This could lead to worse quality of care.

As a translator, I use the power of language to achieve the goals of lower costs, higher quality and higher access to needed care.  The concept of paradox is thus useful.  The definition of a paradox is a statement that apparently contradicts itself and yet might be true.  In our work on health care cost, access and quality, we have learned a number of paradoxes that have proved true. 
  • When you focus only on money in health care, costs go up
  • When you focus only on the scientific tenets of medicine, and not the financial, emotional, cultural, spiritual and social aspects of care, quality goes down
  • When you focus only on the population rather than the individual, the population suffers


Thus a singular focus on the medical or the financial, or even on a specific disease, while helpful analytically is also limiting and must be met by a healthy dose of understanding of the overall goal of helping an individual and their family achieve the overall well-being that is desired.  Only then will we achieve the lower costs, higher quality of care, and better access results we all want.