So Who Are the Creators?

So, the game plan, according to me, is to create the future.  Who is on the team?  You might think, based on my last post, that the team is all engineers and scientists.  But, that is not how it has worked in the past.

Regardless of the technology — steamboats to automobiles to computers — the players in the innovation game have included many artisans beyond those with formal educations.  Players have also included many entrepreneurs, investors and, of course, many “high tech” workers where the definitions of “high” and “tech” were and are completely context dependent.

This immediately begs the question of whether we have a large cadre of such people now.  Where are the mechanical (1800s), electrical (1900s), or computer (2000s) artisans for the future?  In the past, we out-paced English workers because our workforce was better educated and ready to contribute to the processes of invention and innovation.  It does not seem that we are ready to out-pace Chinese workers in the same way.

We need artisans in IT, biotech, and energy.  In the past, such folks would have been cultivated in high school classes and labs in computing, biology and chemistry. People who flourished in these labs, but perhaps floundered with theory exams, may have gone to college for a year or two, or skipped college completely, and immersed themselves in creating the future.  Bill Gates, Steve Jobs and Chris Klaus are recent, but by no means unique, examples.

In my case, high school included woodworking, metalworking and foundry.  While math and physics led me to an engineering degree, these labs led me to hands-on experience and a feel for whether something could be manufactured and how to make it.  My understanding is that those days are gone.  Now, it is all about test scores.  SATs predominate, and welding skills are irrelevant.  Math skills completely trump abilities to use a lathe.

Perhaps abilities to deal with abstractions are all that now matter.  The physical world is no longer where things happen.  That’s what other people do — in China, India and Singapore.  But, then what do we do?  We manage things, count things, borrow money and account for returns.  This sounds a lot like England when we were soon to displace them in innovation and economic growth.  All because we are unable — or perhaps unwilling — to create the artisans who can contribute to the processes of invention and innovation.

Creating the Future

I am a student of history, particularly economic history.  Lately, I have been immersed in reading about technological innovation in the late 19th and early 20th centuries.  Transportation was transformed from stagecoaches and steamboats to railroads, automobiles and airplanes.  Electricity transformed communications from mail, telegraph and telephone to radio, television and now Internet.

In the process, there was much creative destruction.  Industries morphed or disappeared, and jobs changed or disappeared.  The stewards of the status quo did their best to stymie these changes, but they inevitably failed and change happened. We are now seeing fundamental change in healthcare delivery, and will sooner or later see fundamental change in higher education — the former being the incumbent poster child for runaway costs, and the latter soon to become the reigning poster child for costs that far exceed the value provided.

While the stewards of the status quo work to thwart change via endless team meetings and glossy strategies and plans, what should the rest of us do?  We could go to these meetings, check our emails or search the web during the interminable discussions, and help wordsmith the slides and brochures.  We could embrace business as usual, hoping the rules of the game are not changed during our watch.

On the other hand, we could embrace the ambiguous, uncertain future.  How?  Well, I am not a fan of crystal balls or dice.  There is another choice.  We could focus on creating the future.  We could imagine a different future and work to make it happen.  We could create products and services that might transform people’s lives. How about teleportation or mind reading?  Too much?  How about cars that cannot run into things, due to sensing and control technologies, and hence can weigh 70-80% less than current cars?  How about natural chemical agents that can track down cancer cells and convince them to die?

Much of what we take for granted — for example, this iPad on which I am typing — would be seen as pure magic by people of 50 to 100 years ago.  We have created a future most could not have imagined.  Now, we should imagine a future that no one believes is possible — and then go make it happen.  Creating the future is much more productive and satisfying than waiting for the future.  It is much more fun than being a steward of the status quo.

Market Forces

Change happens when it is forced.  The force can be an opportunity or a threat, perhaps embodied in a crisis.  In many domains, the forces for change are manifested as market forces.  Competitors, large or small, recognized or unrecognized, are the sources of market forces.  Thus, change happens when there is competition to meet market needs with better performance, quality, service and/or prices.

Change is much less likely to happen when there is little or no competition.  The stewards of the status quo can then argue that everything is great — as good as it can be within the prevailing constraints.  If competitors are not offering viable alternatives, it is difficult to convincingly argue that the stewards of the status quo are wrong.  Consequently, all investments are focused on preserving the status quo.

Healthcare is currently in crisis.  New alternatives are being driven by information and incentives.  Information will improve overall efficiency, but also enable health consumers to know the best providers, the best treatments, and the best pricing. Changing incentives focused on pay for outcomes will cause providers to focus on procedures that improve outcomes because those are the only ones for which they will be paid.

Higher education is a crisis in waiting.  Costs of administration (per student) have soared while expenditures on education and research (per student) have steadily declined.  At the same time, the merits of the old argument that a college education is always worth it have faded.  Unfortunately, there is a dearth of viable alternatives.  Online education has some benefits, but campus-based education provides a much richer growth experience.

What we need is an alternative that retains the benefits of campus-based education with much less overhead.  How about a university with a president, provost, deans and department heads, with NO vice presidents, vice provosts, associate vice presidents, associate vice provosts, etc.?  How about a university where the faculty members are the majority of employees?  Those two rules alone would constitute a dramatic change.

No mainstream university would agree to these rules.  There are far too many stewards of the status quo to allow this to happen.  But, there could be new universities, perhaps populated by faculty disaffected with the mainstream, which could operate this way.  The result might be a first-rate education for less than $10,000 per year — no fees added, no hidden charges.

This type of alternative would force change.  The best students would opt for this new alternative.  The mainstream universities, with increasingly bloated costs, would attract mediocre students from financially well-off families.  These students and their families would be more attracted to suites at the football stadium than science labs.  This would enable mainstream universities to cut back expenditures on the more academic side of things to focus on campus amenities and intramural enrichments.

How would we convince students — and their parents — that the degree from Alternative U is as valuable, or more valuable, than a degree from Mainstream U?  There are two key elements of making this case.  First, the quality of the faculty could be superb due to the enormous savings from salaries of non-faculty. Faculty members could be paid quite well since the typical five university staff members per faculty member would not exist.

Second, close alliances with industry and, to an extent, government would create great opportunities for internships and virtually guaranteed employment upon graduation.  There would be no graduates from Alternative U with marginal work knowledge and skills.  Everyone would be really good at something, ranging from design and engineering to journalism, theatre and media.  The graduates of Alternative U would run the world, and the students at Alternative U would know this.

Mainstream U could pursue the Alternative U mission, actually much easier than those who would have to start from scratch.  But, Mainstream U will not pursue this opportunity to innovate — they are much too busy.  There are hundreds of faculty members to manage and thousands of staff members to pay and promote.  The administrative assistant to the Deputy Associate Vice Provost has filed a complaint requesting the title of Assistant Deputy Associate Vice Provost and the university’s legal counsel has advised that this be settled out of court.

Disrupting the Status Quo

A few months ago, a colleague asked me, “What if our big idea does not get approved by the powers at be?”  I said, “We will start an insurgency and just do it anyway.”  We are still waiting for approval, and may get it, but we are quickly progressing despite the lack of formal blessing.  Our idea may be too disruptive for the stewards of the status quo to fully support it, but we are determined to prove the benefits of this idea and create a tipping point of demand for these benefits.

These experiences, combined with my recent posts, caused me to ask whether there are limits to the benefits of disrupting the status quo.  Either extreme will, obviously, not work. If everything changed all the time, chaos would result.  If nothing ever changed, complete stasis would be the result.  So, is there some intermediate level of disruption that balances creativity and continuity?

The stakeholders seeking continuity usually far outnumber those pursuing creativity.  The political, business, social, and personal interests associated with the status quo are often strong and compelling.  The interests associated with creative change may be quite energetic, but typically involves far fewer stakeholders.  Thus, the default reaction is often watered down change or no change at all.

One way to pursue the question of the appropriate level of disruption is to consider the extent to which an enterprise is open to entertaining and pursuing change.  Two factors, at least, affect the openness of an enterprise to transformation.

First, to what extent is the enterprise facing crisis or opportunity?  Much fundamental change is driven by crisis.  The crisis in healthcare spending is widely acknowledged because the largest payer has balked.  Medicare and Medicaid have restricted what they will pay in order to limit spending growth.  Employers are also very unhappy.  The broadly defined healthcare enterprise is paying attention.

In contrast, the crisis in higher education is only seen by millions of individual payers who, in general, have little if any leverage.  For the higher education enterprise, the status quo is powerful and hunkered down.  Acknowledgement of the crisis will require a systemic jolt.  One possibility would be the federal government’s limiting of students loans.  The current loan program provides universities with a license to raise tuition and fees.

The flip side is opportunity.  In health delivery, medical knowledge and information infrastructure are enabling enormous possibilities for prevention and wellness, chronic disease management, and patient empowerment in general.  This is driving many ideas and inventions, some of which will surely become innovations — fundamental changes in the marketplace.

There is no lack of opportunities in higher education, many technologically enabled. However, institutional leaders are not pursuing these opportunities.  Instead, they tend to be framed as research projects, typically outside of the mainstream and funded, often marginally, by external sources.  Transforming these inventions into innovations is an uphill battle.

The second factor is the extent to which an enterprise’s dominant stakeholders feel threatened by change. In healthcare, the acknowledged crisis has resulted in the primacy of the physician being redefined, in part due to the opportunities noted above.  There are many ongoing attempts by institutional leaders to disrupt the status quo and it is quite likely that a few will succeed to transform the healthcare enterprise.

In higher education, the primacy of the professor is steadfastly maintained, and faculty governance models strongly limit the extent and pace of change.  With no acknowledged crisis, attempts to disrupt the status quo are not led by institutional leaders.  Instead, these leaders are usually recruited to be stewards of the status quo.

Change is most difficult when the role of the dominant stakeholder is threatened, whether they are physician or professor.  Institutional leaders, usually drawn from the dominant stakeholder group, are very hesitant to alienate their former peers.  Indeed, they may be oblivious to the reality of the threat.

I have encountered this phenomenon in domains beyond healthcare and higher education.  In my many years working with the U.S. Air Force, I was often amazed at how pilot-centric decision making was.  However, given that almost all the senior leadership came from the pilot ranks, it should not have been surprising that the solution of every problem was seen to be an airplane.  In fact, problems obviously not addressable by weapon systems often received little enthusiasm and attention, e.g., enterprise efficiency.

The history of change in politics and religion has also been heavily politician-centric and priest-centric, respectively. Attempts to disrupt the status quo in those domains have resulted in purges, inquisitions and many other bloody reactions.  People who have worked hard to gain knowledge, resources and status are, in general, very reluctant to relinquish power.

Returning to the question of how much disruption is enough, it is clear that the answer depends on the situation.  If the dominant stakeholders in a domain are open to change, perhaps motivated by a recognized crisis, then quite a bit of disruption may be welcomed and productive.  In contrast, if the dominant stakeholders have chosen stewards of the status quo as leaders, then investing energy and emotion in disruption is quite likely to be a very frustrating and unproductive experience.

Stewards of the Status Quo

There are many impediments to addressing and solving executives’ toughest problem – see my last post.  Resource limitations – time, money, and people – can obviously be impediments.  Less obvious, and often much more troublesome, are the stewards of the status quo.  These stewards include people and organizations who are determined to keep everything as it is – markets, products, salary structures, pensions, tenure and so on.  They want all entitlements – legally mandated or socially perceived – to remain just as they are.

Such responses are not unexpected.  Getting people and organizations to buy into and support fundamental change often requires great creativity and compromise.  Often, this creativity is focused on inspiring a sense of urgency or precipitating a “burning platform.”  Once people truly believe that change is inevitable, they will usually constructively engage in deliberations on the nature of change and how it should be implemented.  A good example of this is the healthcare delivery system in the U.S.  There is much valuable dialog going on currently among a wide range of stakeholders.  Few people still believe that this system is fine just the way it is.

Perhaps the biggest impediment to change is when the stewards of the status quo are in charge.  When the leaders of the organization constrain thinking to business as usual, perhaps on steroids, fundamental change becomes very difficult if not impossible.  It is common for such leaders to use the vocabulary of change, e.g., new directions, strategic leaps, and enterprise transformation.  However, this is just rhetoric.  Their real goals are to keep the troops fed, make sure the trains run on time, and avoid rocking the boat.

This form of leadership is most common in enterprises that are shielded from market forces.  Government, education and religion, for example, typically attract and recruit these types of leaders.  The process of searching for new leaders in these types of enterprises places enormous emphasis on identifying candidates that will not be disruptive.  This does not always succeed and occasional change agents will secure major leadership roles.  Frequently, their tenure in these positions is relatively brief.

Stewards of the status quo thwart change to such an extent that the roots of change typically emerge outside of the mainstream.  People such as Alexander Graham Bell and Thomas Edison, and more recently Steve Jobs, formed new types of businesses and, over time, fundamentally changed our day-to-day lives.  The phone business, lighting business, and portable device business were not just business as usual on steroids.  These men and, of course, many other men and women invested little energy in preserving the status quo.

In general, change happens when market forces drive it.  When forces for change are prevalent, enterprises led by stewards of the status quo, suffer, fail and disappear.  Such forces may emerge in education, but are unlikely in government and religion.  If forces for change become prevalent in education, one can expect to see many leaders who are ill prepared to be other than stewards of the status quo.  Then, slowly and painfully, change agent leadership will become more the rule than the exception.

The Toughest Problem

Over the past two decades, I have often asked executives about their toughest problem.  Not surprisingly, they use many different words to answer this question.  However, there is quite a consensus around, “Running the enterprise I have while trying to create the enterprise I want.”

Keeping the existing enterprise running tends to be a very demanding job.  Enormous human and financial resources are needed to stoke the fires of the business.  Pressures to “stick to the knitting” are usually compelling, both financially and within the social network of the enterprise.

As a consequence, I have found that even enterprises that entertain a broad range of future scenarios will, in the end, focus on the “business as usual on steroids” scenario or the equivalent.  This is especially true when resources are tight and time pressures enhanced.  The need to support the reigning business model becomes heightened, regardless of whether or not this model is obviously becoming obsolete.

Nevertheless, there are usually executives that realize that the reigning business model is threatened.  Often, this possibility has been discussed long before the resource constraints and time pressures mounted.  However, it often was the case that it was socially unacceptable to openly recognize the need for change, much less attempt any fundamental change.  The stewards of the status quo would vociferously defend the viability of the current business model.

One or more possibilities for enabling change might emerge — for example, a new product line or new market channel.  However, this nascent solution would whither, subject to Christensen’s innovator’s dilemma.  The near-term revenues and profits associated with these alternatives would invariably be too small to provide the silver bullet everyone was seeking.  Instead scarce resources were sunk into the status quo.

Eventually, Schumpeter’s creative destruction emerges and many enterprises share the fate of the 1,000 companies who have departed the Fortune 500 in the past 25 years. This is great for the economy, but a defeat for each enterprise, all because the executive team could not solve the enterprise’s toughest problem.

The Current Communicator

I recently visited the Ronald Reagan Presidential Library.  One can question the whole “City on the Hill” imagery, but the Great Communicator was undoubtedly able to evoke a positive emotional response from me three decades after the original narrative. How does this compare to the Current Communicator?

Both Presidents inherited troubled economies– one could easily argue that Obama’s inheritance was much more troubled than Reagan’s.  Both looked forward with a message of hope that captivated the electorate.  Reagan, perhaps working from a much shallower economic hole, was able to oversee strong growth by two years into his first term.

Reagan’s enormous investment in defense played a central role in the fall of the Berlin Wall in 1989, following the end of Reagan’s second term in 1988.  It is, of course, much too early to assess Obama at a similar point on his impact on the country.  Let’s imagine, however, we are in 2017, looking back at Obama’s contributions.  What might we see?

Better yet, what might my children and grandchildren find compelling when they visit the Obama Presidential Library in Chicago in 2039, twenty-three years after he leaves office after his second term?  What messages would make them feel as I felt when leaving the Reagan Library last week?

Barring another 9/11 or a war, Obama’s claim to fame will be in terms of domestic accomplishments, and in all likelihood in healthcare.  Thus far, he has accomplished insurance reform — millions of more people provided with government-paid access to an easily arguable inefficient and ineffective delivery system.  This hardly sounds like a success, but it could create a tipping point.

Millions of additional people in the system will stress the system to such an extent that it will break.  This will create the “burning platform” that will enable healthcare reform, not just insurance reform.  Survival will require a move from fee for services to payment for outcomes.  This change will require a fundamental change of how providers deliver care.  They will have to eliminate activities that do not provide better outcomes — because no one will pay for them!

The key question is what is Obama’s equivalent to Reagan’s, “Mr. Gorbachev, take down that wall”. I think this requires that we see the nation’s health to be just as compelling and important as the nation’s defense.  How can President Obama make this happen?

First, it requires transformational leadership.  The President needs to articulate a vision, strategy and plan — and steadfastly hold to this message just as President Reagan held to the “evil empire” message.  He has to lead, not just throw this idea “over the wall” to Congress as a notion that they need to pursue. He needs to bet the farm on this one.

Second, he needs to take the case to the healthcare establishment.  Transforming healthcare will yield better outcomes for lower costs.  The best providers will be much more profitable –and the poor providers will go out of business. Healthcare needs this “creative destruction” with the strong players prospering and the weak players disappearing.

Third, the senior leadership of the Obama administration needs to be relentless in embracing the overarching goal of a healthy, educated and productive population that is competitive in the global marketplace.  Yes, healthcare is just one piece of the puzzle.  Education is next.  That’s needs to be the agenda of the administration following Obama. But Obama needs to stay on healthcare, and little else.  That will be the highlight of the Barack Obama Presidential Library in Chicago.

He Still Looks Like Him

Last Sunday, I had breakfast at the Beachcomber, which is right on the beach at Crystal Cove, just south of Newport Beach, California.  The waitress mentioned that many celebrities eat there often.  She talked about a particular performer, her favorite, and said, “He still looks like him.” I asked what she meant by such an odd choice of words, and she said that many celebrities have had so much plastic surgery that they no longer look like their former selves.

Plastic surgery is pursued in hopes of avoiding the changes typically associated with aging.  The goal is to avoid the appearance of aging.  Of course, this does not do much for actual aging.  Thus, the transformation is only on the surface – literally.  This is not the only form of transformation that only deals with the surface.

I have worked with many enterprises in business, government, and academia that undertook initiatives to envision a new future, formulate a strategy for pursuing that future, and develop a plan to transform their enterprise in the process.  On the surface — of PowerPoint slides and Word documents — these enterprises were transformation ready.

Over time, however, business as usual recaptured people’s attention.  The vision of a new future faded in all but the promotional brochures.  The strategy became more of a slogan than a path to the future.  The enterprise still looked like itself, only more so. The energy with which these initiatives began never got below the surface to enable real change.

Plastic surgery represents easy change, just as PowerPoint slides and Word documents represent easy change.  Change below the surface requires a much greater investment.  First and foremost, it requires committed transformational leadership that can articulate the vision that will compel people to act, in part because they have contributed to shaping this vision.  Leaders who were recruited to be stewards of the status quo will be unable to provide this type of leadership.

Second, change below the surface requires substantial human and financial resources.  In a time of scarcity, which may be one of the drivers of change, these resources are likely to have to be repurposed from other functions and activities.  This means that some elements of the status quo will have to be eliminated.  A leading indicator of successful transformation is the number of functions and activities that are completely eliminated.

Third, incentives and rewards have to be aligned with successful pursuit of the new future.  People will not march to a new drummer if their pay and promotions are still tied to the old marching tune.  Realignment of incentives and rewards usually results in outcries from the stewards of the status quo. Strong transformational leadership is needed to stay the course of change and allocate resources to the new future while also realigning incentives and rewards.

Change on the surface is so much easier than deeper change.  Beyond the plastic smile or glossy brochure, the stewards of the status quo tend to keep business as usual rolling along, with all functions and activities budgeted as usual, and everyone incented and rewarded as usual.  Nothing has really changed, because fundamental change below the surface is very difficult.

What Is or What If

Much of contemporary analytics focuses on tabulating and portraying characteristics of existing systems, whether they are for energy supply, health delivery or a wide range of other complex systems.  This type of analytics addresses “what is” or in many cases “what was.” This approach is backward looking, which makes a lot of sense if there are important lessons to learn from the past and carry forward.

There are some situations, however, where the current system is not one to be emulated.  Health delivery is one of these cases.  While medical science has steadily advanced, the delivery of health has not.  The delivery system is a federation of millions of entrepreneurs with no one in charge. Information systems are highly fragmented and rife with incompatibilities. The incentive system rewards delivery of procedures rather than health outcomes.

We need a very different system in terms of how health delivery is organized, operated, and financed.  This requires that we move from “what is” to “what if” in the sense that we need to explore delivery models that do not yet exist.  We cannot rely on empirical data from systems that have not been designed and deployed.  Further, as these will be very expensive systems, we need some way to drive the future before we write the check.

Computational approaches can provide the means to this end.  What we need is interactive organizational simulations that enable key stakeholders to explore alternatives, eliminate bad ideas, and refine good ideas.  As stakeholders come from a wide range of disciplines, these simulations have to include compelling interactive visualizations that allow extensive “what if” explorations.  When stakeholders move the sliders for key model parameters and choose their own assumptions, they become increasingly committed to the shared models they are developing.

Creation of these types of capabilities requires several ingredients. First, several types of computational models must be linked, e.g., agent-based for patients, discrete-event for delivery processes, microeconomic for providers and payers, rule-based for policy, and system dynamics for exogenous phenomena.  Linking such a disparate range of models can be a substantial challenge.

Second, the parameters for component models must be gleaned from large data sets including clinical data, financial data, and claims data.  Using such data to parameterize process models, for example, can be quite difficult, as most providers and payers have not structured their data sets in terms of processes. Instead, data are organized by codes for diagnoses, procedures, and locations. This requires that processes be inferred from data sets never intended to support such inferences, which often involves filtering out special cases as well as mistakes.

Third, interactive visualizations are needed for decision makers to understand and be comfortable with computational approaches.  They need to view the computational models as a means for exploring a range of possibilities rather than as a “magic box” that produces optimal but, unfortunately, often opaque answers. This requires core competencies in interactive computing and decision support systems.

The three competencies outlined above — computational modeling, statistical estimation, and interactive visualization — are rarely found in one individual or even one discipline.  Multiple disciplines are needed, working as a team to tackle large-scale “what if” problems.  Any initiatives to address the transformation of healthcare requires the multi-disciplinary team needed to assure the availability of these competencies.

Smart health is not just about doing what we now do better.  Indeed, Peter Drucker has cautioned us to never invest in improving something that you should not be doing at all.  For health, being smart means being able explore whole new ways of doing things to eliminate bad ideas and refine good ideas, so that we can then invest in improving and deploying these good ideas to create quality, affordable health for everyone.

Controlling the Costs of Healthcare

We continue to anguish over escalating healthcare costs.  To gain control of these costs, we need to understand one essential equation.   The total cost of healthcare is

Total Cost = Costs Per Use x Number of Uses

Careful design of delivery processes to eliminate unwarranted care process variations can decrease the costs per use.  Variations are unwarranted if practices differ from evidence-based medicine for no beneficial reason.  Such variations may yield significant revenue for providers, but if these variations do not benefit patients, they should be eliminated.

Prevention and wellness programs and chronic disease management programs can decrease the number of uses by keeping people out of in-patient treatment because either they do not get diseased or, if diseased, have crucial variables under control.  Such programs involve small investments per person now to avoid large costs per patient later.  These types of investments have repeatedly been shown to yield attractive returns, especially if one attaches value to healthy, productive people, as employers certainly do.

The central issue is how best to allocate resources across process (re)design, chronic disease management, and prevention and wellness to control healthcare costs with equal or better health outcomes.  This logic seems tractable, but is rarely pursued.  Why?  As I interact with executives of more and more providers, two things strike me:

Few executives are addicted to inefficiency.  They simply do not have the information to improve.  They do not understand their processes; do not know their costs, etc.  So they just try to maximize revenue and keep their capacity fully booked.  We are working on methods that take clinical, financial, and claims data and infer the providers’ processes, including the variability in these processes, to then determine which processes, when given attention by clinicians, should be the first targets for improvement.

However, increased efficiency often decreases revenues until providers figure out how to re-deploy capacity.  While it may increase profits by eliminating “bad” revenue, most providers have no means (i.e., information) to make this assessment.   Thus, for example, using non-MD care coordinators plus e-visits leads to increased costs (for added people and infrastructure) but less, maybe zero, revenue.  For this reason, Patient Centered Medical Homes may be terrible investments for providers unless they can re-deploy clinician capacity in profitable areas or, better yet, be paid in part, at least, for keeping people out of the hospital.  We are using the models described above to determine the best ways to do this.

The bottom line is that we know how to reduce total costs, as defined by the above equation, but there are strong disincentives to do this.  The current fee for service payment model encourages providing many services, regardless of whether they provably benefit patients.  The unwarranted process variations generate significant revenue for providers.  Payment for health outcomes can remove these disincentives.

For prevention and wellness, providers should be paid for risk reduction.  For chronic disease management, providers should be paid for keeping blood pressure, glucose levels, etc. in control.  For in-patient care delivery, providers should be paid for provision of the best evidence-based practices.  Payments should be paid for these outcomes regardless of how they are delivered, i.e., doctor vs. nurse vs. care coordinator vs. health coach.  Payment should also be independent of where they are delivered, i.e., hospital vs. clinic vs. telephone vs. Internet vs. at home.

If payment for outcomes is adopted, and it does not matter who delivers these outcomes or where these outcomes are delivered, providers will have enormous incentives to understand and redesign their processes to maximize the outcomes achieved and earn the economic benefits of these achievements.  We all will then have access to affordable, quality healthcare.