I want to thank the Health Research and Educational Trust for this recognition. In fact the name of this award — the TRUST Award — aptly recognizes that health care is about trust! Trust matters and is in seemingly short supply today.
In her 2002 remarks for the BBC’s Reith Lecture series on the Philosophy of Trust, Baroness Onora O’Neill quoted the ancient Chinese philosopher Confucius on trust. Confucius told his disciple Tsze-kung that three things are needed for government: weapons, food and trust. If a ruler cannot hold onto all three, he should give up weapons first and food next. Trust should be guarded to the end: “Without trust we cannot stand.”
Last year, in accepting the first Trust award, my mentor, David Lawrence, eloquently summarized the gaps in care named by the Institute of Medicine as these: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. He discussed the harm done every year, every day to real people — our neighbors, our loved ones, ourselves — because of these gaps. He compared the toll from safety defects fairly accurately to deaths in the Vietnam War. He said (and we all in our hearts know) that the gap between what we actually do and what we could do is costly, persistent, enormous and indefensible.
And, judging by the behavior of the American health care industry in general, we are missing yet another critical ingredient in trying to close this gap — urgency! Unfortunately, except for a minority of people in health care — such as HRET and its researchers — improving American health lacks a sense of urgency. That puts each and every person’s trust in our health care system at risk. The harm caused by defects in our health care quality is real and has significance beyond belief. It ought to make the people we serve angry. If it were more visible, it would be judged intolerable. Yet, too many of us who are responsible for delivering health care tolerate it.
Last year I was dealing with a difficult matter regarding the transparency of data on the care of a chronic condition — cystic fibrosis (CF). There exists a superb national registry for care process and results data on almost all American patients with CF. That registry is in private hands, developed for the purpose of scientific research. I was asked to help the Board of the foundation that husbands that data to reflect on whether or not to “go public”; whether we should allow the variation of care and outcomes to be unmasked, not for the purpose of reward or punishment but for the purpose of learning. So the best providers could teach the rest of us. The Board was scared — you all know why — that the public release of this data could lead to trouble for the foundation and those who supplied the data. In fact, we were sure that there would be trouble and the key question was whether the trouble was worth it?
This organization was afraid that if they openly revealed the problem, the public would not trust the care. I think exactly the opposite is true. Unless we openly reveal our problems, the public cannot trust the care.
In preparing for my meeting with the aforementioned Board, I happened to be speaking with a woman named Honor Page, who has a daughter with CF. I asked her what she wished me to tell the foundation Board.
She said, “Tell them that for my daughter and me, the clock is ticking.”
The clock is ticking! I am trying to spend my time getting everyone to see and hear the clock, but it is not going well.
Not all the news is bad, though. This Trust Award — recognition for efforts to improve care — does not belong to me. It belongs to the hundreds and hundreds of people I am fortunate to work with every day, who are taking the quality gap seriously. Who hear the clock ticking and are using their courage, time and minds to try to change our defective process of care. We are too few. We need an army where today we have just a squad.
In media interviews, I am frequently asked why there is no army. Why given the information we have — the information to which HRET has contributed greatly; information certified by the National Academies of Science; published in peer review journals; frequently splashed across the pages of USA Today; testified on before Congress; admitted openly by leaders like David Lawrence; experienced in real and personal terms every single day by patients and families — why with the clock ticking and all that reason to act, are our health care institutions not changing? Why are we not quickly, dramatically, and openly rushing to assure reliable, patient-centered, merciful, affordable care for all Americans?
My answer is that it is because we are not yet working together. We are apart and we lack trust. We struggle separately to achieve what we can accomplish only together. Doctors fight administrators; administrators fight Medicaid and Medicare; providers fight transparency; health plans fight each other for market share, while nurses fight the health plans. Payors demand measurements and measurers demand payment. Specialists fight for referrals that gatekeepers fight against. And with all this fighting, economists lament that we don’t have enough real competition in health care. To many, we are not fighting enough. And few, if any, trust the public to deal wisely with what they ought to know about the state of our care, but so far do not.
To tell the truth, I don’t know what we should do to get us moving together. We have the knowledge; we have the methods; we have measured the quality chasm. When interviewers ask me what to do, I have to have an answer. I make something up and this is what I tell them. The problem, I say in the interviews, is fragmentation. We approach health care with the logic of combat, faith in free-market theory, make an idol of competition, and have a magical belief in incentives that we have placed on a pedestal.
Instead, that pedestal should belong to common purpose, common aims, promises, duty and trust. Poor quality in health care is not like poor quality in cars; it is like pollution in the air and water. We will all share in the harm done by the pollution of health care quality, until we share in the intent to reduce it. We cannot, I believe, “compete” to get the pollution out of our health care system. It cannot be removed by creating a perfect market, but when we rediscover our social conscience. To close the quality chasm we need first not an Adam Smith but a Rachel Carson. Until we decide as a nation that the enemy is disease and not each other, we will fail and the clock that Honor Page hears will not only tick but also detonate. And her daughter, whose name is Annie, will pay the price for our inaction.
Maybe fragmentation is a symptom and not a cause. If so, then “trust” or “mistrust” is not a bad candidate to be the culprit. Coming together to stop that infernal clock ticking demands that, across time-honored boundaries and tightly defended beliefs, we begin to find some way to trust that care can be far better than it is today. We do not need zero-sum thinking about resources. We really do have plenty, just poorly deployed. Trust that a better state for patients and the workforce lies on the other side of some difficult changes that we have to face.
We need to trust in knowledge. When the facts — the science — tell us that we are doing wrong, we need to trust that science in order to take action on it and not attack the message because it advocates something inconvenient. In a work of breathtaking importance last year, Elliot Fisher of Dartmouth documented that the areas of lowest health care cost in the US have far better quality than those with the highest costs. Yet not a single leader of a health care system or a single visible policy maker has had the courage to take those findings to the next logical step, in either corporate or public policy planning.
Beth McGlynn from the RAND Corporation, in her landmark paper cited by David Lawrence last year, clearly documented a 46 percent defect rate in the provision of scientifically correct care to 7,000 patients in 12 metropolitan markets. Steve Jencks MD, Health Care Financing Administration, has repeatedly shown the same in the Medicare System. With the conspicuous and welcome exceptions of Medicare and Veterans Health Administration, none of this clear science has led to major action. If we trust our knowledge, how can we simply ignore it?
We need to trust that patients are not insatiable — they are not. That it should not just be right, but safe for the rich to help the poor. It is not just safe, but right for health care to be made a human right in the richest nation on earth. Shifting costs to patients so that they have more “skin in the game” is one of the least evidenced-based, least logical, most morally indefensible public policy positions or marketplace ideas that I have heard in my entire career.
We have to trust that our country has every asset it needs to provide universal care now…immediately! That we are smart enough to figure it out, just as every other developed nation in the world has already done. We need to trust the soul and generosity of spirit among the millions of people who have chosen to devote their careers to caring for others. We need to have the guts — trust in our own moral compass — to tell the few in our industry who do violate that trust that they are not welcome, whether they are neglectful Boards, overpaid executives, doctors who have lost their way or suppliers who think they have no duty other than sell and make their profit goals.
We are in a mess. And yet I see no logical reason whatsoever that we cannot get out of this mess. The route out begins with trust. Trusting in our knowledge, trusting our patients, trusting the public, trusting in transparency, and somehow learning to trust each other.
Thank you so much for this award. It honors my many colleagues and I accept it on their behalf.
