Reality by Decree

January 22, 2010

The health care debate has occupied much of our energies this past year in the United States. We have seen multiple plans, arcane exceptions and a whole lot of opinion on what should, and what should not, be done to remedy what has been termed an intolerable situation by any number of talking heads. In even the somewhat “soft” science of medicine, opinion should be tempered by reality. If someone has a plan, has used it for years with 30,000+ patients, 80% of them like it and it has reduced cost by 40%, shouldn’t it be explored with more than just a little enthusiasm?

Steven Burd, the CEO of Safeway, has developed just such a plan and he did it by a conscious or unconscious recognition that health care is a Complex Adaptive System. The way he tells it (http://online.wsj.com/article/SB124476804026308603.html) he merely borrowed the idea from the auto insurance industry: “the auto-insurance industry has long recognized the role of personal responsibility. As a result, bad behaviors (like speeding, tickets for failure to follow the rules of the road, and frequency of accidents) are considered when establishing insurance premiums Bad driver premiums are not subsidized by the good driver premiums.”

Think of The Birthday Party—Mr. Burd has established boundaries, fostered the behavior he considered positive in reaching the intended goals and dampened the behavior considered negative. He has not imposed order, but allowed emergent order to develop from the agents and the system itself. And IT WORKS.

This is what he did (http://online.wsj.com/article/SB124536722522229323.html): the company pays for a variety of preventive visits and tests. The company contributes $1000 into a health savings account each year. The employee can direct how this is used. After that first $1000, the employee is responsible for the next $1000. After that, they are responsible for 20% of the costs up to a $4000 maximum. Even if the company did nothing more than that, the employee now has “skin in the game”. That first $1000 is spent very wisely, and true value-seeking behavior has developed.

But there is more to the plan. The employees are tested for markers in smoking, weight, blood pressure and cholesterol, and are given premium reductions, up to $1560 per family per year, based upon their performance in these measures.

Safeway’s workforce has a smoking rate and obesity rate 70% of the national average. While health care costs in general have risen @ 40% in the last 4 years, Safeway’s has remained flat. And 80% of the 30,000 covered workers rate it good, very good or excellent.

This approach is not without its critics, however. http://www.mcclatchydc.com/363/story/72532.html:

If you give one person a discount, someone else is going to end up paying more,” said Paul Cotton of AARP, one of more than 60 groups that’s fighting the provision. So the people who aren’t able to change their behavior or participate in the program will end up paying more. Our fear is that premiums will become unaffordable for people who can’t change their behavior.

Paul Cotton appears to be stating that even though the program works, it should be opposed because some people will be negatively impacted by their inability to modify their own behavior. Think of this in the analogy of The Birthday Party: should we attempt to impose order on a system that is unordered, using techniques we know will fail because one or two of the children are determined not to have a good time? While very few people would see this to be a rational course of action, that is, in essence, what many people advocate in the health care debate. They wish to make their own reality, and in the process, attempt to make ours as well.

Society needs to be aware of the “outliers”, and not proceed with policies that ignore real suffering. This is the delicate dance–the Complex Adaptive System of health care has its faults, and some faults are inherent in any system in which innovation and emergent order is operative. As much as we may wish to impose an order in which NO such faults are present, we need to understand the implications. In The Birthday Party (what a great story, David!) do we consign unhappiness to everyone, or try to insure the maximum people are pleased? Our longing for and cultural memory of Eden?……

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