Review of Getting Health Reform Right

I was excited to read Getting Health Reform Right because it approached the problem of health care reform from an international, public policy perspective. The authors all have deep experience working internationally to address health care, and it shows throughout their analysis in the many real world examples of reforms gone right and wrong drawn from across the globe.

The book is meant as a hands on guide for those involved in reform on the ground, so it’s very much a practical, almost how-to guide. I say almost because, as they remind the reader throughout, there is no easy solution to the problem of health care reform, no one size fits all prescription. In every case, in every country, reformers need to take the specifics of the particular national situation into account if they want to have a chance to succeed.

The authors slice up the formidable challenge of health care reform into manageable chunks using the idea of control knobs, i.e., the big bucket categories of health care elements that reformers can address to affect change in the overall system.

They identify the following five control knobs (pp. 27-28):

  • Financing – all mechanisms, such as taxes, insurance premiums, and direct payments by patients, for raising the money that pays for activities in the health sector.
  • Payment – methods for transferring money to health care providers (doctors, hospitals, and public health care workers), such as fees, capitation, and budgets.
  • Organization – the mechanisms, such as measures affecting competition, decentralization, and direct control of government providers, that reformers use to affect the mix of providers in the health-care markets, their roles and functions, and how the providers operate internally.
  • Regulation – the use of coercion by the state to alter the behavior of actors in the health system.
  • Behavior – includes efforts to influence how individuals act in relation to health and health care.

The lion’s share of the book is spent addressing these five control knobs, and the authors do a solid job explaining them fully as well as illustrating how they affect a nation’s overall system of health care.

But as, if not more, valuable is the first section of the book that sets up their discussion of the control knobs with an analysis of health systems in general. Here they tackle the health reform cycle, how ethical theory intersects health care reform, political strategies for reformers, and strategies for selecting appropriate goals and performance measures for health system reform.

These chapters should be mandatory reading for anyone who wants to better understand the current debates on health care reform in the U.S. The generalized, international (or better yet, multinational) perspective allows the authors to set health care reform in a larger context, one that I think makes it easier to see the contours of the U.S. debate than the noise coming from all sides through the media.

And as those of you who visit here regularly know, the book is also chock full of insights for leadership generally: the problem of health care reform is so large and so complex that what leaders need to do to address it will have wide applicability to more narrow corporate challenges.

As usual, would love to hear from folks out there who’ve read the work or who have thoughts about my take on it—jump in and let’s get the conversation started!


Oblique influence

I just finished a long section of Getting Health Reform Right about the role of regulation in health care that was, to say the least, eye-opening. And as usual, I want to leave aside discussions of health reform and talk more about the implications for leadership generally.

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Make sure you tie your carrot to a stick

Changes in external incentives and in internal management are powerfully complementary. Giving managers incentives without also giving them the skills, authority, and resources they need to respond to those incentives is likely to be quite ineffectual. The same is true in reverse. Increased managerial authority is not likely to lead to improved care if managers have no incentive to do so. This is why various writers on organizational reform in health care have seen a need for “consistent” change (Harding and Preker 2002). It is not aesthetics that lies behind their observations, but rather the need to combine reasons to do better with this capacity to do better–in the same reform package.

Getting Health Reform Right, p. 215

I’m still finishing up Getting Health Reform Right, so a review is a week or so off. But in the meantime, I came across this passage on the plane last night and thought it held wonderful insight into leadership generally.

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Leading without authority

I was at a client recently and had a great conversation with a team member about leadership. He was an IT application owner, which in this case meant that he has the primary responsibility for both the care and feeding of a software application as well as acting as the liaison between IT and the business folks who are its end-users. In the course of our talk, he expressed a desire to move beyond his current role and become a leader at the enterprise level, so we shared our thoughts about the process we were both on to do that very thing someday.

The talk reminded me that you can’t wait until you’re given a leadership role to begin leading–you have to start the moment you decide that leadership is something you want to do, and the official title will come later.

After all, if you can’t lead without an official title, how will you do so once you get it? The mantle of authority doesn’t convey leadership abilities, it conveys the authority to tell others what to do and expect them to do it. But the vision to know what should be done and the ability to get people excited to do it–you need to be able to do both of these before formal authority is going to be of any real use to you as a leader.

For the client team member I was talking with, this meant organizing a grass-roots user group for his application so that business stakeholders from across the organization could come together and share their experiences with the technology and the business problems it helped them solve. I encouraged him to go further and evolve this user group into a more formal center of excellence (COE) focused on the core business domain of his users (in this case, customer communications). Such a COE could be instrumental in formulating policies and procedures, defining standard enterprise requirements (business and technology), and training and educating the rest of the organization about its domain.

If he succeeds at driving this kind of organizational change in his current position, think of what he’ll be able to do when he’s given a more formal leadership position. But part and parcel of why he would be able to succeed in a formal leadership role would be because he had already done so much informal leading–that’s the catch. Being a leader and having a leadership title are two different things: one has to be given to you, the other you have to decide to do, no matter what your current title is.