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!

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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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Leadership and the feasible

Talented political leaders, like talented generals, can win battles and campaigns that would overwhelm those less able or less energetic. So, asking if a policy is feasible is, in part, asking a question about the advocates of reform, especially their creativity, commitment, and skills—and about their opponents.

Getting Health Reform Right, p. 66

Although I’m still only early on in Getting Health Reform Right, there’s food for thought in every section. The quote above is from their chapter on the politics of reform, and although the political context of health care reform (particularly in third world countries) is an animal unto itself, this quote got me thinking about what makes a successful first-world corporate leader.

I’d start by rephrasing the meat of the quote: Asking if a corporate initiative is feasible is, in part, a question about the leader who sponsors it, especially their creativity, commitment, and skills—and about their opponents’ creativity, commitment, and skills.

I’ll have to be honest, I love this vision of leadership, not only because of how it describes the leader (creative, committed, skillful) but also because of how it expresses the interrelation between initiatives and the leaders who support them.

Isn’t this the kind of leader we all want to work for? The kind of leader whose initiatives we want to be a part of? And for what it’s worth, isn’t this the kind of leader any of us would want to be?

And while I’ve been fortunate enough to know many leaders who fit this bill, I’d be hard pressed to count on more than one hand the number of CXOs I’ve run across who lived up to this vision. Certainly any reasonably competent CXO will have at least one of these qualities, and more often than not two, but for some reason I simply haven’t come across many who have all three.

To be fair, I’m a latecomer to the corporate world, so maybe ten years is not enough time to have bumped up against more of these exceptional CXOs—but then what does that say about corporate leadership that you could spend ten years working and not encounter lots of great leaders?

Anyway, I took away two things from this vision of leadership. One, I want everything I do at work to draw me towards leaders who have creativity, commitment, and skills and away from those that don’t. Two, I want to have experiences that help me develop these same qualities so that I can live up to this vision of leadership when I take the reins at an organization.

So how about you all out there: What do you think about this vision of leadership? Have another one that you think works better? And what about the lack of exceptional leaders at the C-level? Have you had better luck finding them than I have?

As usual, jump in and let’s get the conversation started.

The execution cycle

I’ve cracked the next book in my quest to better understand the health care problems facing the U.S.: Getting Health Reform Right, by Roberts, Hsiao, Berman, and Reich. This is another long one, so a dedicate review is a ways off, but I came across an interesting framework in the opening chapters, one that, with some slight changes in emphasis, could have applicability beyond government policy to include corporate decision-making.

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