"A Puzzlement"

"Here’s today’s trivia question, Julie.  Our title was a song in what Broadway musical?”

“You know very well that I’m not a child of the 40’s or 50’s, while you, Old Relic, were dating the future Mrs. Curmudgeon in 1954.  Of course I don’t know the song’s origin.”

“The King and I, Youngster, and it was sung by the King, Yul Brynner.  More familiar songs from that show are ‘I Whistle a Happy Tune’ and ‘We Kiss in a Shadow.’ “

“I’m going to need some guidance in finding a link between this particular show and Lean or health care.  You take the lead.  ‘Shall We Dance?’ “

“There are lots of puzzling aspects to our system of health care delivery.  It’s not that I don’t comprehend them; I just find them peculiar.  Lots of other people also find them a bit incongruous, that is, they are not always consistent with the triple aim of providing the best care for the whole population at the lowest price.”

“Whew!  I was afraid that this whole posting was going to be written by Rodgers and Hammerstein.  So Curmudge, you list your puzzlements, and I’ll sit over here and be…er…puzzled.  I suspect that the reason for many of these issues is evident but the rationale is, to say the least, fuzzy.”

Puzzlement: Although the nation is hoping to hold down health care expenditures, why haven‘t physicians’ needs to practice defensive medicine been resolved?  Comment: We know the answer, but why isn’t something being done about it?

Puzzlement: If health care is virtually free for many patients, e.g.. Medicare and Medicaid patients, and providers are paid based on production, why are we surprised that the use and cost of health care are increasing?

Puzzlement: Why don’t buyers (patients) know the prices of the products (procedures) that they buy?  For that matter, why don’t the sellers (providers) know the prices either?

Puzzlement: Why, in Wisconsin, does the cost of a knee joint replacement range from $17,000 to $55,000?  (At least someone knows how much a procedure costs.)

Puzzlement: If a Medicaid patient needed the services of a convenience clinic down the street from where she lives and the clinic’s listed price was higher than what Medicaid would pay, why would a law be broken if the patient paid the difference?

Puzzlement: Why can’t a person purchase health insurance from any insurer he wishes irrespective of the state in which the insurer is located?

Puzzlement: Why are health insurance policies purchased by an individual and an employer treated differently by the Internal Revenue Service?

Puzzlement: Why is a ‘Full Code’ the default order for a patient who is obviously on the brink of death?

Puzzlement: Why won’t (usually) the Food and Drug Administration authorize a promising therapy for terminal patients before it has received their full approval?

Puzzlement: Why do substantial numbers of people in the U.S. believe with almost religious fervor that someone else—government or employers—are morally obligated to pay for their health care?  In that scenario, reimbursements are administered prices; and ‘providers and patients are insulated from market pressures that would normally force efficiencies, greater accountability, and the delivery of increased value’ (1).”

Puzzlement: Decisions about health care are inherently personal, ranging from what we will eat for breakfast to who will do our surgery.  Each of the almost 313 million people in the United States makes these decisions every day.  How can a government committee make personal health care decisions for such a large and diverse population?  Comment: A large, diverse mass of people is an example of a complex system.  This will be discussed further at a later date.

“My turn, Old Guy.  Here’s my puzzlement.  You really sound like a cantankerous curmudgeon today.  Is there a reason for that?”

“Of course there is.  I have to do that occasionally to maintain my reputation.  I certainly wouldn’t want to be called the Kaizen Pussycat.”

Kaizen Curmudgeon

(1) Christensen, Clayton et al.  The Innovator’s Prescription  (2009, McGraw-Hill)