‘The best solutions to the problems of national order lay in education of individuals to the ideals of service, stewardship, and cooperation.’
(Charles W Eliot, 1910)
THE SLIPPERY MEDICAL LANDSCAPE
As physicians, we live in a complex, ever-changing medical landscape. The goal of maximising profits percolated into the healthcare sector, which was once based upon the ‘common good’ of our patients and society. The common good consists of our communal values, about what we owe one another as citizens, bound together in the same society seeking the rules and principles we wish to achieve together. A concern for the moral good is an ethical attitude recognising we are all in it together. If there is no common good there is no society.
A century ago hospitals and health insurers had palpable public responsibilities. The original purpose of health insurance plans, devised at Baylor University in the 1920s, was not to maximise profits. The original intent of the health insurance plan was to share the risk of illness across all demographics and to cover as many people as possible (maximise the common good). The nonprofit Blue Cross and Blue Shield accepted everyone who wanted to be a member. Unique to this plan was the idea that every member paid the same rate, irrespective of age or health. In the 1960s Blue Cross was providing hospital coverage to more than 50 million Americans.1
Then, in the 1970s, ‘entrepreneurs’ seized an opportunity to make vast sums of money by exploiting the common good. This change in the health insurance landscape adulterated the charitable mission of Blue Cross and Blue Shield. These entrepreneurs founded for-profit insurance companies like Aetna and Cigna that accepted only younger and healthier patients. This profit-driven mission allowed them to lower their premiums below the Blues’ while running to their depository with hefty profits.
The Blues were unable to compete so in 1994 they surrendered and became for-profit. This ended the era of nonprofit health insurance. This tragic transition led to a new paradigm where the US health insurance system zealously insured the healthful and avoided the sick population like the plague.
When the only motive is to make as much money as possible in a short time frame the common good is easily displaced.
As physicians we have been thrust into this dismal situation of trying to identify how we reinstate the common good back into the health care of the US. A daunting challenge, but one physicians must accept, individually and as a group. The present-day healthcare pact has put physicians in a triangle composed of administration, healthcare providers, and patients.
We must resist the urge to become tribal. Tribalism is the behaviour and attitudes that stem from strong loyalty to one’s own tribe or social group. Ignorance of tribalism led US policymakers to underestimate the importance of cultural identity in Vietnam in the 1960s, Venezuela in the 1990s, and Afghanistan in the 2000s. As physicians we must understand the cultural, political, and financial identities of the stakeholder sitting at the healthcare policymaking table. We must act as leaders through trusteeship.2,3
Trustee is a legal term, which, in its broadest sense, is a synonym for anyone in a position of trust or responsibility for the benefit of another. Physicians are the trustees of patients.4 Physician leaders must be the stewards of the once unwritten rules we took for granted — the common good.
HEALTHCARE LEADERS
One half-century ago healthcare leaders understood that corporations were not just for shareholders but also for employees, communities, customers, and the public. Health insurers existed to provide coverage to everyone who needed it, not by cherry-picking the young and healthy. Over time and through tumultuous change in the US healthcare arena, leaders have forgotten that their legitimacy depends on advancing the common good and that type of leadership is a public trust. Trusteeship should be inoculated into the understanding of successful physician leadership. Physician leadership must teach every physician the importance of being a fiduciary in the doctor–patient relationship.5
Physicians have a duty to meet in an open-minded manner with administrators and patients to dialogue how to achieve solutions that restore the common good in health care. The lack of a common-good strategy will harm everyone over time. The job of the physician leader is to help educate all stakeholders.
This is not simply about ethics. Leadership as trusteeship extends beyond ethics. It requires a different way of thinking about the central obligation of leaders. Its essence is restoring trust in the healthcare system. Physicians are in a unique position to restore the common good.
- © British Journal of General Practice 2018