Health, Medicine and Society Program

Focus on cultural change

Focus on cultural change. We haven’t paid enough attention to cultural barriers within the health care system to achieving our health care goals. Meaningful reform must address more than the symptoms of a broken system. We must surmount the culture of the current health system that protects the status quo and empower all quarters of our community to produce real change. Health care delivery must be reorganized to suit patients, not the industry. Care should be well coordinated and easy to navigate. Health plans must be refocused on enabling health rather than limiting care. Employers and communities must redirect their efforts toward supporting health. These changes are essential to enable health stewardship and needed improvements in health and health care.

Successful health system reform depends on one critical factor: the need for a significant shift in our health care culture. Our current culture, which discourages thoughtful resource stewardship, is grounded in a fragmented system of health-care delivery, one structured around separate medical specialties, discrete treatments, and individual episodes of illness or injury. Many proposed reforms are largely new expressions of the old culture that surrounds health care—a culture often characterized by cost shifting, the denial of responsibility, a lack of coordination, and a dearth of preventive care.

Changing this culture is the key to health system reform that will drive improvements in value. In health care, value is created at the level of helping prevent, care for, or resolve an individual’s medical circumstances or condition.1 When an individual’s medical problems are resolved effectively and efficiently, or when prevention enables an individual to avoid becoming ill or injured, value is created. So the culture and organization of services needs to be redesigned from the perspective of a patient’s medical circumstances.

But the health care system is currently organized around medical specialties, the doctor’s perspective. The result is poor coordination of care, difficulty accessing and scheduling needed care, lack of communication and sharing among the clinicians, repetitious tests, and far too many errors. Instead, the organization and culture need to be patient-centric, coordinating the care and information that the individual needs throughout the full cycle of care (that is, prevention, monitoring and assessing risk, diagnosis, preparation and treatment, and ongoing rehabilitation or long-term disease management). A system that organizes care along the full cycle will be in a position to capture the benefits of prevention and early diagnosis. Such a system would recognize that the expense of cholesterol-lowering drug therapies is cheap compared to the $50,000 cost of a heart attack, or the $250,000 cost of congestive heart failure.

Health care delivery by medical condition (or co-occurring medical circumstances) requires coordinating and relocating the medical specialties and services that are needed to treat that condition. A cancer patient will find that the medical oncologist, surgeon, radiologist, and imaging and lab facilities all occupy the same premises and work together as part of the same team. Institutions such as the M.D. Anderson Cancer Center, which have already made this change, have found that redesigning health care delivery around medical conditions enables dramatic leaps in learning, quality, waste reduction, and efficiency.

Every stakeholder in the health care system can participate in this cultural and structural change. For example, drug and device manufacturers working in conjunction with clinicians can orient their businesses around improving results for medical conditions over the full cycle of care. Some, such as Novo Nordisk and Genzyme, attempt to ensure that their products are embedded in the right care-delivery processes and are actively working with physicians to improve those processes and to improve results.2 Health plans, too, could organize around the individual’s perspective and accelerate their learning on how to enable effective care with improved outcomes. Individuals in a reformed health care system could truly become active partners in enabling their own health and improved results.

Cultural change is a difficult undertaking in a system where professional values are ingrained into organizations over time. Yet such change is possible, even on a large scale. The Cleveland Clinic is progressively reorganizing its multi-hospital health system—1,700 staff physicians and 3,000 independent physicians—into this new structure. 

We are receiving a poor return for our financial and social investment in health care. Only by shifting the culture underlying our health care system can we make real progress toward a system that is affordable and sustainable, and delivers quality health care to every American.

[1] A medical condition is a set of interrelated health circumstances best cared for in an integrated way. It includes not only a disease, but also its common co-occurrences, such as diabetes with hypertension or vascular problems. From the patient’s perspective, this interrelated set of circumstances is his or her medical condition. Not all health circumstances are interrelated: an ulcer and a broken arm are two medical conditions because they do not typically occur together and integrating care is not critical to improving results. See M.E. Porter and E.O. Teisberg, Redefining Health Care (Boston: Harvard Business School Press, 2006), pages 105-107.

[2] Porter and Teisberg, Redefining Health Care, pages 289 and 293; Novo Nordisk, New UK diabetes centre to improve quality of life, 2007, available at: