ANITA MCGAHAN

on healthcare’s role in value creation

General Motors and the IN OCTOBER 2005, United Auto Workers reached a compromise to reduce GM cash outlays on healthcare benefits for active and retired personnel by an estimated $1 billion. The agreement was hailed as a victory for both parties because it would lower the company’s costs while preserving jobs. But the seeds of GM’S demise had already been sown. In that same year, its annual report had warned investors that escalating healthcare costs were an existential threat:

Healthcare in the United States is one of our biggest competitive challenges, and if we do not make progress on structurally fixing this issue, it could be a long-term threat to our company. In 2005, GM was challenged with the compound impact of escalating healthcare cost rates and falling discount rates used to determine future healthcare liabilities. As a result of these factors, in 2005, GM’S U.S. other postretirement employee benefits (OPEB) expense, consisting of retiree healthcare and life insurance, increased to $5.3 billion, an increase of more than $1 billion from 2004. Four years later, on June 1, 2009, GM filed for bankruptcy in the U.S., Canada and Ontario. In hindsight, it is clear that the structural issue of escalating healthcare costs had indeed set the foundation for failure. As The Economist explained, “Every year, the cost of retired workers’ healthcare diverted billions of dollars from developing innovative new models and added $1,400 to the cost of each car compared with those made in Asian and European plants.” In other words, the company’s past success created obligations that eventually took it down.

GM’S problems are not unique. Over the years, escalating healthcare costs have been cited in the bankruptcies of Kodak, Xerox and Data General, among others. Of course, healthcare expenditures and issues have both positive and negative implications for firms: Healthcare benefits help to attract and retain talent, drive productivity and reinforce a company’s values and image of being socially responsible. However, as the cost of providing healthcare escalates, the achievement of competitive advantage through each of these mechanisms becomes more difficult.

In many markets, escalating healthcare costs also create opportunities for value creation. Innovation is richly

rewarded in the pharmaceutical, medical-device manufacturing, healthcare provision, acute-care, insurance, tertiary healthcare, food-manufacturing, restaurant, informationtechnology and lifestyle-support industries. Companies in each of these sectors can disrupt incumbents by introducing innovative products and services that improve health, reduce the likelihood of illness and/or reduce the cost of care. Consider the following examples:

• Medical-device manufacturers have been introducing cheaper and more accurate dental-imaging machines than those currently in use, developed decades ago;

• Information-technology companies have analyzed health data to provide more accurate and comprehensive assessments than were previously available; and

• Lifestyle-support companies now offer holistic ‘wellness’ solutions designed to reduce the costs of healthcare by averting illness through better fitness, healthier diets, mental-health support and other means.

Thus, just as escalating healthcare costs have threatened companies like GM, they have also created a powerful incentive for firms to innovate in various markets. The question is, ‘Can companies innovate to improve quality of life and lower healthcare costs quickly enough to counteract the threats to general business from escalating healthcare costs?’

A fundamental point — one that is central to the sustainability of our way of life — is that the cost of healthcare must go down in real terms. We simply cannot afford the healthcare system that we have now. In 2015, the estimated expenditure on healthcare per person in the U.S. approached $10,000 per person — about 17 per cent of GDP. The figures for Canada and the UK were about half that level — nevertheless, a high percentage of income.

The heart of the problem is that our current model of healthcare was conceived and built in the late 19th and early 20th centuries on principles that reflected industrialization. The individual was conceived as an essentially healthy be- ing, with the challenges of disease and illness remediated by medical care. This ‘medicalization’ of healthcare meant that interventions generally occurred after patients became symptomatic. In other words, we went to doctors after we got sick, not before. The incentives associated with the system were therefore developed to reward the remediation of illness: Doctors got paid the most when they saw sick patients, not well ones.

In his brilliant book Being Mortal, Dr. Atul Gawande describes the consequences of the systemic problem in human terms:

You don’t have to spend much time with the elderly or those with terminal illness to see how often medicine fails the people it is supposed to help. The waning days of our lives are spent in institutions — nursing homes and intensive-care units — where regimented, anonymous routines cut us off from all the things that matter to us in life. Lacking a coherent view of how people might live successfully all the way to their very end, we have allowed our fates to be controlled by the imperatives of medicine, technology, and strangers.

We have created a healthcare system that reflects our values, which are of economy, rationality, technology and a kind of self-determinism that leads to isolation of the elderly. What is needed to counteract the threat of escalating costs is a new way of thinking about healthcare that rests on a 21st-century mindset about what is possible in both human and economic terms.

My students know what to do in order to avoid a heart attack at age 50 and to avert other types of cardiovascular conditions and cancer: eat right, go to the gym, sleep enough, stop smoking, drink in moderation, develop strong relationships and reduce stress. Yet, when I ask them why they don’t do all of these things, they tell me variations of the following: ‘It’s too hard’; ‘On a Friday night, my friends expect me to go drinking with them’; ‘I can’t find the energy to go to the gym’; and ‘I’m so worried about finding a job that

Escalating healthcare costs create signifificant opportunities for value creation.

I stay up all night studying.’ These students are on track to suffer the same kinds of diseases, at the same stages of life, as my generation.

To support the practices that my students know are best for them, we need an entirely different way of approaching healthcare. Incentives must change so that patients tell physicians about risky behaviour and physicians are rewarded for helping them stay healthy. Products and services that sustain health must be as abundantly available as those that damage health, which means that these sustaining products and services must be profitable and desirable.

Furthermore, physician culture must change to emphasize health and quality of life. Medical schools must become ‘health schools’, and they must offer courses of education that yield qualified physician assistants, nurses and community workers as health providers. The dissemination of knowledge about heath must have safeguards to prevent any undermining by private conflicts of interest. And national conversations must develop on late-life quality of life.

In short, the whole system needs to be redesigned to emphasize prevention, early diagnosis, comprehensive treatment, social support, mental health and meaningful work. The managerial research suggests several fruitful ways to begin, and already a number of principles have emerged.

THE GOAL FOR CHANGE MUST BE MAINTAINING AND SUSTAINING HUHealthcare organizations — like organizations MAN HEALTH. in any industry — tend towards processes that sustain their organization. This occurs for a range of reasons: preservation of jobs, belief in purpose, preservation of legacy and concerns about risk. However, the goal should not always be the sustainability of the organization. Especially in healthcare, the most successful organizations could actually put themselves out of business over time as their missions become fulfilled.

Consider the following example: President Jimmy Carter has had a passionate commitment to the eradication of guinea-worm disease, and the Carter Center’s anti- leishmaniasis program has been organized to pursue that goal. President Carter would like nothing more than to put this program ‘out of business’ by achieving that mission. The goal is to sustain health rather than sustain the organization. This type of perspective needs to be purposefully cultivated on a larger scale. People should always be mindful that, in many cases, their ultimate success can be achieved only when their organization is no longer needed.

CLIMATE CHANGE THREATENS HUMAN HEALTH. As a consequence, it threatens the entire healthcare system that we have in place today. The effects are already in motion: droughts that diminish agricultural productivity, storms and warm temperatures that together promote infection, weather disasters that create humanitarian emergencies and pollution that harms crucial ecosystems. As climate change progresses, the demands on the health sector will escalate. In response, the following are crucial priorities that present opportunities for innovation: improving systems for producing and distributing high-quality food, identifying weather events in advance of their occurrence, and configuring effective humanitarian responses on an international basis.

THE FUTURE OF HEALTHCARE IS DIGITAL. The list of opportuni- ties for improving health systems through digitization is so extensive that any attempt to capture that scope is daunting. Yet despite the range of opportunity, the health system often resists digitization. For example, in one hospital in downtown Toronto, new applications cannot be adopted because the enterprise computing system is too old to accommodate them. In other cases, legitimate concerns about privacy and effective diagnoses must be addressed before progress can occur. And in still other situations, digitization requires the development of new protocols that physicians resist because they are concerned about the risks for patients and the administrative burden of too much change. Our research suggests that relatively few providers actively resist digitization out of self-interest, laziness or ignorance.