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End the “tragedy of the commons” in health care

In a year when health care reform is uppermost in national politics, the Institute for Healthcare Improvement’s 21st Annual National Forum on Quality Improvement in Health Care took on special significance.

IHI President Don Berwick’s keynote address challenge to forum delegates in Orlando, Fla. (and remotely to viewers around the nation, including at CareOregon’s office in Portland) was to avoid the tragedy that befalls all when all interest groups are making the ‘correct’ choices for themselves.

Berwick compared the situation with health care to the classic allegory penned by William Forster Lloyd in 1833 and recalled by Garrett Hardin in 1968, describing how villagers’ individual actions beneficial to themselves collectively destroyed the common ground they all depended on to graze their sheep.

“Like the villagers, rational health care stakeholders are eroding the common good simply by doing what makes sense to each of them separately,” Berwick said. “In the short term, we each win. But, in the long term, we all lose. We lose the Triple Aim: better care for individuals, better health for populations, and lower per capita cost, all at once.

“Name any stakeholder—hospital, physician, nurse, insurer, pharmaceutical manufacturer, supplier, even patients’ group—every single one of them says, ‘Oh, we need change! We need change!’ But, when it comes to specifics, every single one of them demands to be kept whole or made better off.

“Here is my challenge. I challenge us to end the Tragedy of the Commons in health care. I challenge us to prove Garrett Hardin wrong.”

Berwick acknowledged that it will be hard but said it can happen, because there are places where it does happen. And the consequences of not acting for the common good will be felt in common.

“We can wait for the rules to be written by others and for the laws on tablets chiseled by others to rescue us,” he said, &ldsquo;but those rules will be less wise than the ones we can write, and those tablets will be, not our salvation, but weights upon our spirit.”

For a report on the IHI conference, see the IHI website. A video clip of Berwick’s speech is also available here.

Nation fares poorly on longevity scale

The United States ranks near the bottom in life expectancy among wealthy nations, according to a recent report by the Organization for Economic Cooperation and Development (OECD). With a life expectancy at birth of 78.1 years, the U.S. ranks above only Czech Republic, Poland and Mexico of the 30 richest member nations included in the survey.

The United States also ranks near the bottom in infant mortality rates. With 6.7 deaths per 1,000 live births, the United States infant mortality rate was far higher than the OECD average of 3.9, and better than only Mexico and Turkey.

At the same time, American health care costs far surpass that of every other nation. The United States spends $7,290 per person, nearly 2.5 times as much as the OECD average of $2,984 per person.

Data cited in this study are from 2007. For more details on the report, see the Associated Press story of December 9, 2009.