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The Keckley Report

Radical Incrementalism or System Re-design: Which Way Forward for U.S. Healthcare

By April 23, 2018March 1st, 20233 Comments

In Catholicism, purgatory is the intermediate state after physical death in which sinners destined for heaven must first atone for their sins before entering. It’s a holding place. It’s temporary.

The U.S. healthcare system is in purgatory. It’s caught between the tyranny of the present and the possibilities of its future. We do some things well, but intramural conflicts, financial incentives that often reward short-term results and a structure that’s flawed limit its potential. We all see it. They’re the sins for which we must atone.

Here’s the reality: we’re at a crossroad. Our focus on the near term is distancing us further from reaching a future state that’s different and better. Our dichotomies are perilous:

  • We struggle with the whether healthcare in the U.S. is a fundamental right or privilege.
  • We love our drugs but hate their costs and our addictions.
  • The public expects healthcare anytime, anywhere and wants someone else to pay for it.
  • Our physicians are trusted and well-paid but frustrated and burned out.
  • We need more healthcare professionals but refuse to challenge the guilds that control access.
  • We preach the importance of social determinants, primary and preventive health, mental and dental care, post-acute and alternative health but spend the lion’s share of our resources elsewhere.
  • We guarantee patients access to their medical records through our laws but hope they don’t acquire or use them lest it require us to answer questions about what we do on their behalf.
  • Our politicians dodge meaningful discussion and civil discourse about difficult healthcare issues in favor of focus-group tested soundbites and we re-elect them.
  • We talk about consumerism but treat people as wholesale cargo incapable of making decisions without their aid.
  • We talk about affordability but shun cost transparency.
  • We declare our work purposeful but pursue profit at all costs in some organizations.
  • We call it a “health system” but it is neither. 

Our physicians are the highest paid and most respected in the world. Our facilities are the most modern. Margins are stable in most sectors. But life expectancy is decreasing, public satisfaction is eroding, and the political environment for meaningful discussion about needed change is toxic.

The current state is not sustainable. We have perfected radical incrementalism. We defend it vigorously with three worn barbs: patients don’t want it, physicians will resist it, and radical change is impractical, especially when the incumbents are strong and the status quo is profitable. And we fight the entry of outsiders who dare invade our turf.

Think tanks and academics have offered varying views about the future state. All begin with the obvious—the system’s incentives are flawed, quality of care is highly variable, access is uneven, technology’s under-utilized, consumers are not engaged and affordability is a large and growing issue. Then each offers a solution, filtered through the biases of the special interests to which they’re beholden. Invariably they result in radical incrementalism– piecemeal solutions that placate the incumbent trade groups, lobbyists, and the elected officials they support.

I just returned from the Health Evolution Summit in Dana Point, California, arguably the most significant gathering of influentials across our industry. It’s an intense look at the future of our industry through the lenses of its prominent leaders. The tone was positive. All see a future state that’s dramatically improved over the current state. They’re optimistic but realistic: they recognize we’re a long way from getting there. They envision a new system that balances care for the sick with health and wellbeing for the rest. They know it’s easier to make excuses than to make the fundamental, systemic changes that all recognize are needed. They recognize the system’s currently in purgatory.

Designing the Future State: The Private Sector Must Take the Lead

Replacing radical incrementalism with a system of health that’s efficient, effective, comprehensive, equitable and affordable will require private sector leaders who set aside their commercial interests to pursue the greater good. It can be accelerated through regulation and adopted by the policymakers but the future state design scheme must be birthed by the private sector if it is to be successful. The public wants our system to remain private but easier to navigate and more affordable. They’re skeptical of schemes designed through our political processes and think government-run healthcare problematic. They want the private sector to step up.

It’s time for private sector leaders to take the lead in designing the future state for healthcare in the U.S.

The process should be inclusive: each sector should be at the table, represented by the organizations and companies that have made investments beyond radical incrementalism and their proprietary self-interests.

The design principles should be simple: there are no sacred cows. Nothing is off limits. Concepts prominent in our current effort to transform the system like meaningful use, transparency, alternative payment models and others—should be enhanced or set aside. No sacred cows.

The timeline should be strategic: design and implementation should not be a by-product of political campaign seasons or extracurricular distractions. The food fights in our industry between sectors eager to gain an upper hand are getting more raucous and the public’s losing faith. We provide the world’s best care for those who are sick or injured, but at a steep price fewer are willing or able to pay. There’s little time to waste.

Is radical incrementalism our future or something else? If yes, it is inevitable we’ll be a government run health system in a generation. If no, what replaces it needs attention now and selfless leadership by the private sector is key.


P.S. Barbara Bush’ death Tuesday and the purposeful manner in which she and her family conceded to her natural end was a reminder to us all that death is a part of life and an important part of our healthcare system. As we construct the future state, palliative care, advanced directives and end of life care are as important as breakthrough therapies, machine learning and technologically-enhanced self-care.

Also, this Thursday, President Trump will address drug prices. While new policies are not expected to be announced, it’s clear the spotlight on how we develop, distribute, prescribe and use prescription drugs will get more attention.


  • Ric says:

    Thanks for this – it really resonates.
    Could the Commonwell Health Alliance serve as a model of what the industry can do when ostensibly for-profit companies work together for the best interests of patients, not themselves?

  • Lynn Vogel says:

    Excellent discussion, Paul. Although I am concerned that your confidence
    in the private sector is misplaced. We’ve seen very little creativity on
    the part of private sector leadership, whether for-profit or non-profit.
    As long as the federal government continues to play such an outsize role in
    the payment process, leaders find it hard to focus on anything but chasing
    the dollars, even as they shrink. I think the problems are systemic. To
    change it we are going to have to develop new models of change; transfers
    from the corporate sector simply don’t work.

    I have just completed a manuscript tentatively titled, "Who Knew? Inside
    the Complexity of American Health Care", which points out specific factors
    that together have made health care not only the most unique but the most
    complex industry in our economy. Until healthcare’s complexity is
    recognized, I fear we will continue to stumble along and little will change
    especially with regard to access and cost. Quality measurement also
    continues to elude us for the most part.

  • Ryan Champlin says:

    You continue to nail it. Full professional risk capitation worked because incentives became aligned and physicians, as captain of the ship, helped patients choose wisely.