Joseph Cramer, M.D.: Saving our health care from the tragedy of the commons
A "commons" is a parcel of land set aside by the community for shared grazing of their collected animals. The Boston Common is an example of that practice. The problem with a commons is that if the villagers, in their own self-interest, let loose too many animals, the critters would destroy the meadow’s ecosystem. The grass would be gone, the water ruined and the fences broken.
Garrett Hardin called this disaster “the tragedy of the commons.” He posited it is the inevitable and immutable failure of human nature's inherent self-interest that drives the destruction of the commons.
For the individual, it is to his or her personal advantage to have as many animals as possible. With more cows, there is more milk and meat. When one owns more sheep, there is more wool and more profits. As the neighbors see this growing enterprise, they feel compelled to join in the hooves race. If they don’t, they will be left behind. For pride, greed or mere survival, the result is the same. Soon there are too many animals chewing on the finite amount of pasture. The tragedy of the commons plays out. There goes the neighborhood.
Then along came Elinor Ostrom, the first female recipient of the Nobel Prize in Economics. She saw it differently. In her work, "Governing the Commons," her emphasis is on self-organization. The locals, for their own sake, unite to regulate themselves.
Dr. Don Berwick, who provided the ideas and references for this story of the conflict of the commons, likened the imagery of the commons to modern American health care.
He pointed out in a keynote address a couple of years ago that as we spend more on CAT scans, expensive surgeries, bigger hospitals and more costly drugs, we are eating up our commons. The more we pay for redundant studies, unnecessary operations and inappropriate hospitalizations, the less we have for schools, parks, roadways, social needs or even medical research.
It is his call and the growing cry of others for a safe, effective, efficient, equitable, timely and patient-centered health care system. Without such a system, there goes not only the commons but also our whole way of life.
Berwick is strongly optimistic that we are not doomed to the tragedy of the commons. He wants to prove Hardin wrong. He believes that we can come together to cooperate for our best interest and economic salvation.
Cooperation, not competition, is the solution. A term used by others is to have "competitive cooperation." Each person strives to better his or her position without the destruction of the others. In other words, a bunch of grown-ups must play nicely together, or everyone will lose.
In health care, that means if one MRI machine is adequate, the two hospitals in town don’t both buy one. If one cancer center provides enough care, four others are stealing from the commons. The family of medicine works with the community of payers, hospitals, home health agencies, governmental agencies, pharmaceuticals and patients to create a better medical ecosystem.
Today, that is not happening as often as it should.
Hardin would argue the solution is to have a strong central regulator. This judge, jury or executor would stand at the entrance to the commons and prohibit villagers from sneaking in another goat or cow. If they do, they are in real trouble. Ostrom, on the other hand, says the cost of regulation is high and its effectiveness is always in doubt.
Therefore, if we want to save the commons of our civilization, we have to have our solution with all the herders committed to competitive cooperation. The whole village saves the commons.
That is why we need to improve the system of health care. We need to stop all harm, reduce all waste and eliminate all errors. Otherwise, the only thing we will have in common is dead grass and a lot of dung.
Joseph Cramer, M.D., is a board-certified pediatrician, fellow of the American Academy of Pediatrics, practicing physician for 30 years and a hospitalist at Primary Children's Hospital and the University of Utah. Email: firstname.lastname@example.org
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