Is covert rationing a vast conspiracy?
It might seem impossible to conduct widespread rationing in a huge industry like healthcare, which consumes nearly fifteen percent of the GDP and directly affects all of us, and to do it in secret. Wouldn’t the rationing of such a visible commodity be apparent to everybody?
Actually, it is quite apparent if you look for it. But we’ve more or less agreed not to look. Covert rationing is not a conspiracy being foisted on millions of innocent Americans by a vast and evil cabal. Much of the rationing activity is only poorly hidden, and its covert nature relies on a willful failure to recognize it for what it is. Most of the individuals who are actually conducting the rationing - the doctors, the hospital administrators, the managed care and health insurance executives, the scientists, the policymakers and regulators - subscribe to the same no limits mentality as everyone else. Most probably find the notion of rationing healthcare repugnant and would take offense at being accused of carrying it out.
The covert rationing of healthcare is a textbook case of subconscious collusion. Subconscious collusion is a defense mechanism invoked by any social order faced with a condition that is both unavoidable and unacceptable. It is an unspoken, often subliminal decision to coexist with the unacceptable condition but not to notice it, acknowledge it, or confront it. Consider the wife who subliminally decides not to notice that her husband is having a string of extramarital affairs. And consider the German populace during World War II, apparently failing to notice the Holocaust. Subconscious collusion is a common survival technique that allows a social order to persist, for a time, when some fundamental tenet of that order has been severely compromised. The problem with subconscious collusion is that it allows the root problem to grow unchecked - and by definition unnoticed - until the social order being protected by this defense mechanism implodes.
In the case of healthcare rationing, subconscious collusion operates like this: First, the economic forces that require rationing and the social forces that forbid rationing line up to foster a certain attitude, a certain way of looking at things. Then, within every entity in the healthcare system, those who embrace such an attitude become ascendant, not by conspiracy or plot, but by natural market forces.
That certain correct attitude, the new “right stuff,” is the ability to suggest ways of limiting healthcare services, while spinning those suggestions as being consistent with the culture of no limits. This kind of thinking allows organizations to direct the rationing of healthcare while advancing the notion that rationing is unnecessary.
There is surprisingly little hypocrisy under this scenario. While some of the individuals directing the rationing behavior understand exactly what they are doing, most continue to subscribe to the myth of no limits. Most believe (or want to believe) that their actions are not reducing useful services, that, instead, they are reducing waste and improving the efficiency of the system. Those who do understand the true nature of their actions shield themselves from having to communicate that knowledge. They become the quiet, private CEOs or directors whose spokespersons and PR specialists (individuals who are entirely sincere about what they are telling the public) do their speaking for them.
So there is no conspiracy. The covert rationing of healthcare is conducted by a myriad of organizations, acting independently and responding to economic and social imperatives. The key for organizations that want to flourish within our Quadrant III healthcare system, then, is to identify leaders who can respond both to the need to ration healthcare and to the need to rationalize such behavior in terms acceptable to the rest of us. Those individuals, men and women of vision, are the Most Valuable Players in Quadrant III healthcare.
The visions advanced by such individuals - visions that enable covert rationing to go forward freely and often profitably - fall into two schools of thought that we will examine in coming posts. A brief introduction will suffice for now.
