No one can predict the final outcome of Washington's efforts at healthcare reform. The healthcare system, however, is not waiting.
As Congress continues its wrangling, providers and healthcare organizations are negotiating new relationships to govern what they do and how they do it: new payment schemes, innovative collaborative arrangements and self-styled budget controls. In the long run, these negotiations may have more of an impact on the cost, quality and accessibility of healthcare than anything conceived on Capitol Hill.
What is happening in these negotiations? What is being created? In what ways will the bargaining process itself affect the outcome of these changes?
Changing times.A new balance is being created in healthcare. The emphasis on high-cost specialty services is shifting to primary care. The tradition of solo hospitals is giving way to interdependent networks. And while consumers' knowledge of their own healthcare needs is increasing, patients' autonomy is diminishing because of managed care. In each case, what people do and their relationships with one another are changing. Those changes bring shifts in decisionmaking, control and accountability.
Old assumptions that guided relationships among insurers, providers and patients no longer work in this emerging system. The anticipated give-and-take of negotiation changes in the process. Because of the overcapacity of the acute-care system, providers are more willing to give on price in exchange for assurance on volume. For capitated systems, there's a premium on keeping patients healthy, not merely treating them when they're sick. And for a hospital, offering the community access to care and improving health status is now a means to assure its future.
Naturally, with so much change, conflicts emerge: primary-care physicians with specialists, medical staffs with hospital managers, payers with providers, and so on. These conflicts stem from the contest between reform and resistance: Those who benefited in the old days strive to hold on, while those seeking to create new ways fight for change. If each views the other as the adversary, the two sides stay locked in battle and deprive the system of the potential rewards of reform.
Other sources of conflict are the kinks in the system-the structural design flaws that result from or cause misunderstanding and animosity. For example, the drive for primary care may precede the capacity of primary-care practitioners to meet the new demand. When patients must wait months to see their primary caregiver, the physician ultimately becomes more of an obstacle than entry point to appropriate care. If unattended, the resulting frustration only reduces confidence in the system.
For or against?As we recreate healthcare relationships, differences can become either pluses or minuses.
The differences are minuses when they become fodder for adversarial disputes. Issues become polarized. Rather than searching for a solution, the parties are obsessed with asserting the rightness of their positions. As one side seeks to overcome the other, the costs of battle detract from the benefits of resolution.
The differences are pluses when approached with the purpose of finding problems in search of solutions. The constructive give-and-take of negotiation becomes a learning opportunity. There are bound to be differences on the road to reform, given the wide range of participants and the enormous complexity of issues. But the differences offer opportunities for progress. For example, when solo practitioners join to form group practices or when hospitals collaborate with their medical staffs to negotiate capitation, the very process of finding new ways to work together can generate the good will to enhance the success of these new ventures.
Teamwork.How can we generate the constructive opportunities of negotiation?
Contrast integrative and distributional bargaining. Integrative negotiation brings parties together to achieve solutions that address common interests. On the other hand, distributional bargaining frames the interaction as an adversarial process. The parties seek to conquer rather than collaborate, with one side seeking to win at the expense of the other. The loser builds resentment and the winner becomes more obsessed with staying in power than with doing what's good for the organization and the community.
Integrative negotiation seeks solutions that address a range of concerns. The parties work to discover arrangements assuring all sides a fair measure of satisfaction. Each side, of course, wants to achieve its negotiation objectives, but it does so by articulating its interests and by learning about those of others. Negotiation becomes an inventive technique for synthesizing the intentions, motives and concerns of all parties.
This approach to moving beyond conflict is termed "whole image negotiation." It is a framework for negotiation that fits the current changes and challenges of healthcare.
"Whole" points to the big picture in our transactions, that of finding the common purpose. If we only look at our own department, institution or profession, the chances of making the system work as a whole will be greatly diminished. Building solutions based on shared interests and objectives will create outcomes that work better in the long run for the interdependent work that is the nature of healthcare.
"Image" requires us to envision something that is not readily apparent. The healthcare system is in the midst of change. What emerges on the other side of this tumultuous period is only in our imaginations. If we aim for an arrangement that best meets our common needs and interests-one that fairly balances resources, services and costs-our chances for constructing a workable system will be enhanced.
The best negotiators are those who bring with them creativity and a willingness to be flexible. They can invent unique solutions and introduce processes the other parties never would have considered.
Combined, the components spell WIN, a triumph for healthcare all can share.
Now is the time to better understand conflict, negotiate choices and build systems to improve the processes of decisionmaking. We have the unique opportunity to achieve an improved healthcare system in this country. The right brand of negotiation offers a constructive process for getting there.
