Preventing the Clash of Two Cultures

A noted British scientist and novelist, C.P. Snow, argued in a famous 1959 lecture that social progress was confined by conflict between two cultures—the sciences and the humanities. His paradigm has been applied to other polarized relationships and is viewed as a helpful model for understanding communications failures that prevent competing groups from getting together to solve serious problems.

Recent events show that elected officials in Washington are not close to solving the serious problems of health care. Hence, it’s time for a “two cultures” analysis. Having concluded that collaborative solutions must be crafted ASAP in the private sector, I believe we should focus on cultural differences between providers and payers. Understanding these differences is a precondition for creating the efficient and effective health care we ought to be getting for 17% of GDP.

To launch discussion, I suggest that provider culture enshrines a sacred doctor-patient relationship centered on hospitals (AKA doctors’ workshops). Provider culture seeks to expand facilities and technologies that allow physicians to practice medicine at the state-of-the-art—that is, to do everything possible for every patient. It fiercely resists economic considerations because money is not supposed to influence a doctor’s decision. Provider culture can be traced back several thousand years to Greek philosophers.

Payer culture, on the other hand, is uniquely American and not even a century old. Unlike every other country in the Western world, the United States formally rejected government finance mechanisms for health care in the decades surrounding World War Two. The third-party payer is as American as apple pie, purposefully created as a private business to channel funds from purchasers (mostly employers, until now) to providers. Payers can only survive by generating revenues in excess of expenses. Requiring payers to spend more—the final focus of politicized reform in 2009—compels them to raise revenues or to develop new “work-arounds” that make the medical marketplace even more inefficient.

The clash between provider and payer cultures is predictably dysfunctional. It pits two groups of generally good people, doing the jobs we expect of them, against each other in a negative-sum game. If disaster is to be avoided, creative and visionary leaders must find ways that the two cultures can work together to improve the health of Americans. Given today’s political gridlock, can you think of any more important reform than reconciling providers and payers? If not (like me), what steps would you take to align the two cultures for producing consistently good health care as inexpensively as possible?