For those of you who have had the good fortune of planting a vegetable garden (or owning a farm) you have a profound understanding of the unique (and slowly timed) gratification of seeing the fruits of your labor unfold much after you expend your immediate effort. This is the essence of the “farmer” as a metaphor of productivity via patience in labor. The idea of the metaphorical farmer as a creator of things that have enduring value was a very big part of American culture when I was a child. At the heart of this simple idea is that it takes time, effort and patience to create something with enduring value. This is core to a culturally sustainable worth ethic.
Much like the ever-so-slight change of weather as one season blends into another, the music of the farmer beats slowly and deliberately to its goal.
A farming mentality is how generations of parents justify the sacrifices they make for their children’s future. This is how nations with a farmer’s ethic, slowly but surely overtake other nations bent on immediate results and gratitude. Sound vaguely familiar?
The pace and patience of the farmer lies in stark contrast to that of the “hunter”, who sees his prey, effort and dinner all wrapped together in a narrow window of time. The hunter works and eats for today. Make no mistake, a great hunter understands patience, but his type of patience is experienced within the carefully silent minutes surrounding and waiting out his prey. Hunters are the consummate short-term gratification junkies. The hunter’s heart beats to the rapid music of frequent and emotional crescendos.
American film culture has celebrated the soul of the hunter and the many Cowboy, Rambo and Martial Arts scripts that frame conflict, challenge and rapid resolution. In the global community, Americans have come to be known as hunters/cowboys. Our most recent financial crisis and all the short-term hunter-like events that created it, is just now settling into our Psyche. Welcome to a meltdown in credit markets and real estate/stock market values rapidly metastasizing from short term greed and objectives. Oh yes, while we're at it; welcome to global warming and a rapidly changing planet responding to a petroleum-based instant gratification fix.
So here we are; lying in the wake of a hunter’s financial and environmentally-blind life that our newly minted President signed a $737 billion hunter’s fix (a.k.a stimulus funding package).
In this very interesting moment in time and our cultural history, enter a very curious event that is described in the excepted article from the BBC below.
“First notes for 639-year composition, by John Cage” – (from BBC News – February 10, 2009)
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The first notes in the longest and slowest piece of music in history, designed to go on for 639 years, are being played on a German church organ on Wednesday. The three notes, which will last for a year-and-a-half, are just the start of the piece, called “As Slow As Possible”.
Composed by late avant-garde composer John Cage, who died in 1992, the performance has already been going for 17 months. The music will be played in Halberstadt, a small town renowned for its ancient organs in central Germany. It was originally a 20-minute piece for piano, but a group of musicians and philosophers decided to take the title literally and work out how long the longest possible piece of music could last. They settled on 639 years because the Halberstadt organ was 639 years old in the year 2000.
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So, there you go! While the heavily populated world of hunters is now in shock as it deals with the effects of un-tethered rates of accelerated financial gratification, a dead composer, some philosophers, musicians and a small town in Germany have somehow come together to provide an exaggerated antidote to our need for the return of a farmer’s mentality. Germany is also the country that brought us the great Cathedral in Cologne (which coincidently took 632 years to build from start to finish).
I am moved by these events because I see great relevance to slowing down and re-awakening the natural pace/rhythm of life that we have somehow been seduced away from. I see great insight into how badly we need to understand the need to shift to the pacing of expectations related to key strategies and policies used by those who govern us. We need to bring back a solemn reverence for the farmer.
So, you might ask; "why are farmers, hunters and 639 year-long pieces of music relevant to healthcare policy?"
You see, over the last 40 years we have increasingly shifted our cultural orientation from a farmer’s point of view; where we understood that sustained-concerted effort created long-term and durable value… to a hunter’s perspective; where rapid actions and adrenaline created (very) short term expectations and results (but little enduring/self-sustaining value). This shift in our orientation spilled into our country’s political/governance systems, where politicians sought favor via the setting of rapid/unrealistic expectations for the electorate to feed on. These promises made during the political campaign process relied on debt and other instruments of mortgaging our future. Welcome to our current financial meltdown/nightmare!
The demon here is the hunter-like cycle time of rapid expected outcomes. We are victims of our growing appetite for unrealistic/instant gratification.
So it is so with our healthcare policy. Each year, we shape policy based on the immediate pressures to satisfy the short-term appetite of the many constituencies vying for finite resources (that are dwindling in a less buoyant economy). In these seemingly benign acts of allowing these short term forces to guide our healthcare future, we (unconsciously) play God.
Case and point; U.S. health care policy and the notion of “playing God”.
Anyone who has held military command responsibility and who has been placed in the extraordinary position of deciding who gets to live (when everyone can’t) comes to instantly understand a profound truth about the nature of responsibility at the highest possible level. Some have called this almost impossible role; “playing God”.
In this role, the “live or die” calculus of which and how many lives are best saving is a spiritually challenging one to be sure. Obstetricians sometime face this issue with life-threatening births – who lives; the mother or the child?
Up until now, our country has had the luxury of not (consciously) making such decisions in our healthcare system. Or have we?
Over the recent years under our “managed care” healthcare model, there have been a series of significant forces that have come together to create a “playing God” moment. Each of these forces on their own did not have a profound effect, but taken together, they have conspired to deny medical care coverage to over 50 million Americans and reduce the quality and safety of care to the other 250 million.
This “non-intentional” denial of quality-safe-accessible medical care is the benign act of these forces “playing God” with the lives of our citizens. What are these forces?
1. Growing demographic burdens of an older population – America now boasts a lot more older people…which results in more illness…which drive more costs…which results in less money to pay for those who are not older
2. Increased incidence of chronic disease – we are now experiencing the growing incidence of diabetes, heart disease, respiratory disease and treatable cancer….which creates more medical episodes/hospitalizations…which demands more cost…which results in less money to pay for those who do not have chronic disease
3. The dis-integration of medicine so that no individual provider is accountable as the “healer” anymore – as we have separated the healing process and delivery system, we have (unintentionally) created more specialists…more tests… more forms…less single point of accountability…more costs…poorer outcomes…less provider satisfaction with the act of healing…and yes, in the end, less money to pay for people with less complex medical needs
4. The growing level of high-tech/very costly therapies and diagnostics – while these new technologies are life-saving in their intent and nature, in most cases they demand more frequent usage by hospitals and doctors to create a financial return on their investment in these technologies…thereby creating more costs…which results in less money available to pay for treatments to those who do not have healthcare insurance coverage that really need to access these technologies
5. Healthcare delivery moving from a privately held professional model to a corporate structure – while theoretically beneficial, industrialized medicine has not delivered a safe, consistent and predictable product…which (unintentionally) has created a series of process-driven activities without an underlying “healing mission” …which creates bad outcomes in medicine…which creates high levels of litigation…which creates high costs for medical providers…which results in less money available to provide healthcare coverage
6. Healthcare insurance coverage is too complicated – between the deductibles, co-pays, in-network/out-of network systems, PBM programs, Medicare Part B, formularies and other “consumer-driven benefits”, most Americans need third-party help navigating our healthcare delivery model…this complexity creates more costs...this complexity creates poor outcomes…which creates a loss in worker productivity…which creates a loss in employer profitability…which drives a reduction in healthcare coverage for employees
7. Employers are no longer financially capable to bear the full burden of growing healthcare cost coverage – because of growing financial pressures, each year, employers are “cost-shifting” or dropping healthcare coverage to/for their employees…which creates more uninsured Americans (P.S. - the largest single cost of a car produced by General Motors is the cost of health care coverage for its assembly line workers – oh yes, tax payers just “lent” GM $12 billion and they have already come back for $4 billion more)
8. Because of very challenging emotional/spiritual obstacles, thousands of patients that are candidates for palliative care (end-of-live Hospice care), are consuming vast/costly healthcare resources…which (unintentionally) consumes resources and capacity for those who cannot get care…which drives a reduction in available care for those who are not at the end of their lives
So, here is the math. The above eight forces have created the following outcomes;
+50 million Americans (and counting) are now uninsured
Healthcare coverage for the “covered Americans” is rapidly declining
98,000 people die each year from preventable medical errors (mostly in hospitals)
Roughly 75% of America’s healthcare costs are consumed by 20% of Americans with chronic disease
30% of our nation’s nearly $2 trillion in healthcare expenditures funds end-of-life medical treatments
The World Health Organization reports that the United States spends a higher portion of its gross domestic product than any other country in the world on healthcare, but ranks 37 out of 191 countries according to its performance. Yikes!
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So you see, there are forces “unconsciously” playing God with our healthcare resources. Many of our fellow citizens are victims of this unintentional effect. These forces are the benign “acts of God” that are unconsciously guiding the many life and death healthcare decisions made every day, but without a visible decision maker to point to (or hold accountable).
So…what if we “consciously” decided to play God and shape our strategies and policies in a manner that recognizes our current reality? What would our healthcare system look like if there was an intelligent and beneficent hand guiding healthcare policy?
In this type of scenario, here is what I believe would happen;
People with chronic disease would be cared for differently than those without chronic disease – there would very handsome rewards for providers who kept their patients out of the hospital
Patient’s homes would be used for 50% of the procedures currently being treated in the hospital
There would be more/healthy incentives for integrated healthcare systems where the hospitals, primary care physicians, specialists, diagnostic companies, home care companies, long term care facilities and insurers were operated with a single point of accountability (and common information/electronic medical records)
Patients, families and religious leaders would be better educated regarding palliative care and its humanity
These four strategies would in effect result in us consciously playing God. In my view, we are long overdue in the need for this approach.
I take my hat off to John Cage (and his 639-year piece of music) and the builders of the Cathedral in Cologne (a 632 year effort) because it is in these two efforts that the heart of the farmer reveals itself. It is in these two efforts that we feel a natural calling to a more sustainable way of creating expectations. It is also in these two efforts that we can be inspired to develop a healthcare policy that is built to last and to give the most number of Americans access to a healthy and productive life that is in concert with the objectives of our society, economy and national security. Said most simply, if we are to play God, let us wear the hat of the farmer and not the hunter as we do our work.
Oh yes…one more thing...
If (through the miracle of viral internet content access and distribution) this blog should find its way to President Obama’s policy makers, I humble offer the following advice;
A truly stimulating/sustainable stimulus package should culturally respond to the true evil that created the problem in the first place – a hunter’s mentality
President Obama’s economic stimulus plan could have been very simple;
Create 10 million new sustainable jobs...
Five million new jobs in healthcare using the above described healthcare strategy
Five million new jobs building sustainable energy infrastructure (solar, wind and renewable fuels) and sustainable energy manufacturing zones that use renewable energy as a source of competitive advantage
By creating these 10 million new sustainable jobs, we would build long-term (farmer-like) U.S. competitive advantage in healthcare and energy. By pursuing this path, we would be aggressively address global warming, our health care crises and financial crises at the same time (very farmer like indeed!)
Build global dominance in two domains that the world requires for sustenance and growth (the world would now come to us for energy and healthcare like they once did for food)
Thank you….
With respect and gratitude
A Farmer at Heart
Richie
One more thing…
In keeping with the spirit of the farmer, my good friend, Matt Walton shared a thought of his with me that bears a closing and relevant quote (for which I will be eternally grateful)
“It is very easy to make numbers…but hard to make pencils”...Matt Walton, 2/09
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