A Healthy Revolution Awaits
George C. Halvorson is chairman and chief executive officer of Kaiser Foundation Health Plan, Inc. and Kaiser Foundation Hospitals, headquartered in Oakland, California. Kaiser Permanente is the nation’s largest nonprofit health plan and hospital system, serving more than 8.6 million members and generating $40 billion in annual revenue.
George Halvorson serves on the Institute of Medicine Task Force on Evidence Based Care and the Commonwealth Commission for a High Performing Health System. He serves on the American Hospital Association’s Advisory Committee on Health Care Reform. He chairs the World Economic Conference Health Governors for 2009 and chairs the International Federation of Health Plans. He has received the Modern Healthcare/Health Information and Management Systems Society CEO IT Achievement Award. The Workgroup for Electronic Data Interchange also awarded him the 2009 Louis Sullivan Award for leadership and achievements in advancing health care quality.
Halvorson has written several health care reform books, including the newly released Health Care Will Not Reform Itself: A User’s Guide to Refocusing and Reforming American Health Care. He also wrote Health Care Reform Now!, Health Care Co-ops in Uganda, Strong Medicine, and Epidemic of Care as guidebooks for health care reform.
Halvorson served as an advisor to the governments of Uganda, Great Britain, Jamaica, and Russia on issues of health policy and financing. His strong commitment to diversity and inter-ethnic healing has led him to his current writing project, a new book about racial prejudice around the world.
Prior to joining Kaiser Permanente, Halvorson was president and chief executive officer of HealthPartners, headquartered in Minneapolis. With more than 30 years of health care management experience, he has also held several senior management positions with Blue Cross and Blue Shield of Minnesota.
Question: What could this revolution in information technology do to the American health care system as a whole?
George Halvorson: Well, I think we need a database for the entire country that helps us track how well we're doing in the major areas where we're not performing well. But I think we need to do it sort of step by step and condition by condition. So take asthma: asthma is the fastest-growing condition among kids. It's the number one killer. It's the number one expense item. It's a horrible condition when kids have asthma attacks. One of my sons had multiple asthma attacks years ago, and you know, when they're almost dying because they're going through the misery they're going through, that's very, very traumatic to everybody. And sometimes they do die; I mean, it's all bad. And when you look at the country, how well we're doing in asthma care, the most recent RAND study showed that we're getting it right 47 percent of the time. So, fastest-growing condition, horrible condition, and we're only getting it right 47 percent of the time. We should fix that. If we covered every kid in America -- which is why we need universal coverage -- if we covered every kid in America, that's a start, because then they can get the inhaler and then they can get the medication.
But in addition to that -- covering them is not enough -- in addition to that we need to have information about every kid with asthma. We need to know who they are, and then we need something tracking whether or not those kids are getting the appropriate care, whether or not they're refilling a prescription, like I talked about earlier with the heart patient. We need to know if those inhalers are being refilled, and if they're not, we need to intervene. And what we really need to know is if the kid has a crisis, if they have an asthma attack and they're in the emergency room, we need to know that that crisis happened, and then that needs to trigger an intervention so that somebody can do something meaningful to make it better. And in the current unconnected system, nobody knows. No one has a clue. So the person has the asthma attack, and the hospital has that information, but the hospital has no one to give it to, and they have no mechanism to give it through, and so what you end up with the kid having another attack, another attack, another attack. Some die, and some crippled and debilitated, and certainly demoralized. I mean, it's a bad condition. We could easily say as a country, we're going to focus on that; we're going to fix that; we're going to make that better; and we're going to use universal coverage and the new database to do that.
So that's what we need to do as a country, and if we fix a few things -- if we fix congestive heart failure -- you know, we can cut the congestive heart failure admissions for Americans in half by having absolute consistent follow-up care. But we're not going to do that until everybody has coverage and until there's a care coordination process embedded in the coverage. But there's no reason not to do that, and we will save a lot of money for the country, and we'll save a lot of misery and agony and terror for the people involved if we do that.
Question: Will current health care proposals advance the vision you have laid out?
George Halvorson: It can be. It can be. There are some things in the bills that are directionally correct. They really do want to have database connectivity. There's kind of a pointer in that direction. The details of how to do that are not fleshed out, so the ability to figure out how do we actually create connectivity isn't there, and there's enough resistance to connectivity that I can imagine a scenario where five years from now we've spent an awful lot of money on IT and haven't connected anybody. And I can also imagine a scenario where five years from now we've spent a lot of money on IT and we've connected everybody. I mean, you can get to either out come from here, and part of it's going the be the steerage; part of it's going to be Secretary Sebelius, who in these bills is given all kinds of accountability for doing pieces of this work, which I think is a good thing to do rather than trying to design all the pieces of it; point it in a direction and assign someone. And if she has the kind of years that I really hope she has, care could be a lot better in America.
On the other hand, there are enough people resisting change and happy enough with the status quo that we could also run up against roadblocks and end up not making the progress. So we need to cover everyone. We really do need to cover everyone. Every other country in the world -- every other industrialized country -- covers all of their citizens. We're the only outlier, and we really need to cover everyone because there are some really serious health conditions that we cannot fix until everybody has coverage. I mean, asthma's one of them. All the kids need coverage so we've got continuity of care. And then they need to be in a database so we can track the care and we can follow up on the care. And if you have that kind of a vision for where we're going, you can get there. The bills would allow for that, but it's going to take execution on the back end.
Question: Why isn’t technology front and center in the health care debate?
George Halvorson: Because nobody knows what to do with the technology. People don’t have a sense of how to use it. I just talked about how to use it for asthma care. But when people talk about technology, what they generally say in this very generic way -- almost magical thinking -- let's put all the data on a computer, and then care will get better. Well, that doesn't work. Care doesn't get better when you put it on a computer. Then you have to do something with the data, and somebody has to be accountable for doing that. And so you have to create a data infrastructure, but then you have to create an accountability, and then you have to create the mechanisms. And if all you do is put it on the computer, that's not enough. And then people know that, but what people talk about up front is, let's get all the data on a computer.
So if an individual doctor says, I'm getting a lot of pressure to computerize my office, and they go down that path and they invest all the money to computerize their office, and then when they're done, instead of having a paper file with information about you as a patient they have an electronic file with information about you as a patient, but it's the same information. It hasn't expanded, it hasn't gotten better, it hasn't gotten interactive; it's just electronic. And electronic doesn't cure anything. What cures things is if that database is then connected with another database and every other doctor you have is in the database, and then there's team care that can come out of that and also more informed care. But the agendas up to now for American health care, because the doctors are all in solo practice, hasn't connected the data. It's just computerized it, and that doesn't -- that's not enough.
So people need to have a vision for what you can actually do with it. There are some people who are kind of zealots and saying, let's get all the data on the computer, and that's a good first step as long as it's a first step. But if it's a final step, it's a completely inadequate and incredibly expensive final step. And the other thing is, typically when a doctor has worked with the same piece of paper for 30 years, they know that piece of paper really well. Now, they can put a little note here, little note here. If they're going to a computer screen, now they have to learn a whole different interaction, and they have to -- you know, just think about when you change from, you know, Blackberry to an iPhone or whatever. I mean, you have to go through all this learning curve. If you go through the learning curve to go from paper to electronic, and you get nothing out of it except it slowed you down, well, of course you're not going to do it. I mean, when you -- one of the things I talk about in the book is, all of the information for all of the patients all the time is really important.
But the second thing is, make the right thing easy to do. And that's really important. You've got to make the right thing easy to do. And whoever is writing in, if you make the right thing easy to do as a result of the computerization, doctors will go there and the care system will go there. And if you don't make the right thing easy to do, then the barriers to moving in that direction will be insurmountable.
Question: What’s the biggest technology breakthrough on the horizon in health care?
George Halvorson: I think a couple of things are exciting. I think the ability to take a DNA database and figure out on cholesterol-reduction drugs -- we know that the drugs work really well on a portion of the population, and we know they don't work so well on another portion of the population. But we don’t know why they work in some, and we don't know why they don't work in others. If we could do a DNA analysis and figure out which patients benefit from Zocor, and make sure those patients get Zocor, then we've got a very different, much more effective, care delivery world. So I think the ability to personalize care around the patient based on DNA is really exciting, and I think the research that will follow from that is really exciting.
And I think the connectivity issue, the ability to deliver care remotely, to have -- there's a shortage of primary care on the one hand, and there's logistical issues relative to specialty care on the other hand, and if you can resolve the logistical issues by doing many of the things virtually, and if you can solve the primary care issues by reaching out into a broader continuum and then having the care delivery up front delivered in some cases by nurse practitioners who have a close ally who is a primary care physician, who is completely supported by an infrastructure of specialists, the combination of that sort of a tiered system is going to be a more effective, more efficient, better use of energy and more patient-responsive sort of care delivery system than much of what we have now. So I think there's some opportunities to re-engineer care delivery as well as to personalize care and get care right.
Recorded on November 18, 2009
George Halvorson believes in the power of information technology to transform the American health care system. So why isn’t it front and center in the current debate?
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One victim can break our hearts. Remember the image of the young Syrian boy discovered dead on a beach in Turkey in 2015? Donations to relief agencies soared after that image went viral. However, we feel less compassion as the number of victims grows. Are we incapable of feeling compassion for large groups of people who suffer a tragedy, such as an earthquake or the recent Sri Lanka Easter bombings? Of course not, but the truth is we aren't as compassionate as we'd like to believe, because of a paradox of large numbers. Why is this?
Compassion is a product of our sociality as primates. In his book, The Expanding Circle: Ethics, Evolution, and Moral Progress, Peter Singer states, "Human beings are social animals. We were social before we were human." Mr. Singer goes on to say, "We can be sure that we restrained our behavior toward our fellows before we were rational human beings. Social life requires some degree of restraint. A social grouping cannot stay together if its members make frequent and unrestrained attacks on one another."
Attacks on ingroups can come from forces of nature as well. In this light, compassion is a form of expressed empathy to demonstrate camaraderie.
Yet even after hundreds of centuries of evolution, when tragedy strikes beyond our community, our compassion wanes as the number of displaced, injured, and dead mounts.
The drop-off in commiseration has been termed the collapse of compassion. The term has also been defined in The Oxford Handbook of Compassion Science: ". . . people tend to feel and act less compassionately for multiple suffering victims than for a single suffering victim."
That the drop-off happens has been widely documented, but at what point this phenomenon happens remains unclear. One paper, written by Paul Slovic and Daniel Västfjäll, sets out a simple formula, ". . . where the emotion or affective feeling is greatest at N =1 but begins to fade at N = 2 and collapses at some higher value of N that becomes simply 'a statistic.'"
The ambiguity of "some higher value" is curious. That value may relate to Dunbar's Number, a theory developed by British anthropologist, Robin Dunbar. His research centers on communal groups of primates that evolved to support and care for larger and larger groups as their brains (our brains) expanded in capacity. Dunbar's is the number of people with whom we can maintain a stable relationship — approximately 150.
Some back story
Professor Robin Dunbar of the University of Oxford has published considerable research on anthropology and evolutionary psychology. His work is informed by anthropology, sociology and psychology. Dunbar's Number is a cognitive boundary, one we are likely incapable of breaching. The number is based around two notions; that brain size in primates correlates with the size of the social groups they live among and that these groups in human primates are relative to communal numbers set deep in our evolutionary past. In simpler terms, 150 is about the maximum number of people with whom we can identify with, interact with, care about, and work to protect. Dunbar's Number falls along a logorithmic continuum, beginning with the smallest, most emotionally connected group of five, then expanding outward in multiples of three: 5, 15, 50, 150. The numbers in these concentric circles are affected by multiple variables, including the closeness and size of immediate and extended families, along with the greater cognitive capacity of some individuals to maintain stable relationships with larger than normal group sizes. In other words, folks with more cerebral candlepower can engage with larger groups. Those with lesser cognitive powers, smaller groups.
The number that triggers "compassion collapse" might be different for individuals, but I think it may begin to unravel along the continuum of Dunbar's relatable 150. We can commiserate with 5 to 15 to 150 people because upon those numbers, we can overlay names and faces of people we know: our families, friends and coworkers, the members of our clan. In addition, from an evolutionary perspective, that number is important. We needed to care if bands of our clan were being harmed by raids, disaster, or disease, because our survival depended on the group staying intact. Our brains developed the capacity to care for the entirety of the group but not beyond it. Beyond our ingroup was an outgroup that may have competed with us for food and safety and it served us no practical purpose to feel sad that something awful had happened to them, only to learn the lessons so as to apply them for our own survival, e.g., don't swim with hippos.
Imagine losing 10 family members in a house fire. Now instead, lose 10 neighbors, 10 from a nearby town, 10 from Belgium, 10 from Vietnam 10 years ago. One could almost feel the emotion ebbing as the sentence drew to a close.
There are two other important factors which contribute to the softening of our compassion: proximity and time. While enjoying lunch in Santa Fe, we can discuss the death toll in the French revolution with no emotional response but might be nauseated to discuss three children lost in a recent car crash around the corner. Conflict journalists attempt to bridge these geotemporal lapses but have long struggled to ignite compassion in their home audience for far-flung tragedies, Being a witness to carnage is an immense stressor, but the impact diminishes across the airwaves as the kilometers pile up.
A Dunbar Correlation
Where is the inflection point at which people become statistics? Can we find that number? In what way might that inflection point be influenced by the Dunbar 150?
"Yes, the Dunbar number seems relevant here," said Gad Saad, PhD., the evolutionary behavioral scientist from the John Molson School of Business at Concordia University, Montreal, in an email correspondence. Saad also recommended Singer's work.
I also went to the wellspring. I asked Professor Dunbar by email if he thought 150 was a reasonable inflection point for moving from compassion into statistics. He graciously responded, lightly edited for space.
Professor Dunbar's response:
"The short answer is that I have no idea, but what you suggest is perfect sense. . . . One-hundred and fifty is the inflection point between the individuals we can empathize with because we have personal relationships with them and those with whom we don't have personalized relationships. There is, however, also another inflection point at 1,500 (the typical size of tribes in hunter-gatherer societies) which defines the limit set by the number of faces we can put names to. After 1,500, they are all completely anonymous."
I asked Dunbar if he knows of or suspects a neurophysiological aspect to the point where we simply lose the capacity to manage our compassion:
"These limits are underpinned by the size of key bits of the brain (mainly the frontal lobes, but not wholly). There are a number of studies showing this, both across primate species and within humans."
In his literature, Professor Dunbar presents two reasons why his number stands at 150, despite the ubiquity of social networking: the first is time — investing our time in a relationship is limited by the number of hours we have available to us in a given week. The second is our brain capacity measured in primates by our brain volume.
Friendship, kinship and limitations
"We devote around 40 percent of our available social time to our 5 most intimate friends and relations," Dunbar has written, "(the subset of individuals on whom we rely the most) and the remaining 60 percent in progressively decreasing amounts to the other 145."
These brain functions are costly, in terms of time, energy and emotion. Dunbar states, "There is extensive evidence, for example, to suggest that network size has significant effects on health and well-being, including morbidity and mortality, recovery from illness, cognitive function, and even willingness to adopt healthy lifestyles." This suggests that we devote so much energy to our own network that caring about a larger number may be too demanding.
"These differences in functionality may well reflect the role of mentalizing competencies. The optimal group size for a task may depend on the extent to which the group members have to be able to empathize with the beliefs and intentions of other members so as to coordinate closely…" This neocortical-to-community model carries over to compassion for others, whether in or out of our social network. Time constrains all human activity, including time to feel.
As Dunbar writes in The Anatomy of Friendship, "Friendship is the single most important factor influencing our health, well-being, and happiness. Creating and maintaining friendships is, however, extremely costly, in terms of both the time that has to be invested and the cognitive mechanisms that underpin them. Nonetheless, personal social networks exhibit many constancies, notably in their size and their hierarchical structuring." Our mental capacity may be the primary reason we feel less empathy and compassion for larger groups; we simply don't have the cerebral apparatus to manage their plights. "Part of friendship is the act of mentalizing, or mentally envisioning the landscape of another's mind. Cognitively, this process is extraordinarily taxing, and as such, intimate conversations seem to be capped at about four people before they break down and form smaller conversational groups. If the conversation involves speculating about an absent person's mental state (e.g., gossiping), then the cap is three — which is also a number that Shakespeare's plays respect."
We cannot mentalize what is going on in the minds of people in our groups much beyond our inner circle, so it stands to reason we cannot do it for large groups separated from us by geotemporal lapses.
In a paper, C. Daryl Cameron and Keith B. Payne state, "Some researchers have suggested that [compassion collapse] happens because emotions are not triggered by aggregates. We provide evidence for an alternative account. People expect the needs of large groups to be potentially overwhelming, and, as a result, they engage in emotion regulation to prevent themselves from experiencing overwhelming levels of emotion. Because groups are more likely than individuals to elicit emotion regulation, people feel less for groups than for individuals."
This argument seems to imply that we have more control over diminishing compassion than not. To say, "people expect the needs of large groups to be potentially overwhelming" suggests we consciously consider what that caring could entail and back away from it, or that we become aware that we are reaching and an endpoint of compassion and begin to purposely shift the framing of the incident from one that is personal to one that is statistical. The authors offer an alternative hypothesis to the notion that emotions are not triggered by aggregates, by attempting to show that we regulate our emotional response as the number of victims becomes perceived to be overwhelming. However, in the real world, for example, large death tolls are not brought to us one victim at a time. We are told, about a devastating event, then react viscerally.
If we don't begin to express our emotions consciously, then the process must be subconscious, and that number could have evolved to where it is now innate.
Gray matter matters
One of Dunbar's most salient points is that brain capacity influences social networks. In his paper, The Social Brain, he writes: "Path analysis suggests that there is a specific causal relationship in which the volume of a key prefrontal cortex subregion (or subregions) determines an individual's mentalizing skills, and these skills in turn determine the size of his or her social network."
It's not only the size of the brain but in fact, mentalizing recruits different regions for ingroup empathy. The Stanford Center for Compassion and Altruism Research and Education published a study of the brain regions activated when showing empathy for strangers in which the authors stated, "Interestingly, in brain imaging studies of mentalizing, participants recruit more dorsal portions of the medial prefrontal cortex (dMPFC; BA 8/9) when mentalizing about strangers, whereas they recruit more ventral regions of the medial prefrontal cortex (BA 10), similar to the MPFC activation reported in the current study, when mentalizing about close others with whom participants experience self-other overlap."⁷
It's possible the region of the brain that activates to help an ingroup member evolved for good reason, survival of the group. Other regions may have begun to expand as those smaller tribal groups expanded into larger societies.
There is an eclectic list of reasons why compassion may collapse, irrespective of sheer numbers:
(1) Manner: How the news is presented affects viewer framing. In her book, European Foreign Conflict Reporting: A Comparative Analysis of Public News, Emma Heywood explores how tragedies and war are offered to the viewers, which can elicit greater or lesser compassionate responses. "Techniques, which could raise compassion amongst the viewers, and which prevail on New at Ten, are disregarded, allowing the victims to remain unfamiliar and dissociated from the viewer. This approach does not encourage viewers to engage with the sufferers, rather releases them from any responsibility to participate emotionally. Instead compassion values are sidelined and potential opportunities to dwell on victim coverage are replaced by images of fighting and violence."
(2) Ethnicity. How relatable are the victims? Although it can be argued that people in western countries would feel a lesser degree of compassion for victims of a bombing in Karachi, that doesn't mean people in countries near Pakistan wouldn't feel compassion for the Karachi victims at a level comparable to what westerners might feel about a bombing in Toronto. Distance has a role to play in this dynamic as much as in the sound evolutionary data that demonstrate a need for us to both recognize and empathize with people who look like our communal entity. It's not racism; it's tribalism. We are simply not evolved from massive heterogeneous cultures. As evolving humans, we're still working it all out. It's a survival mechanism that developed over millennia that we now struggle with as we fine tune our trust for others.
In the end
Think of compassion collapse on a grid, with compassion represented in the Y axis and the number of victims running along the X. As the number of victims increases beyond one, our level of compassion is expected to rise. Setting aside other variables that may raise compassion (proximity, familiarity etc.), the level continues to rise until, for some reason, it begins to fall precipitously.
Is it because we've become aware of being overwhelmed or because we have reached max-capacity neuron load? Dunbar's Number seems a reasonable place to look for a tipping point.
Professor Dunbar has referred to the limits of friendship as a "budgeting problem." We simply don't have the time to manage a bigger group of friends. Our compassion for the plight of strangers may drop of at a number equivalent to the number of people with who we can be friends, a number to which we unconsciously relate. Whether or not we solve this intellectual question, it remains a curious fact that the larger a tragedy is, the more likely human faces are to become faceless numbers.
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