Conflict in health care has dominated the news in the United States lately with the political showdown over the Affordable Care Act followed by the shaky launch of the federal health insurance exchange. Conflict, however, is not new to the health care system; it is a fragmented landscape with many players with sometimes conflicting interests and objectives. Yet the nuances of negotiation and conflict resolution are too rarely taught in medical or business schools.
We have been engaged in health care negotiation and conflict resolution for two decades. We have worked on conflicts as mundane as work assignments and as complex as hospital mergers. We use and teach a simple four-step structured process that works in cases ranging from simple one-on-one interactions to extended multi-party discussions.
After assembling representatives of all stakeholders in a conflict, the first step is to have each stakeholder articulate their “self-interests” so that they are heard by the others. What does each need to get from this exchange? The second step is to look at where the overlap among these self-interests reveals agreement, what we call the “enlarged interests.” In our experience, these agreements always outnumber the disagreements. The third step is to collaborate to develop solutions to the remaining disagreements, or “enlightened interests.” This is the time for creative problem solving. The fourth step is to certify what has now become a larger set of agreements, or “aligned interests.” Any outstanding disagreements are held to the side for future negotiations. We’ve taught people in as little as 30 minutes how to use this approach. (See our book Renegotiating Health Care for more detail on the process.)
We call this process the Walk in the Woods after a play that dramatized a well-known negotiation over nuclear arms reduction. The delegations from the United States and the Soviet Union were at loggerheads. During a break, the two lead negotiators went for a walk during which they unearthed their personal as well as each nation’s deeper, shared interests in peace and security. This understanding enabled them to break the deadlock and move forward.
The same negotiation principles that can reduce nuclear stockpiles can be effectively applied even at the front lines in health care. For example, there is often pressure to change who does what when new technologies are deployed or initiatives are undertaken to lower costs. Consider the situation in a traditional orthopedic practice where a physician sees every patient who comes through the door. Is this really best for the patient, the practice, and the larger system?
Most patients who arrive at an orthopedic office suffer from straightforward conditions such as a simple, non-displaced fracture or a sprain. These can be adequately treated by a properly trained physician’s assistant (PA), and patients can typically be seen much more quickly by a PA than by a specialist. If outcome quality and patient satisfaction can be maintained and costs lowered, this should be an easy move to make. Such shifts in responsibility, however, are often resisted and the resulting conflict can be acrimonious. Why?
Both physicians and patients have come to expect to interact with each other. Doctors prize their clinical autonomy and their relationships with those they treat, and the fee-for-service model rewards them for taking care of patients themselves. Patients, meanwhile, want to be treated by an “M.D.” and often a board-certified specialist rather than their primary care physician (PCP). The PCPs value their relationships with the specialists in the network and focus on their gatekeeper role rather than stretching the scope of care they provide. Insurers want to control costs, of course, and they and others exert pressure to divert simple cases from high-cost specialists to less expensive physician’s assistants or other non-specialist care-givers. No one is happy with the resulting conflict: Orthopods fear losing their patients; patients are anxious about getting lesser care; PCPs worry that their relationships with specialists will erode; and insurers and administrators find the resistance by all parties frustrating, time-consuming, and expensive.
Now, imagine that the physicians in our orthopedic practice host an open house Walk in the Woods discussion that includes referring PCPs, patients, and representatives from insurers. Engaging in the four-step process, the parties would find that high outcome quality, patient satisfaction, and keeping care affordable are on everyone’s list of self-interests. Through the process, the orthopedists could educate both the PCPs and patients on when a specialist’s expertise is truly needed. Patients could articulate how they weigh the trade-off between waiting time and the provider they would see. The insurers could explain some of the cost implications of different options. One can envision the idea of physician’s assistants treating routine injuries emerging from the process as each party identifies the benefits that meet their combined and self-interests: The orthopods may be freed up to see a greater number of more complex and interesting cases; the PAs are able to work to the level of their ability; the PCPs expand their relationships with more members of the orthopedic practice; the insurer reimburses less for uncomplicated treatments; and patients would get appropriate care, save time, and help keep premiums down.
The two aspects of this approach that can be extrapolated to myriad other conflicts are the use of a structured process and inclusion of all key decision-making stakeholders. The structured process minimizes the ego battles and tangential scuffles by keeping all parties focused on productively resolving the central issues. Depending on the number of parties and complexity of the negotiation a Walk can take from 10 minutes to 10 days or more.
The inclusion of all stakeholders is essential because people only truly embrace solutions that they help create. Anytime that one party tries to impose something on another, the natural inclination of the imposed upon party is to resist. A little time spent upfront engaging in joint problem solving saves many hours — and headaches — that come with a mandate.