Gary Oftedahl: Addressing the Commons Dilemma– a RARE Opportunity
It all began with a local issue in a distant time, with a pasture, a group of herders, and a limited place in which to graze livestock. It now has become a major concept highlighted in many arenas, which may help us better understand how to transform health care. But it also may be a distraction if not considered in the proper context.
In 1833, in medieval Europe, William Lloyd produced a pamphlet addressing how best to ensure that a limited amount of pasture land, shared by individual herders, could successfully be shared, both to maximize their individual ability to “fatten” their livestock, but also to ensure that their personal needs did not lead to a destruction of a limited resource. It was in the herder’s individual interest to maximize their own livestock’s grazing time (personal benefit), but at the risk of destroying the pasture through overuse (the resource)–where the danger was shared by the entire group.
And thus was born a topic around which discussion, disagreement, and multiple interpretations have raged for almost 200 years–and which I believe is worth considering in the context of the work of health care transformation which consumes many of our efforts in today’s complex environment. For the initial pasture issue became a “commons dilemma” to be revisited by Garrett Hardin in 1968 as the “tragedy of the commons” and subsequently became the framework for Nobel Prize winning work by economist Elinor Ostrom, who used this as a context for addressing many issues challenging the world of limited resources but an associated exponential demand for products and services.
In fact, for those of us in health care, it is possible that we might still be relatively unaware of this concept, had it not been for Dr. Donald Berwick using the “tragedy of the commons” as a framework for one of his legendary keynote presentations as the former leader of the Institute for Healthcare Improvement. Subsequent to that talk, we often hear of the need to consider the “tragedy of the commons” as a framework which could contribute to a better understanding of the challenges we face in trying to implement change in our health care system.
The “tragedy of the commons” refers to a dilemma which arises from a situation in which multiple individuals, acting independently, and seemingly rationally considering their own self interest ultimately deplete a shared limited resource in the face of recognized knowledge that this is not in the long-term interest of any of those involved. But perhaps in considering health care we can step back from resorting to language suggesting “tragedy” and address the more fundamental issue–the “commons dilemma.”
The term “commons dilemma” refers to a social situation in which people’s short-term selfish interests are at odds with the long-term interests and the common good. Many academicians have created careers by relabeling and flagellating the concept–resource dilemma, take-some dilemma, and common pool resource to name a few. I’m a simple person who looks for simplification in the face of overwhelming complexity, and I believe that while not a perfect overlay, it is of value to consider how these concepts may drive and influence our health care reform efforts.
More specifically, I believe I’m personally involved and experiencing an effort, which may be a concrete example of how we can both apply this concept, and how we need to avoid overstating the synergies–the RARE (Reducing Avoidable Readmissions Effectively) campaign in Minnesota. It’s important because while I’m fascinated by learning more about principles and concepts, they serve little value unless we have something concrete and real around which to engage in a lively debate and discussion. And as a non-academic, non-economist, non-policy person, I expect I’m misinterpreting or extrapolating on some of the principles, but am interested in catalyzing a conversation.
RARE is a multi-stakeholder campaign being developed to reduce avoidable readmissions in hospitals across Minnesota. It is a collaborative effort of multiple organizations, many of whom previously worked on this topic independently, coming together to make a dramatic impact. (I refer you to the web site– http://www.rarereadmissions.org/–for more details) As this effort evolves, there are many attributes which I believe are worthy of considering in the context of our social need to address the “commons dilemma” which permeates our communities.
What has caused me to consider how the work of Lloyd, Hardin, Ostrom, and many others as an opportunity to consider this linkage? One must look at them in the context of how this issue reflects the principles described as fundamental to a “commons dilemma.” First, with the present health care payment system, the short-term advantages and benefits for health care providers, hospitals, and others involved as individual organizations is best served by maximizing our services, admissions, readmissions today—the first component of the “commons dilemma.” However, it is clear that in the long term, the resources and finances available to us will become more limited and potentially lead to potentially devastating consequences—perhaps that “tragedy” which many of the economists expound upon in their discussions.
I believe that in Minnesota the RARE campaign is driving an effort that is asking each of those organizations committing to this project, be it hospital, clinic, long-term facility, home care, specialist/generalist, patient, etc. to look at the common long-term good to protect what is becoming an increasingly fragile resource–both from a human resources and financial perspective.
What are some critical factors that will drive this effort and are significant in considering the “commons dilemma” which I believe RARE is in part addressing. First, research in this area shows that some are more motivated than others to manage this common resource. It is critical to engage those who demonstrate a more “pro-social” perspective in the initial efforts, and begin to apply social pressures on other similar facilities not demonstrating those characteristics. In RARE, the commitment from a large number of organizations recognizing the need to work together on this is a powerful recognition of that element.
Second, the ability to conserve a common resource (protect the commons) is promoted by a group’s ties. If people have an identity with a group, they are more likely to exercise personal/organizational restraint. The ability to build social ties is imperative in creating an increased force with which to address those who are seen as a threat to the good of the community through their personal interests. The structure supporting the RARE campaign is focused on building those essential ties as a part of the community being developed.
We also need to better understand the state of the common resource to shape those motivations mentioned above. Many of us in health care have functioned solely with our own personal interests in mind. This is not a condemnation, but a reflection of the reaction to the environment, and the uncertainty we see there. One element of the “commons dilemma” is that much of the short-term individual activity is driven by an uncertainty about the future. We see this in RARE in addressing the readmissions issue. In addition, while not in total harmony with this element of thinking, the potential for punishment, either economically or personally, can be a unifying factor for those who have concerns about the long-term good. Many conversations regarding our RARE campaign reference the impending and anticipated “penalties” to be imposed by the Center for Medicare and Medicaid Services if certain readmissions are not reduced—increasing the potential for a group to attempt to protect the “commons” which is threatened.
Strategic factors also come to play in addressing this extremely complex situation—it wouldn’t be a dilemma if it wasn’t convoluted and uncertain. In addressing the threat to the commons, the order in which one can extract their individual value from that resource is important. If it is seen as a sequential situation, individuals adopt a first come-first served rule, whereas with simultaneous collaborative activity, people adopt an equality rule. In a fundamental way, that is an underpinning of the RARE effort—together on a similar time line.
Another but equally important consideration is the impact on one’s reputation. Research has demonstrated that if there is transparency, and not anonymity among those involved, one will take much less from the common pool—whatever that pool might be. Those who are seen as part of an equalitarian and public- minded process gain greater prestige. While it is not clear how this will be manifested by RARE, the commitment by almost all the major hospital systems in the state to this campaign thus far can only reinforce that element of addressing the “commons dilemma” which might be seen as part of the problem but also the potential solution for our RARE efforts.
It is perhaps a stretch to relate our readmissions work to the “commons dilemma” and to the potential of a “tragedy of the commons” situation but it does serve as a trigger to us in thinking about how we need to work differently. I’m well aware that this is an extreme oversimplification of many of the attributes and controversies surrounding this socio-economic principle that in reality has been around since the time of Thucydides and Aristotle, and has been both modified and attacked. But in many ways, the health care issues in this country truly have become a “commons” issue, where we have limited resources (both financially and access wise) but a seemingly infinitely increasing demand for these services.
At this time, with a few exceptions, health care seems to more closely resemble those individual herders, concerned only over their own part of the herd, and insensitive or perhaps unaware of the impact on the common resources they all need in the long term. In addition to the items mentioned above, there are many nuances and inconsistencies which are deserving of further conversation. But that is precisely the opportunity I see. Using the “commons dilemma”, cross walking it with our efforts in health care (specifically as I’ve briefly outlined in the evolving Minnesota effort on the RARE campaign), may allow us to gain a better understanding of the challenges we face and the opportunities we have in working together in co-creating the health care system which will avoid that social tragedy staring us in the face today. That’s my dilemma, what’s yours? Do we have anything in “commons” to talk about?