Collaboration as Best Practice


collaboratiionBy Tia Will

This article is an opinion piece. I offer anecdotes and examples to support my case. No facts, no graphs, no charts, no numbers. Just how I see the possibilities of life and how it might be made a little better for all.

This weekend is the opening of the movie Sully about the successful water landing of a plane by Captain Sullenberger and his crew, and the subsequent investigation of this event. The following is a quote from the New York Times.

“Captain Sullenberger, who retired from US Airways in 2010, said in an email that the tension in the film accurately reflected his state of mind at the time. ‘For those who are the focus of the investigation, the intensity of it is immense,’ he said, adding that the process was ‘inherently adversarial, with professional reputations absolutely in the balance.’”

I would like to focus on one particular point of this quote. He states that the process was “inherently adversarial.” I believe that this point could be applied equally to many of our societal processes. We see the inherently adversarial nature in our school system in which children compete for the best college placements, in our job market which is manipulated to produce winners and losers (artificially holding down the number of doctors for financial gain as my most immediate example), in how grants are distributed for research and social programs, in our legislation and policy making (the Democrats vs the Republicans, liberals vs conservatives), in our justice/legal system (prosecution vs defense) as opposed to maximizing opportunity and truth seeking for all concerned.

As Americans we are taught from childhood that competition is inherently good. We are taught that to succeed, we must compete. And we tend to buy it wholesale with few questions asked. But is competition universally the best approach?  Might there not be a better way? And what might that look like ?

I believe that there is a better way and that way is collaboration. Not compromise, collaboration. I further believe that the earlier in any process that collaboration begins, the more likely the endeavor will proceed as economically and efficiently as possible and that the best outcome possible for all concerned will be achieved.

I will use, as my example, my own career in medicine. Qualifying for medical school was inherently competitive and very stressful. The means I chose to decrease my stress and improve my chances of acceptance were collaborative. I became part of a study group. We helped each other with areas of difficulty, we rooted for each other, we encouraged each other and coached each other. We celebrated each other’s successes, even when their grades were better than our own. The result?  All who remained in the group and chose to apply were accepted. This was good, but how much better would it be for all if the number of medical school and residency positions was enlarged to allow everyone with the requisite determination, learning skills, and passion for the subject to attend and become doctors ?

I chose my career with Kaiser because of its non-competitive, collaborative model. I saw almost immediately that a system in which doctors were not competing for patients, or to see who could do more procedures, or who could earn more money had profound advantages for both doctors and patients alike. In Kaiser we are salaried. We are paid the same amount whether we are operating, or examining patients, or doing office procedures, or advising by phone or email.  There is no incentive to do either more or less than what is medically indicated for each patient. There is no financial incentive to do anything other than what is best for the patient and what we are most qualified to do. If I see a patient whose surgery I am trained and qualified to do, but I know that one of my partners does this procedure better than I do, I refer the patient. This would not happen if the other doctor and I were in competition. This costs me nothing and is a true win-win.

The collaborative model has also been demonstrated to be superior at the administrative level. Each year, the chief of our department picks one or two major innovative programs for us to work on. Each of us who had a special interest would present the concept to the group. Note the presentation of concept, not a fully fleshed out program sold to the group by presenting only advantages and neglecting to mention, or minimizing the downsides. My project advanced that year precisely because I presented the idea not only in terms of its benefits, but with all the potential obstacles and challenges that I could think of. To my surprise, in response to one of my stated obstacles, one of my colleagues (who was also presenting a concept) said, “I can help you with that.” Rather than remaining silent, or suggesting that it was prohibitive, she was willing to share resources from her clinic that I did not have in order to make my proposal work. This sparked a response in others who chimed in with ways that they could help. The pilot project went forward and ultimately was accepted throughout our department, resulting in improved access while reducing costs. This would not have been possible had each of us insisted on promoting our own projects to the detriment of others.

So what does this have to do with our community ?  I see two major areas in which we could choose to adopt more collaborative processes to our mutual advantage.

One is in city planning and development. The other is in policy making.

With regard to city planning, I do not favor the now common practice of deciding on the desired project including purpose, size, who will be the partners and investors (which intentionally or unintentionally excludes anyone who is not well connected or “in the know”). I would favor a much more open process in which potential developers reach out to the community for suggestions, ideas and concerns – long before they put extensive resources into specific project designs. I would recommend that all of the advantages and potential disadvantages of any project be fully laid out in advance by the developers. I have heard the concern from some that this would only give the “opponents” more “ammunition to oppose the project.” But what if there were no “opponents” but only individuals concerned in making our community the best possible for all? What if we saw future neighbors as potential allies instead of opponents? I know from experience that this is possible. It does require a major change in mind set, but paradigm shifts are possible and often lead to improved processes.

I suggest that the same could be achieved for policy making. What if instead of acting on a proposal, whether that is the MRAP or downtown nightclubs or the Gandhi statue, we were all to take a deep breath, and start upon a pre-established process of judging the proposal on an organized vetting of the pros and cons – with plenty of opportunity for the discussion of not only goals but also underlying needs and values, in a collaborative manner in which the good will, rather than the obstructive nature of those with differing views, was the operating assumption?

I see collaboration as a superior option to our usual default of competition in many areas of life. This is not utopian thinking.  I have seen the advantages of collaboration over competition in one of the most highly competitive arenas in our country, that of medicine. If collaboration can produce superior outcomes in this setting, I know that it could be beneficial for our community. It would, however, require large amounts of open-mindedness, good will and trust. I have seen it work in my profession, I would like to see it at work in our community.


About The Author

Tia is a graduate of UCDMC and long time resident of Davis who raised her two now adult children here. She is a local obstetrician gynecologist with special interests in preventive medicine and public health and safety. All articles and posts written by Tia are reflective only of her own opinions and are in no way a reflection of the opinions of her partners or her employer.

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55 thoughts on “Collaboration as Best Practice”

  1. hpierce

    Not compromise, collaboration.

    Here, in those words, we can find (perhaps) common ground.

    The qualifier was used because there are some, who, in ‘espousing’ “collaboration”, really mean, “in order for you to collaborate with me, you must accept my viewpoint as a moral imperative for you”.

    I am not wired that way, and have never (maybe a few times) forced my viewpoint on others as a “moral imperative”… when I have, it was almost always a ‘push-back’ to someone who I perceived was doing that to me.  I detest folk who tell me how I should feel, how I should think.  My “Achilles’s heel”, if you will… if someone pulls that on me, I do tend to respond, in kind, ‘in spades’ [not meant as a racial term… think “cards”].

    During my career [and life], I have focussed on ‘problem identification’, and ‘problem solving’… never “compromise”… but I lose interest quickly when it becomes apparent that the other party is not so inclined, but is looking to leverage, intimidate, whine, etc.  Don’t know if that meets your definition of “collaboration”… I do know, experientially, that many say “collaborate” when they mean “you have to do, believe, act on what I want”.   Am not wired to handle those folk… except to counter-attack.  Ain’t a happening thing.

    Saw “Flight 93” last night… very personal to me on several levels… some would say the passengers didn’t try to find “common ground” [yet, they did! (yeah, bad comment)]… some would say the passengers should have talked about restorative justice… some would say that the passengers murdered the poor, delusional, well-intentioned hijackers…

    Collaboration is a good thing, often/usually… but, sometimes, completely inappropriate.  And wrong… do you recall the phrase “Nazi collaborators”?

    Not meant as an attack nor refutation… am laying my essence/elan out here… hope it helps folk understand where I ‘come from’… and keep real discussion and problem solving going…

    BTW… 15 years ago, there were many heroes… many on Flight 93…


  2. Tia Will Post author


    Saw “Flight 93” last night… very personal to me on several levels… some would say the passengers didn’t try to find “common ground” [yet, they did! (yeah, bad comment)]… some would say the passengers should have talked about restorative justice… some would say that the passengers murdered the poor, delusional, well-intentioned hijackers…”

    I think that this paragraph more than any other in your post may explain how we sometimes arrive at an adversarial point of view. I honestly cannot think of anyone in a fairly large list of acquaintances who would say any of those things about the passengers on Flight 93. This includes friends of all political stripes. I am honestly wondering if you actually know people who have made similar statements, or if you just made it up ?  I don’t object to your making something up to illustrate a point. But I cannot help but wonder whether once you have made up such a scenario, you do not tend to attribute those thoughts to individuals who have expressed other opinions in opposition to your own ?

    I am not accusing, I am asking. Frankly does this frequently with regard to my positions and I find myself continuously correcting him on what my actual thoughts are. I genuinely wonder if this might not be the dynamic that sometimes frames our interactions.

    Finally, I find it very encouraging that you think that there may be common ground  for discussion. Another point in which we are in agreement is that no one has the right to tell anyone else what to think. I try very hard, unless discussing my own area of expertise, to specify that my words are a reflection of my opinion only. That sentiment is in my bio for the Vanguard and precedes most of what I write.

    1. hpierce

      Not made up… real people… not family or friends… but real people… not off the internet… maybe not exact words, but the ‘sentiments’ I heard…

      Obviously, there is no point in my discussion further…

  3. jrberg

    Gonna stick my neck out and say that NO progress occurs in life without collaborative behavior.  My first real career was in a company that designed and sold scientific instruments.  I, as a chemist and heavily involved in R&D, had to collaborate with engineers (Hi, hpierce!), software professionals, machinists, assemblers, product testers, marketing, sales, field service, and, sometimes unfortunately, management.  Every person in the company had to have some ability to collaborate, or the company would have failed.

    Yes, we competed with other manufacturers, but it wasn’t the kind of competition you would find in football or finance.  The goal was to find the best solution for a problem from our understanding of the problem, and if we came up with the best approach, then customers would reward us with sales.  Of course, that’s the ideal, and many other factors meant customers might not respond as we had hoped.  But nothing would have been achieved without the collaborative teams within the company, and I’m proud of the products we produced.

    If I were still in the business, I would be looking for opportunities to create solutions with chemical/physical/electronic instrumentation to help mitigate climate change/global warming.  I would hope that there are some smart business people out there doing this right now.  We’re going to need their efforts.

  4. Tia Will Post author


    Thanks for sharing your experience. I would like us to take your experience one step further but I will use my own experience to explain. Kaiser is in competition with the other major health providers in our region for share of patients. I do not see this as a positive.

    My preference would be for collaboration amongst all groups. If there is a spectacularly successful heart surgeon at ( for example) UCD, we should all feel free to refer our patient’s for his specialty procedure regardless of whose group the patient came from without accruing additional cost. This would be offset if someone at Kaiser was particularly good with certain eye surgeries ( again for example only). Instead we decide who will go to which system based on their insurer. This is not good for patients and is arguably not good for doctors either since those with lower skills sometimes end up doing procedures knowing that within the region there are others whose statistical success rate is higher than their own. Not a good service, not a good feeling.

    Health care is not like shoe shopping. If I want to spend vastly more money on a designer shoe at Nordstrom’s when I could by a similar but less exclusive product at DSW, I have that choice. With the costs for medical procedures being prohibitive, patients most often cannot afford to simply shop around for the “best medical care” or even have any way of determining who actually provides the best care.

    I am an advocate for single party payer with the premise that patient’s will always be referred to the doctor best able to handle their individual problem. I am aware that I am an outlier, but I believe that health care should be a right, not a commodity. However, I see the Kaiser model as the most collaborative that we have at present, and have advocated for greater collaboration between our regional systems throughout my career ( albeit with virtually no success) possibly because of Frankly’s stasis advocates who wish our system to remain the same.  Ok that last was me poking fun at Frankly,,,,,sort of.

    1. jrberg

      OK, my experience was with instrument companies, not healthcare.  There is a bit of a difference, because instruments are somewhat neutral, but healthcare is very personal.  Having said that, I am a strong advocate of single payer.  I’ve also been a member of Kaiser Healthcare since around 1974 or so.  I have seldom been dissatisfied with Kaiser services, except perhaps for their mental health services.  But that’s another story.


    2. hpierce

      My preference would be for collaboration amongst all groups. If there is a spectacularly successful heart surgeon at ( for example) UCD, we should all feel free to refer our patient’s for his specialty procedure regardless of whose group the patient came from without accruing additional cost. 

      To Kaiser’s credit, about 35 years ago, they did exactly that… a good friend of mine had a child who presented as a child with a heart defect (prognosis, maybe 1-2 years of life)… Kaiser referred the child to Stanford… my friend credits God for the chain of events… I won’t dispute that… bottom line, that child got the care he needed, and according to my friend, the doctors were surprised not only for what they did (they thought it would buy a few years), but also on a follow-up, found no other problems, in spite of what they originally thought, medically.

      That child grew up, got married/had children, and has a grandchild… he is still working in a very active occupation.  The family had little out-of-pocket costs.  Kaiser covered almost all…

      Damn good referral, 35 years ago, and you should give the Kaiser system credit… I actually think you meant to…

      1. Tia Will Post author


         you should give the Kaiser system credit… I actually think you meant to”

        Wonderful story. And I certainly do give credit when it works like this. Yes, Kaiser does this on occasion, as I am sure do the other systems. We not uncommonly send pathology to Stanford for second opinion as another example.  I would like to see this be the norm rather than an exceptional story. I would like to see it be the norm throughout our business world and our society. And I would like to see the service offered without additional charge.

        On a few occasions when shopping or seeking a service, I have encountered a sales person or service provider who, knowing that someone else’s product is superior has directed me to the  best  for my purpose rather than just selling me what they have or turning me away. I would like this to be the mind set with which our entire society operates.

        1. hpierce

          Your second paragraph gave me my “smile of the day”…

          When Mark Friedman sought to get the Davis Commons approved, with Borders bookstore as its anchor tenant, the local bookstore owners went berserk, including one of the co-owners of the Avid Reader, Stan Forbes, who was on the CC at the time (now THERE was a potential ‘conflict of interest’… ).

          Project got approved, got built.  A few months later, my spouse and I went to Borders, looking for a “children’s book”… I overheard a conversation where a customer was seeking a book, and the bookstore employe said, “We don’t have that in stock… I can order it for you, or you might try The Avid Reader…”  Then went on to give the customer directions, AND offered to call the “other” store, to check availability.

          I almost had an “accident”, a rolling on the floor laughing kind of moment… the irony was delicious!  Immediately flashed on one of the sub-plots of “The Miracle on 34th Street”, where Kris Kringle [working as a Macy’s Santa] suggests that a customer would do better shopping at Gimbels [and you have to know history to understand the significance of that sub-plot!].

          Thanks Tia, you have gotten my week off to a great start!

  5. Ron


    How would collaboration work, when goals are quite different?  I’m thinking of those who are strong advocates of development, vs. those who prefer much slower growth.

    In terms of something that “most” of us can (probably) agree on, I’m wondering why the council doesn’t put forth a modest tax measure for road maintenance.  (Not sure if that directly relates to your article, but perhaps something that doesn’t bring out diametrically opposed sides.)


      1. Ron

        Don:  Good question.  I don’t really have a number in mind.  Perhaps it could start with the “need” to adequately maintain roads as is.  (Perhaps a range, at this point.)

        Personally, I’d suggest that it include adequate maintenance of dedicated bike paths, as well.  (But, not sure how that would impact the numbers.)

        Perhaps the council is holding off, until the school tax is settled.

        1. Ron

          Don:  Again, I’d like to know what the actual need is, to maintain roads as is.  But, I doubt that a $3,000/year tax (per household/unit?) would be approved.

          In any case, I assume that even a lesser amount would help.

        2. Matt Williams

          Don, $3,000 per year would cover more than just the roads and bike paths.  That amount would also cover the parks and buildings and grounds, as well as pensions and retiree healthcare.  Approximately $625 per parcel per year for 20-30 years would take care of the roads and bike paths at an average Pavement Condition Index of 63.  That is worse than the California statewide average.  If Davis wants to get its roads and bike paths back to a level consistent with the “above average” sense we have of ourselves, moving the parcel tax up to $1,000 per parcel per year for 20-30 years would probably do it.

          Of course that would not include anything for parks and buildings and structures.

        3. Ron

          Matt:  Just wondering if the same problem exists as with school taxes.  (That is, would an apartment complex gets charged the same amount as a single-family dwelling, regardless of the number of units in the complex.)

        4. Ron


          Well, that’s good news.  I guess it hasn’t been “tested”, yet.

          Perhaps this means that the example ($625/year parcel tax) can be more “fairly” distributed among dwelling units, so that single-family homeowners are not uniquely burdened. (Presumably, this would reduce the amount that single-family homeowners pay.)

          Such a tax might be within range of approval by voters, and an example of collaboration.

          Thanks, and good night.



    1. Tia Will Post author


      How would collaboration work, when goals are quite different?”

      This is of course a much, much more difficult issue than when goals are at least similar if not identical. I think that this is where a truly different mind set than we usually see today is needed.

      The mindset that I see today is  ( greatly simplified and generalized for purpose of discussion) :  We have a need, this is important to me, and because it is important to me, I am going to act on it. I will talk to people who have a similar mindset to mine, establish my partnerships, attract investors, acquire the necessary resources ( in our case usually land) and move forward with my project. Once I have my proposal in order, I will start discussions with other groups. This mind set is seen not only in those who act for profit, but also those whose goal is some public policy ( think water fluoridation for example).

      When the idea is sprung ( or appears to be sprung out of the blue) on the other side we have those who say : We have a need. It is important to me. But this proposal is not the right approach. It does not honor my values. And it is against the current rules. I will talk to people who have a similar mindset to mine, establish networks and connections, hire lawyers if necessary, and fight.

      What I would suggest is that we at least consider a completely different paradigm. What if we were to talk from the beginning about potential solutions to a particular problem or how to capitalize on a potential opportunity with those whose priorities are different before we become heavily invested in our own specific project. ( As in my example of the administrative projects….we all wanted our own to advance….and yet others were willing to support mine.) The part that I didn’t share was that the next year, the first woman to support me, saw her project go forward the next year. Collaboration up front, leads to greater trust and more willingness to collaborate in the future.

      When goals are truly in opposition, true collaboration may not be possible. This is where I see a role for compromise as early as it is determined that true collaboration is not possible. This is what I see having occurred at Paso Fino. Developer makes a proposal. Community finds the precedent ( and some other factors) unacceptable, and ultimately a compromise solution is reached.

      Although collaboration in my mind will always be the superior solution, I see that there will be times of need for compromise. What I do not believe there is need for is what is called for by some posters on the Vanguard. If people do not see things my way then they need to get out of the way. For me, there is no room for this approach in a community.


      1. Ron

        Interesting thoughts, Tia.  I agree – collaboration is generally much less stressful and more productive than conflict.  And, in America, there seems to be too much emphasis on competition. (Almost a “mantra”, here.)

        Also, I wonder what would happen if, say, a developer seeking a zoning change approached those most opposed to development, in the beginning?  For example, I recall that Mike Harrington repeatedly offered to meet with developers to discuss land mitigation.  I know that some seem to have a negative reaction whenever Mike is mentioned, but some of his ideas are actually quite sound – such as identification of mitigation land in advance, if possible.

        Regarding Trackside, how much time, energy, and money were wasted due to not adequately reaching out to neighbors before launching a proposal?  As you’ve pointed out, at least some neighbors already supported some type of redevelopment of that property. Instead, it seemed that the process/proposal went off-the-rails immediately.

  6. Frankly

    Successful collaboration requires the preceding identification of shared interests.  If there are none then collaboration is a waste of time and we should proceed to arbitration instead.

  7. Frankly

    I chose my career with Kaiser because of its non-competitive, collaborative model.

    Part of the reason that health care costs are breaking the backs of so many in this country is due to the lack of competition in that industry.

    That is the cost of soothing the nerves of the competition-anxious.

    And it is always a hoot for me to read this from an MD… one of the most competitive professional certifications.

    There is no doubt that unbridled and unregulated competition can result in a race to the bottom.

    But so can a lack of competition.

    Both are unsustainable trajectories.

    We need balance.

    Funny how the Obama administration is trying to push the healthcare industry to become completely non-competitive while also pushing global trade agreements so that the rest of the economy can be picked apart by low-rent foreign competition.

    Of course the healthcare industry is largely unionized and unions give all their political contributions to Democrats.

    So there you have it.

    1. wdf1

      Frankly:  Part of the reason that health care costs are breaking the backs of so many in this country is due to the lack of competition in that industry.

      Healthcare costs appear to be lower in industrialized counties where the government runs the healthcare, such as Great Britain or France.  In such a model, there is no competition.

      1. Frankly

        There are a number of reasons why US healthcare costs are the highest on a per-capita basis than for other industrialized countries.  But the US does not have a competitive system.  The US has a bloated system precisely because it is over-controlled by government and government control causes a lack of competition.

        1. Tia Will Post author


          The US has a bloated system precisely because it is over-controlled by government and government control causes a lack of competition.”

          In at least one area of health care, it is not government control that causes a lack of competition ( which in and of itself is no panacea) it is the doctors themselves who have caused the lack of competition by artificially creating a paucity of doctors. You consistently ignore this when health care is mentioned .


        2. Frankly

          The current scarcity of doctors has been caused by the government intrusion in the system… exploding demand without doing anything about capacity.   This was an anticipated problem for all except Nancy Pelosi who had to vote on the legislation so she could read what is in it.

    2. Ron


      Just wondering (if it’s not too far off-topic):

      What do you think is the best solution, regarding healthcare (and insurance).  Would a single-payer system (something like they have in Canada or the U.K.) work better than what we have?

      I’ve also never really understood the negative reaction to “Obamacare”.

      If those systems don’t work, do you have any ideas regarding how to handle the uninsured?

      How would any solution reign in costs for healthcare and pharmaceuticals in this country?

      Seems like a complicated subject.  I’m not sure that it lends itself to strictly a conservative, or liberal approach.


      1. Frankly

        Ron – are you a retired government worker or a current government worker with a Cadillac healthcare plan?  Or do you get subsidized care?

        Because if you are like most working people that have to cover much or most of their healthcare costs out of their own pocket, you would know what the problem with Obamacare is.

        And if you were a person living where there are zero or only one Obamacare provider options, you would know what the problem with Obamacare is.

        The solution to driving down the cost of healthcare is to inject the industry with competition… requiring transparent pricing for related products and services… and disclosures on service outcomes and qualities to help healthcare “shoppers” make better choices.

        It is already this way in a lot of places, but I can see a day where property values are impacted by the value and qualify of available medical services close by.

        1. Tia Will Post author


          Because if you are like most working people that have to cover much or most of their healthcare costs out of their own pocket, you would know what the problem with Obamacare is.

          And if you were a person living where there are zero or only one Obamacare provider options, you would know what the problem with Obamacare is.”

          Which completely ignores the fact that neither paying ones costs out of pocket, not Obamacare would be necessary if we had single party payer with universal health care and complete transportability of that health care without question.


          1. Don Shor

            My hope was that Frankly would answer Ron’s question, but apparently he chose to go on a rant instead.

    3. Matt Williams

      Frankly said . . . “Part of the reason that health care costs are breaking the backs of so many in this country is due to the lack of competition in that industry.”

      Part, but an incredibly small part.  The principal reason (well over half in my opinion) is the massive collusion and greed and redundancy and waste in the healthcare insurance industry.

        1. Frankly

          There are no natural incentives to do the hard work to reduce redundancy and waste if there isn’t any competition.  Without competition the organization focuses on things other than improving customer value.

          Improving customer value requires constantly striving to learn how to be more efficient without reducing quality… ideally reducing costs AND improving quality… the “doing more with less” credo.  That is really hard… really hard.  It goes against human nature unless there are motivations and incentives to drive it.  Competition provides the incentives.

          This is the general explanation for why collectivist systems eventually fail and why capitalist systems have been so fantastically successful by comparison.  Collectivists tend to pick at the imperfections of a competitive system… primarily the unfairness they see and feel when some win and some lose… even when losing is only a temporary situation because the loser can get back up and compete again.

          But I see the clearly just being a different pursuit of their own self-interest… where they are not as confident about their ability to produce, compete and win in the economy, and so they want to change the rules of the game to better suit them and allow them to at least loot and win.  Evidence of this “self-pursuit” driver can be found by assessing the criticism of competition in the economy from people that absolutely support extreme competition in academia.   This hypocrisy does not escape detection.

          There is a tendency for a race-to-the-bottom with unbridled economic competition.  From a more macro perspective this isn’t a problem as industries will cannibalize themselves and the strong will eventually win.  And then the strong become bloated and bureaucratic until they are taken out by a new upstart seizing the opportunity to provide better value.   The challenge with this is the social cost to people in their lifetime.   We simply cannot wait around for these cycles of destruction and rebirth to happen in the economy because the destruction can be devastating to the economic life of families.   So we need some top-down rules and enforcement to attempt to prevent the extreme swings of boom and bust.  We also need some social safety nets to help people caught in a bust cycle.  But we should not allow the safety nets to become a replacement for the need to compete.  It is Darwinistic social suicide to develop this mindset in a people… that they will be taken care of and we will eliminate the stress of having to strive and compete.

          Scandinavian countries do a much better job at this.  It takes adopting the principles of capitalism as almost a religion within governance.   The key of that religion is that government policy should foster and foment competition in the economy.  Anti-trust and anti-monopoly should be more frequent challenges when companies take over large chunks of a share of market.

          We should consider a franchise model where there are metrics to help with licensing a certain capacity of business within a given territory.  We should do much more public-private partnership… where government gets out of the business of end-user services and instead certifies and licenses private companies to provide those services… with the government becoming an auditor and overseer instead.

          Competition is the key to growth and constant improvement.  No I don’t trust that the well-educated can just power-through their animal nature that causes them to opine for policy that benefits them and theirs at the expense of others. We are all selfish at out core.  There is no perfect altruism.  The hierarchy of needs dominates all human behavior.  Competition gives us the platform to meet our needs… all the way to the top of self-actualization… and it allows for dynamic adjustment that, even though inherently flawed from a perfection in social care perspective, is infinitely better in outcomes than any system that attempts to legislate outcomes.

        2. Matt Williams

          There is a wealth of competition in healthcare.  Sutter competes aggressively with UC Davis Medical System and with Dignity Health and with Kaiser.  They and other healthcare providers like them spend tens of millions attempting to differentiate themselves from one another in the eyes of the consumers and in the eyes of the insurance plans.  The problem isn’t with the amount of competition (to torture a metaphor, they are working very hard on their competitive efforts).  The problem is with the quality (focus) of the competition (they are not working smart on their competitive efforts).  As a result the consumers of healthcare services are not receiving any benefit from all that innovative competition.  All they are seeing is the cost of that competition passed on to them in the cost of the services they use (or don’t use).

          When I joined the healthcare industry in 1981 the non-care-giving overhead (administrative and marketing costs) was a bit less than 8% of the total costs.  Now it is approximately 20% of the total costs.  The lion’s share of that incremental 12% is due to the cost of competition under the current fractured, dysfunctional, corrupt private insurance system we have. Until we apply some actuarial and fiscal sanity to the length and breadth of healthcare delivery here in the US the lining of the pockets of insurance companies across the nation will continue.




        3. Frankly

          When only Godzilla and King Kong are competing it generally does not benefit the people.

          We need a lot more consumer choice in the business of healthcare before the claim of competition would apply.

          Before the Japanese started making high-quality cars, after embracing Demming’s TQM, there were only 3-4 US automakers… and they generally made crappy products.  Or at least they failed to innovate and improve at a similar post-global-competition pace.

          But they still competed against each other.

          Most customers of health care providers are captive customers.  They have very limited choice.  Just try to get them to price out a procedure for you… tell them you are value shopping for your next MRI and you want the direct consumer price and the price they would pay your insurance company.  See how far you get with that.

  8. Tia Will Post author


    I read your reference and do not doubt that within the system that we currently have, this is true. I do not believe that the current system is the one we should have. This presupposes that we are going to treat health care as a commodity. If we see it as a commodity, then yes, scarcity (or lack of competition) will drive up prices. This is in no way addresses my premise that health care should not be seen as a commodity, but rather as a right. If we were to see health care as a right rather than as a commodity, if we saw it in the same light as we see the right to military protection, we would not be discussing its relative market value at all. We would work on the assumption that everyone had an equal right to preventive services and treatment just as we believe that everyone has the right to military protection.

    1. Frankly

      Here is the problem Tia.

      The elite ruling class of this country has proven beyond a shadow of doubt that they are incapable of designing, development, implementing and running sustainable and high-quality end-user service business.

      Everything the Federal government does related to end-user services is crap and ripe for corruption because there is no higher power of oversight.   At one point years ago I might have looked forward to the judicial and the press being the watchdog.  But no more… they are corrupted too by the steady work of the ruling class to get their people planted.

      A single-payer (government owned and operated) healthcare system in this country would be the biggest boondoggle to the crony capitalists and looting politicians that the world has every seen.

      It would be as crappy as the VA system and drive costs WAY higher than they are today.

      The ONLY way this country will succeed in driving down costs while maintaining service quality is to unleash the power of the free market within a regulatory framework that demands transparency and accountability.

      Frankly (because I am) I think the US healthcare system would be better if there were more Kaiser-style operations throughout the country.    I would start making policy to encourage that transformation in a beneficial public-private partnership.

  9. Tia Will Post author

    Collaboration” anything near “Obamacare”?


    Actually, I believe that they are closer as topics than might meet the eye. Obamacare in my opinion was an attempt at compromise. I believe that Obama wanted to make health care as ubiquitously available as possible, but accurately perceived that within our system of beliefs a “socialist” like system would never gain enough support to be passed. Compromise with incentives for the existing health insurance industry was a necessity to get anything done.

    My preference would have been for a truly collaborative approach in which all interested parties would have acted in concert to provide health care for everyone. I see this kind of compromise as a sad admission that not everyone believes that everyone should have their medical needs met regardless of their ability to pay. But it was certainly better than what proceeded it.

    1. Frankly

      i don’t know anyone that wants to see people without healthcare just like I don’t know anyone that wants people to go hungry.  Your points here are DNC political propoganda and are harmful to your goal of collaboration.

      This debate is about the best ways to satisfy the most care needs and to provide the best care for the lowest cost.

  10. Tia Will Post author


    I think the US healthcare system would be better if there were more Kaiser-style operations throughout the country.    I would start making policy to encourage that transformation in a beneficial public-private partnership.”

    So if you see the Kaiser model as superior, as I do, why would it need to be competitive ? Why not just let Kaiser take over in the areas where it is now predominant in the market and let other systems such as Sutter, Mercy…. convert to this model. Why the artificial need for “competition when we have a vastly superior model which is now being emulated by many of these systems anyway. Why not have Kaiser trained doctors and administrators collaborate with other systes to help them make the necessary changes ?  In other words, why is your default always to competition when you have already stated that Kaiser has a superior model which is based on a constant state of collaborative change as I expressed in my example of our administrative innovation programs ?

  11. Ron

    Thanks Frankly, Tia, Matt, and Don.  Took a break from the Vanguard, before looking at the responses.

    I’d have to agree that it’s an area that requires some collaboration, and probably competition, as well. (I recall that even Donald Trump said that we can’t let people “die in the streets”, or something to that effect.)



  12. Tia Will Post author


    i don’t know anyone that wants to see people without healthcare just like I don’t know anyone that wants people to go hungry.  Your points here are DNC political propoganda and are harmful to your goal of collaboration.

    This debate is about the best ways to satisfy the most care needs and to provide the best care for the lowest cost.”

    You switched gears three times in this post.So I will address all three points.

    I think that we can agree that no one wants to “see” people without healthcare. But that is an interesting choice of words. I believe that for some people who do not “see” people who do not have healthcare in their own personal lives, it is easy to pretend or simply not care that such people exist. just as it is easy to “overlook” and therefore not “see” that people are hungry.

    As for DNC propaganda and getting the best way to satisfy the most care needs and to provider the best care for the lowest cost, it is clear that we were not approaching this goal through our employer based or fee for service insurance based means.. The existence of “propaganda” from a source one does not like, does not mean that there is no validity in what is being said. In the case of a more socialized medical system, there are many industrialized nations that spend less per capita and have statistically better outcomes in many areas. So just because you do not like this approach and don’t like hearing about it from a source you do not like, doesn’t mean it cannot be more effective.

    As for the idea that without competition, Kaiser will become “lazy”. This is predicated on your belief that people are inherently lazy and without a driving measurable outcome ( increased wealth on the positive side or going out of business on the negative side) that innovation will die. I can guarantee you that this is not universally true within the medical field.  Those innovation projects that I was telling you about. I do not believe that a single one of those was driven by the desire to get more money or prevent ourselves from being fired, or Kaiser from going out of business, or even losing market share to Sutter. What drove all of the innovation projects in which i took place was how do we provide better care for our patients. How do provide safer practices for our patients, how do we lessen wait times between detection of a breast lump and definitive diagnosis and treatment, how do we get interdepartmental consults more quickly so that our patients do not have to make an additional trip to see another specialist when their phone advise alone would suffice ? The latter actually reduces money for Kaiser since it provides the same service without the additional copays.  I can only think of one project that I worked on in my 25 years here that was geared specifically to lessening costs, and that one also had the benefit of reducing patient wait times.

    I do not believe that people or organizations are inherently lazy. I believe that those who feel that they have a “mission” in life will work hard and be innovative even if they are not going to see any immediate reward or punishment for how hard the do or do not work. I believe that if we enlarged the artificially small funnel through which potential doctors must pass in order to practice and emphasized the “mission” of providing good health care over the lucrative nature of it as we have today, we would attract many more such self motivated individuals to the field. I know from past conversations that you find this a foreign concept, but self economic enrichment is not everyone’s highest goal in life. Some truly are dedicated to making a contribution as well as making a living.

    1. Don Shor

      “i don’t know anyone that wants to see people without healthcare

      If that’s the outcome of their policy — for example, refusing to expand Medicare — then it doesn’t matter whether it’s what they “want.” It’s what happens.

  13. Tia Will Post author


    So here is a broader thought about the power of collaboration.

    You and I clearly see the world very differently. We each see it the way we do because of our own life experiences. It is these experiences that inform our very different “truths” about the world. A critical first step in collaboration is to trust that the other person is sincere in their expression of their truth.

    Another critical step is to realize that each of our ‘truths” is limited because it does not include the “truth” of the other. One small example of this. I believe in your view of the “free market” in some instances. This would include any luxury item. If something is not necessary to the existence ( food and medical care for example) then I have no problem using your free market paradigm. Charge a million dollars for a designer pair of shoes if you can get them to sell for all I care, as long as there are foot coverings available to all who need them.  Luxury items, I see as completely amenable to your free market. Necessities, I believe that we should cover for all as a right. Food and health care fall within this category for me and should not be treated as commodities at a basic level.  I may be wrong, but I believe that you do not ( with the exception of military and police and fire protection ) believe that there is anything that should be available for all regardless of their ability to pay. Please correct me if I am wrong.

    So my point is, that in order to collaborate, we will have to be wiling to admit that there is some truth in the point of the other rather than simply defaulting to calling the others “truth” propaganda or bleeding heart, or from my side giving in to urge to see you as heartless and uncaring. To begin an effective collaboration, we must not only have some commonality of goals, which I believe that we do, we must also have the willingness to drop the labels and honestly consider anew what truths may lie in the positions of the other side.

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