Creating Health Care Covenants
Health Care Under Siege – The Climate is Chaotic
Healers today face an impossible task. The demographics of aging, the expectations of patients,
and the opportunities of science are clashing with the willingness of the nation to pay for care.
The credibility of providers has eroded. Tensions are rising, occasionally to the blowing point in
Congress and in the courts. Can such conflict be resolved? Or will health care melt down under
the pressures to care for the increasingly aging, demanding, obese, chronically-ill population?
Finding Solutions – And Getting It Wrong
At one time I believed that public policy debates would create viable solutions. I no longer
believe that. Too many of our policy debates occur in political settings and politics, by its nature,
is hard-wired for conflict—witness any recent Presidential Election. Conflict may well be a
necessary part of politics, but it is not the best way to resolve the important decisions of the day
in an enterprise of healing.
Seeking Covenants – A Surprise Finding
Little did I know what I would find as I went looking for an answer to help organize the chaos.
Historically, the healer-patient encounter was a relationship held sacred by the healer, the
patient and the community. It was called a covenant. Not a contract, a covenant. Covenant
meant that the relationship would be permanent, or nearly so. It meant that the deity, or deities,
had blessed the healer, that neither the healer nor the patient would benefit to the detriment of
the other, and that the community would do its part to create healthy environments and pay for
care. There were two types of covenants that emerged in our cultures and were applied to our
healing systems, imbedded in medical oaths: covenants of grant, and covenants of obligation.
The covenant of grant that we know best in Western society is the one between the Hebrews
and their God and is best exemplified in the “granting” to Noah that the earth would never again
be destroyed by flood. This grant came to Noah after the waters of the great flood had subsided
and without his having to do anything in return. Later, came a covenant of obligation at Sinai,
which established a set of responsibilities for both parties—God and man—and defined the
obligations for each.
The Oath of Hippocrates followed the form of all the other covenants of the day, those between
fathers and sons, husbands and wives, and kings and subjects. Hippocratic healers entered into
covenants of obligation in the oath – but only with each other. To their patients, they granted
health and healing. It was only much later that Maimonides crafted a new, and nearly unknown,
oath that called on patients themselves to be obligated to participate in their healing by
complying with clinical advice.
As our societies and our health care systems became more sophisticated, we lost sight of these
covenant concepts, and we have layered them over with contracts. The valuable notion of
covenant was lost and, even worse, the Hippocratic foundation of western medicine never
matured enough to support the complexities of modern health care. The time has come to return
to covenants and to reconsider how patients and others should now be called into covenants of
Glenna M. Crooks, Ph.D. | 1075 Fort Washington Avenue | Fort Washington, PA 19034 | 215-646-8182| www.createcovenants.com
obligation to support healing. To heal health care, we need to step outside our conflicts and
contracts and enter into covenants.
Recommended Solution – Three Easy Pieces
My prescription has three parts. Part One: all healers need to embrace covenants of caring.
Most physicians, nurses and pharmacists already do. But today’s new healers should join them.
Insurance company executives, legislators, regulators, health care company staffs, internet
players, Madison Avenue health product advertisers, pharmaceutical company sales
representatives and evening news anchors are the modern extensions of the ancient healers
who crafted the values and ethics to which physicians subscribe in their oaths. These healers
may not examine patients, but they make equally important health care decisions. As societies
became more complex and segmented, so too did providing care. Since physicians have the
longest history and richest experience in being in covenant with patients, they are the best ones
to lead the way for all the others. Physicians, by tradition and by oath, know that to be in
covenant means to accept responsibilities to act ethically and morally, to act in the best interests
of patients, and to study and share knowledge for the healing of the patient. If more of today’s
players in health care ascribed to a covenant oath with patients, many of our problems would be
more easily resolved.
Part Two: patients should be invited into these covenants of obligation and called upon to be
better managers of their own health. Part Three: communities should be called into the
covenant as well, by asking that they better support healing through funding and better public
policy choices for safe and healthy communities.
Initiating Healing – Now and Forever
The time has come to acknowledge that while we may be required in our current health care
business climate to live with contracts, we must also return to the covenants – and especially to
covenants of obligation among healers, patients and communities. The time has come to end
the political debate and begin a healing dialogue. We need to disarm our hair-triggered
willingness to shoot at the enemy on the other side of whatever healing ventures we share. If
health care is to be healed, everyone involved in the healing enterprises of the day—the healers
themselves, patients and communities—must now consider the nature of the relationships they
have with each other. The following are some questions people frequently ask about this
paradigm.
How will patients respond to covenants of obligation?
Patient reactions have been ultimately positive, and that has surprised me. After venting their
anger over the state of health care today, they readily accepted the notion that they too are
responsible for their health, and that they have been less than faithful to the self-care and
lifestyle choices that would improve their health and reduce the costs of care. Both groups—
physicians and patients—were equally frustrated and looking for a solution. Both feel
vulnerable. Neither wants health care wars to escalate.
How do communities respond to the idea of covenants?
Communities, and in particular, employer or workplace communities are positive, but cautious.
They worry about the reactions of their employees, and in particular their unions, if they
embrace covenant notions. They, too, are looking for solutions and feel more trapped than ever
in the current paradigm of payment and contracting.
Glenna M. Crooks, Ph.D. | 1075 Fort Washington Avenue | Fort Washington, PA 19034 | 215-646-8182| www.createcovenants.com
Be more prescriptive, will you?
Sorry, I can’t. By definition, only the parties to the covenant can work out the specifics. I’ve
been about as specific as I can be in the examples and policy issues I’ve included and other
suggestions I make. I outline who the parties to various covenants might be and have pointed
them in a direction. Only they can determine if they want to walk the path. Once underway,
they’ll decide how fast to progress and whether to detour from the route. Taking the first steps
will not be easy, but the next steps will be even harder and no observer can second-guess the
results.
It is within covenant relationship that the toughest questions must be addressed, but we tend to
avoid them: they are questions of reciprocity and responsibility. If a patient can sue a managed
care provider for failure to provide care (e.g., experimental therapies not covered by contract),
can managed care sue patients for failure to follow medical advice? If patients do not take their
medicines or change their lifestyles, should payers be responsible for covering the cost of the
more expensive diseases that will result? If employers cover the cost of a flu shot, can they
deny sick leave to employees who choose not to be immunized but then get the flu? If the
nation allows its citizens to carry guns, can insurers levy a surcharge for the likelihood of higher
emergency room costs in areas of high gun ownership? In other areas of our lives we pay—
financially—for the consequences of our choices. If we change an airline ticket, arrive late to get
our children from daycare, check-out of hotels early, or fail to show up for restaurant
reservations, we incur financial penalties. Should it be any different in health care?
Why so many questions and so few answers?
Few health care problems and policy issues today have clear answers or easy resolutions, and I
can’t imagine that the next several decades will be any easier for any of us—healers, patients,
or communities. Today’s health policy, which is so dominated by the economics of care, could
benefit from an infusion of new ideas to frame our analyses. This is an offering of that type. I
wanted to bring a new perspective, some structure for analysis, a vocabulary for negotiations,
and some tools to help. I applaud everyone in health care, e-commerce, and telecommunications working to create efficiencies. Their work deserves support, encouragement,
and reward. Squeezing the cents from the dollars is a good thing. Squeezing the soul from the
system of care is not. I’ll continue to pose the questions that get to the soul of healing.
If health care is to become consumer-centric, do covenants go against the tide?
I see the consumer-centric trends, but I hope it does not end there. Consumer-centrism is most
likely a phase of our development as a society as a whole, and is a healthy maturation from
“one-size-fits-all” health care. I hope that it will only be a phase and that we transition beyond it.
Health care will benefit from consumers with the incentive to care for their health and the
personal skills to do so. Healers and communities can and should help them do that, and doing
so may be the most important covenant-focused activity that healers and communities can fulfill
in the near future. Healers and communities should avoid reinforcing the dependencies we’ve
created over the past 50 years in this country, however. The ideal, in a covenant paradigm, is
interdependence among consumers, communities, and healers. If health care of the future is
only consumer centered, lacking in covenants of obligation among the parties involved, the
many challenges we face now will become even more serious problems, and the many
opportunities before us today to solve problems won’t be realized.
How can you expect that we can do what you advocate when all of our policy
discussions are political debates? How can we get Congress involved?
What I fear most today, in our political climate, is that communities will band together and use
legislation or regulation to set prices, require free care, and shift the patient’s and community’s
Glenna M. Crooks, Ph.D. | 1075 Fort Washington Avenue | Fort Washington, PA 19034 | 215-646-8182| www.createcovenants.com
responsibility for financing even more of the care to the healers. If the community wants all of its
members to receive care, the community should be willing to step forward and pay for it, not
legislate healers to do it for them. Medi-Cal, on behalf of taxpayers, pays a physician $43.25 to
fix a broken arm, while veterinarians in the state get $500-$800 for repairing a dog’s broken leg.
It seems to me that’s a misplacement of payment priorities.
We should talk to each other, not to Congress, about what ails us in health care. It is my
observation that we turn to Congress reluctantly, and in anger, when the relationship between
us breaks down, and we want the Congress to impose controls to fix the "other guy." I was in
the audience at one of the farewell addresses of Congressman Barber Conable, at his
departure to head the World Bank. "Do not expect us to lead," he announced. "We were elected
to represent, not to lead. In that regard, we will have to be dragged kicking and screaming into
any issue we deal with." Reluctant congressmen, dragged into issues after years of local
constituent anger and hostility, are not in the best frame of mind for crafting a health care future.
Perhaps if we talked to each other, we could sort out our needs, our wants, and our differences
of opinion. This means that every encounter, every phone call, and every e-mail becomes an
opportunity to deal with someone else in the covenant. Take those opportunities. In those
instances where Congress is already involved, let’s at least advise them to avoid rash solutions
and eleventh-hour compromises that please no one. Doing the first will take our time; doing the
latter will require our restraint. Doing both is absolutely essential.
Glenna M. Crooks, Ph.D. | 1075 Fort Washington Avenue | Fort Washington, PA 19034 | 215-646-8182| www.createcovenants.com