Inbetweenisode: The Narcissism of Small Differences Is a Really Must-Know Concept When Attempting to Fix the Healthcare Industry

Introduction and Overview

[00:00:02] Stacey Richter: Inbetweenisode, “The Narcissism of Small Differences, Is a Really Must-Know Concept When Attempting to Fix the Healthcare Industry”.

American Healthcare Entrepreneurs and Executives You Want To Know, Talking. Relentlessly Seeking Value.

This Inbetweenisode is me geeking out, so if that's not your thing, you've been warned.

Understanding the Concept of Narcissism of Small Differences

[00:00:37] Stacey Richter: There's a term I'd like to encourage anyone interested to look up. It's the "Narcissism of Small Differences". Links in the show notes. 


It explains a lot. The "Narcissism of Small Differences" is the idea that those who may be in theory should be friends, BFFs, working side by side toward the same major goal, are not. We divide ourselves into these micro camps. Why? It's a thing to get really narcissistic about small differences. Consider vegans and vegetarians who are so often all up in each other's business in really nasty ways. 


Who knew whether or not someone decides to eat cheese or not could create such enmity. Or like there's subreddits on Reddit dedicated to people fighting about like fantasy football. You would think that everyone who plays fantasy football, would be friends, except not. There's apparently major schisms in the fantasy football world. 


Or consider branches of the same religion who are at war with one another. Consider people in the same political party fracturing over who is the very most whatever. Pick something.  


Applying the Concept to the Healthcare Industry

[00:01:44] Stacey Richter: So now let's talk about the narcissism of small differences and how it's relevant when we're thinking about helping patients in the United States get better healthcare for an affordable price. 


We have these gigantic corporate entities right now very industriously vertically integrating to control supply chains and cornering markets, buying up physician practices and using every trick in the book to extract maximum profitability from patients and taxpayers and employers. Achieving some kind of tipping point where these incredibly well orchestrated and well funded profit machines are driven back will only happen when enough people, individuals, amass behind that tipping point. 


It will take more than a village. And my ardent request here is to, I don't know, we quit it with the narcissism of small differences. Do not succumb. When you cling to an, in air quotes, my way, you preclude your ability to synthesize, cooperate, support, or even in some extreme cases, peacefully coexist with other members of your tribe. 


The Impact of Narcissism of Small Differences on Community

[00:02:41] Stacey Richter: You destroy a fundamental reason for belonging in the first place, community. That whole last bit was a quote from a blog post by Frances Cole Jones, link in the show notes. I love the community who I interact with most on LinkedIn, and there's also some Listservs and some Slack groups that I love. Even X and Threads, for the most part, are lovely nests of great people trying to understand one another and further a common cause. 


I guess when you get into the kind of wonky stuff that you and I get into, there's a finite group of us who are even reading these tweets or posts or whatever they are. It's a small junior high school, as one of my clients used to call it a long time ago. But there's also often enough that somebody who swoops down and in the name of something slams a like 95 percent alliance cause. 


The Role of Narcissism of Small Differences in Decision Making

[00:03:32] Stacey Richter: It's like two people agreeing on the restaurant to go to lunch, but one wants to go there to get the rice dish or because it's closer to their house, and the other one wants to go there because the restaurant serves a great tortilla. And then, like, the two of them fight over what's the right reason to go to that restaurant or what the best item is on the menu. 


This is literally a metaphor that describes some of the sniping that I have seen, that you have seen, amongst mostly aligned folks trying to figure out how to put patients over profits. I mean, guys, go to the restaurant. Once you're there, you can place separate orders. Work together to just get to the restaurant. 


It's certainly easier to say than do.  


The Importance of Focusing on Common Goals

[00:04:08] Stacey Richter: But if we're aware of this and we focus on the points of agreement and maybe just think a little bit about whether the points of difference really even matter in real life, not theoretical philosophy life, because a lot of times they don't, and then divided we fall. 


I think a lot about small difference narcissism-ing when someone comments derisively that a post or an article puts too much emphasis on dot dot dot, I don't know, transparency or employers or mental health or pick something.  


The Role of Priorities in the Village

[00:04:38] Stacey Richter: But here's the thing, in the village, everybody is going to have different number one priorities. 


That's why it takes a village. Maybe I'm wrong, but I'm thinking it's not a zero sum game. Just because someone is angling hard for patient empowerment or consumerism or whatever, doesn't make it harder for anybody else to promote patient health literacy or better quality measures or integrated behavioral health. 


Probably, it will make it easier since both are trying to figure out how to put patients over profits. Both are pushing in the same direction, albeit one is headed northwest and the other one might be angled really far northeast. Point is, everybody will get momentum as long as we're all roughly headed northbound. 


Now, caveat and sidebar. There are people emphasizing things because they're actually working on them.  


The Influence of Marketing on the Narcissism of Small Differences

[00:05:25] Stacey Richter: And then there are people promoting things because it's good marketing. Jeff Hogan wrote about this at the beginning of January, and I agree with him here. Here's what he had to say, and then I'm going to connect it back to what I think is a really important point about the narcissism of small differences. 


Jeff wrote, "Over the course of the last month, I have been asked no fewer than 20 times about exactly which conferences I am attending this year. All of my conference intentions are focused on one question. What will this conference do to promote a complete change in our healthcare paradigm, focused on superior patient access and outcomes as well as payment reform and care transformation? 


Said a different way, is this conference literally a honeypot for those who have screwed up the existing system and who are merely virtue signaling? Who is speaking at this conference? Is it representative of the same health systems and the same payers and perpetuating legacy moats and monopolies? Or is it a conference promoting change makers, risk takers, and provider models and systems? 


Embracing risk and health care transformation. What kind of change and innovation ever came out of an echo chamber? Challenging my friends and health care influencers to think carefully about their choices. Conferences create the opportunity to leverage great ideas and movements. We're finally seeing first followers having expanded influence. 
Are you one of them?" 


So, talking about that conference that happens at the beginning of January, I heard that a CEO of a major PBM stood up in front of that room. And use the word transparency or synonym six times in five minutes. There's a couple of links in the show notes as to why my eyebrows are sky high on what transparency actually means for the CEO. 


When you look at what this PBM is actually doing. If you look at quarterly reports, again, of some of these big entities, the cover of that annual report has lots of wonderful patient centric words on it, while if you look at how those entities are actually making money, it is in direct conflict with those words. Now, there's always going to be nuances here. 


Always. And that's what makes this very subjective and very personal. Everyone doing well by doing good is going to have a marketing statement, and it wouldn't be a marketing statement if it didn't sound amazing, right? The nuance or the question is to what degree are they actually achieving that marketing statement? 


What's the line that separates pure spin from an acceptable level of achievement of the marketing statement? Because we want to support the organizations that are trying here while at the same time make sure that we're kind of quarantining those who are just all talk, in ways that confuse the marketplace and don't help patients get affordable, quality healthcare, just like Jeff just said. 


I gotta say, sometimes I struggle here myself.  


The Impact of Narcissism of Small Differences on Career Choices

[00:08:06] Stacey Richter: This is why I wrote a manifesto, episode 399 and 400, and you might struggle too. It's probably no coincidence that sometimes the loudest individuals advocating for patients over profits are retired. And throwing in no shade here, I love the whistleblowing and the truth telling, but I think we have to be a little careful because who is actually going to do the changing and the tipping point reaching are those who are still working for a living on or about the healthcare industry. 


And when I say working for a living, I mean we're taking money and putting it in our pockets. We need to pay the rent and go on vacation every now and then and we need money to pay for our family's healthcare. If we didn't take money, if we just volunteered, that cash might have funded more patient care, or maybe made that care or premiums more affordable. 


Every one of us is a cost center if we think about it from the standpoint of the patient or plan member. Every one of us. If you did it for free, the money could accrue to patients, right? I also keep in my mind that there are for sure individuals within any of these profit seeking, financially motivated, maybe not patient motivated organizations, and these individuals have a job to do the good that that organization is doing. 


These are the ones who are actually working on pilots that actually work, or doing work with social determinants of health or behavioral health that are actually, again, working. While I dislike the overall impact, potentially, of the one who is paying their paycheck, I gotta keep in mind that the more successful this individual is within that corporate entity, the more good that that entity is gonna wind up doing. 


I think about this because again, my main concern is doing better by patients, helping the sort of insurgents within some of these entities. These entities should be held accountable, no doubt, but the people who work within them should, I don't know, I still want to encourage them to do better. The goal is to help patients, not catch up some good people in a quest to, you know, punish their boss. 


So, it's always a matter of degrees. It's always nuances. It's always how much value got delivered back for the dollars that we took in compensation for the work that we did. What did the work we do add up to? In my personal case, and I covered this in the manifesto again, episodes 399 or 400. I worked really hard. 


By the way, I was sweating bullets when I was creating that manifesto. I was not sure whether I was going to get skewered. It really was hard and it took some major soul searching to create. Again, episodes 399 and 400. What I try to do, I usually shoot for trying to get patients better outcomes in a way that is cost neutral. 


The work that I do most of the time, ie, my day job, is probably not going to lower costs. It's not going to lower costs. It's just not within the parameters of what I do and it's not within the parameters of my expertise. Others, who I count on to do their thing here, they might be working the opposite angle. 


The care might be the same, but costs are reduced. Again, a fine way to go. Maybe some of you have figured out how to get patients better care at lower costs. That's the holy grail and big kudos, but not everybody can do it. It's just not possible a lot of times on any number of levels that we don't have time to get into today. 


Again, all of this is why I wrote my manifesto. For how I reconcile my own self and determine what having personal integrity means to me and for me and also for my company. And maybe over the years, I've made some choices that I wouldn't make again. But those choices ultimately have wound up funding this podcast. 


So maybe that's my redemption, potentially. I don't know. We all live and learn and we can't start to hate ourselves because we haven't been perfect. A lot of times you don't realize the ultimate impact of something until after you've done it. And at that point, you just got to regroup and try again and do better this time. 


 We all just have to contemplate patient impact. On the other hand, there are often conversations with very motivated entrepreneurs that I've had where the words affordability, impact on patient premiums, access or better actual measurable health, these words don't come up, at all. Or you talk to somebody else who works at one of these behemoth payers or hospital systems or whoever, and those words do not come up at all. 


Again, tracking back to the narcissism of small differences here, are we fighting with someone who is basically 95 percent aligned with what we're trying to do? Or is this somebody on the other side who's really not in the village because they do not have the same overall intent?  


The Role of Narcissism of Small Differences in the Healthcare Industry

[00:12:37] Stacey Richter: The point I'm making here in this inbetweenisode is simply that if we're thinking about this from the standpoint of the patient, then every one of us who isn't retired or independently wealthy or volunteering, we all have a great opportunity to do some amazing work. 


But we're also all living in glass houses, and if somebody really wants to get all small difference narcissistic about it, they probably could very self righteously take out most of us. This isn't some kind of cartoon where all the good guys all look the same and everything is black and white and there's no nuances. 


I'm belaboring these points because if we want to build a village, we cannot do so without contemplating who we choose to let in it and who we're going to beat up on on LinkedIn or wherever.  


The Importance of Accepting Imperfections

[00:13:19] Stacey Richter: But we can be a motley bunch and still work together as long as we accept each other for the imperfect souls that we are. 


And what we can in the aggregate add to the common cause, there's no one size fits all for what we want for ourselves and what we want our legacy to be. I want to just track back for one sec to that earlier comment I made about people who work for a company that's actively working to take as much money out of the system as possible and give it to their shareholders at the corporate level. 


Because here's an actual case study example of that and maybe it will be helpful. The other day I was talking to an actuary who works for a large, again, payer. And this actuary was trying to figure out ways to create win wins for plan members within the constraints of his job. This actuary, if he can figure out the math given the scale of members that he'll reach, he could have a really large positive impact, even if he only changes the trajectory of his math by, like, a fraction of a percentage point. 


I want this guy on my team and in my tribe. He is trying to help, and he has the power to incrementally fix some stuff that is gonna matter to potentially millions of people. I'm not going to kick him out of my village anyway because of who pays his paycheck. Conversely, I'm going to try to encourage him to spread his way of thinking to other actuaries that he works with. 


Or I get emails all the time, all the time, from people especially at the beginning of their careers and they're looking to find a job where they can make an impact. These are smart, ambitious, young job searchers, and I hear from them so often, I actually have a very long template response that I've been poking away at for years. 


And I always tell them some variation of many of the things that I have said on this podcast. Often enough, though, I'll get a response back that's something like, wow, thanks so much. This was also helpful. After much thought, I've decided I'll go work in private equity. I'm going to go work for private equity firms so I can fund startups who are going to make a difference for patients. 


They may go on and they mention how they were reading the Slack channel of one of these many groups where they don't talk about the stuff that we talk about on Relentless Health Value. They talk about the thrilling worlds of startups and health information technology and scaling and AI and repeatable whatever. 


However, hold your judgment. I am managing to keep mine in check. I consider that, you know, Iora Health and ChenMed really help a lot of patients. There are some great new companies out there. People also have made lots of money at some of them, nuances, choices, also who's their leadership. Now, it's inarguable that anyone that's working for a profit seeking missile of a publicly traded company or a PE funded company is going to have to contend with a moral framework that is more of a money framework than a moral framework. Same thing goes for anyone working at a huge consolidated hospital system, like the ones that get written up in the New York Times for all kinds of egregious stuff. This money focus may be irrevocably misaligned with the values of someone who works there, and the person may ultimately quit because it becomes too much cognitive dissonance. 


And if and when they quit, great, they're at a different place in their journey. Maybe they listened to Relentless Health Value long enough and began to realize some of their employer's Kool-Aid might not taste quite right. For them to get to the next stage of their journey and have the impact that they may ultimately want to have, they kind of had to start out in the belly of the beast. 


And I won't hold that against them, especially if they were able to alter the trajectory of the organization or help patients along the way while they were there. Here's another example to think about as we think about the narcissism of small differences and who gets to be in the village and who we're gonna tell to talk to the hands. 


The Impact of Narcissism of Small Differences on Patient Care

[00:16:58] Stacey Richter: I was talking to a friend of my dad's who literally was going to die from a neuroendocrine cancer. He had weeks to live, maybe not even plural. He was given a new immunologic cancer drug and it's now two years later and he's still here and in remission. According to the package insert of this drug, he'll probably have 47 months, almost four years of extra life. 


Yeah, that drug was expensive. I opened my mouth to say something and my dad's friend, he kind of shushed me. He said, do not say anything bad about the pharma company or my doctors at the big consolidated health system where I got my care. I am alive and I should be dead. This is why I started RHV, Relentless Health Value, and why I continue to do this thing. 


Conclusion: Overcoming the Narcissism of Small Differences

[00:17:42] Stacey Richter: It's because almost everything in the healthcare industry along the good for patients curve is a matter of degrees. Tip too far in one direction and we start to cost more than the value we put out in exchange. Tip too far in the other direction, we go out of business. Everything I talk about on Relentless Health Value is in the service of helping myself, you, and anybody else I can reach. 


It's in the service of us figuring out how all of these nuances work in the real world to help figure out who gets what, when, and how that might impact patients caught in the crossfire. It's to help figure out my own path forward that I can be proud of and maybe I can help others trying to do the same. 


But at the end of the day, we're all going to make slightly different choices and evaluations. Please don't let the narcissism of small differences prevent us from creating a village large enough to fix healthcare for patients. Also it's just a nicer way to exist. My name is Stacey Richter. This podcast is sponsored by Aventria Health Group. 


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