For a full transcript of this episode, click here.
This inbetweenisode is me geeking out, so if that’s not your thing, you’ve been warned.
There’s a term I’d like to encourage anyone interested to look up. It’s the narcissism of small differences. It explains a lot. The narcissism of small differences is the idea that those who, maybe 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 could create such enmity? Or there’s subreddits on Reddit dedicated to people fighting about fantasy football. You would think that everyone who plays fantasy football would be friends, except … not. There are 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.
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 ‘my way’ you preclude your ability to synthesize, cooperate, support, or even—in [some] extreme cases—peacefully co-exist with other members of your tribe. You destroy a fundamental reason for belonging in the first place: community.” That last bit was a quote from a blog post by Frances Cole Jones.
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 95% aligned cause. It’s like two people agreeing on the restaurant to go to lunch, but one wants to go there and get a rice dish or because it’s closer to their house and the other wants to go there because the restaurant serves a great tortilla—and 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, 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 … I don’t know, transparency or employers or mental health or … pick something. But here’s the thing: In the village, everybody is gonna 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, 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 gonna 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 honey pot for those who have screwed up the existing system and who are merely virtue signalling …? Who is speaking at this conference? Is it representatives of the same health systems and the same payors [and perpetuating] legacy moats and monopolies or is it a conference promoting change makers, risk takers and provider models and systems embracing risk and [healthcare] transformation?
… What kind of change and innovation ever came out of an echo chamber?
Challenging my friends and healthcare 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 (pharmacy benefit manager) stood up in front of that room and used the word transparency or a synonym six times in five minutes. Check out this LinkedIn post/video and this article 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. This is why I wrote a manifesto (EP399 and EP400). And you might struggle, too. It’s probably no coincidence that sometimes the loudest individuals advocating for patients over profits are retired. And, throwing 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 gonna 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 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, EP399 or EP400)—I worked really hard, by the way. I was sweating bullets when I was creating that manifesto. I was not sure whether I was gonna get skewered. It really was hard, and it took some major soul searching to create (again, EP399 and EP400). 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 gonna lower costs. It’s not gonna 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 gotta 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% 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 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 gonna beat up on LinkedIn or wherever. 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 wanna 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 worked 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 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 gonna kick him out of my village anyway because of who pays his paycheck. Conversely, I’m gonna try to encourage him to spread his way of thinking to the 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 all so helpful. After much thought, I’ve decided I’ll go work in private equity (PE). I’m gonna go work for a private equity firm so I can fund start-ups who are gonna 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 world of start-ups and health information technology and scaling and AI and repeatable whatever. Hold your judgment. I am managing to keep mine in check. I consider that Iora Health (now One Medical) 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 kinda 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 hand. 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 kinda 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 Relentless Health Value and why I continue to do this thing. 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 and 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 gonna 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.
Also mentioned in this episode are Frances Cole Jones; Jeffrey Hogan; Eric Bricker, MD; Iora Health; and ChenMed.
For more information, go to aventriahealth.com.
In addition to hosting Relentless Health Value, Stacey is co-president of QC-Health, a benefit corporation finding cost-effective ways to improve the health of Americans. She is also co-president of Aventria Health Group, a consultancy working with clients who endeavor to form collaborations with payers, providers, Pharma, employer organizations, or patient advocacy groups.
00:42 What “the narcissism of small differences” means.
02:18 How does this narcissism of small differences show up in the effort to fix the healthcare industry?
10:12 “What did the work we do add up to?”
16:31 Why we shouldn’t judge someone for working within the “belly of the beast.”
For more information, go to aventriahealth.com.
Stacey Richter discusses small differences and #healthcaresystem fixes on our #healthcarepodcast. #healthcare #podcast #pharma #healthcareleadership #healthcaretransformation #healthcareinnovation
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