Choose a path.....if you dare.

Every time that we are faced with budgetary reductions, the entire organization buzzes with frustration and angst. No one ever likes this part of the life-cycle of governmental service organizations. We all spend many months in a very unhappy "place." Having been a visitor to this "place" many times before, I totally understand the anger and frustration that I sense in the organization now.

The facts before us are brutal, and very sad to say the least. To reiterate:

1. For the current fiscal year (2008-09), the Contra Costa County budget is very much in the red--revenues from property taxes, state programs, and sales tax are way down because of the national recession.

2. Demand for services is way up--also because of the recession and job loss.

3. And, even if #1 and #2 could be changed with the "wave of a wand," Contra Costa still has a built in ongoing financial deficit because the employee costs will escalate geometrically over the next 10 years.

So, what are the options? Frankly, nothing in the short run that anyone would like to see. Very stark paths are in front of us indeed. Unless new money arrives unexpectedly (which it won't), there are only three options for CCRMC:

1. Reduce access to health care services,
2. Reduce the level of services offered,
3. Or reduce the cost per unit of service provided (fundamentally change the way that we provide service in order to be more efficient and effective).

All of these options are easy to say, but very difficult to do. And, we will probably need to exercise all of these options in many different ways as we move on. A daunting task set with very important questions presented constantly before us.

Are any, or all, of these options consistent with our mission as a county health care system?

How should access to services be limited, if it is to be limited? Who should get less? How do we make the choice? Who makes the choice? How do we implement the choice? At what point does reduction of access mean that there is no longer a good reason for the system to exist?

If the level of services are to be reduced, which services? Can patients get these services elsewhere? What are the critical services that must be preserved? What is safe? What about new standards in health care? When is the service no longer "worth" the effort?

It sounds more attractive to lower the cost per unit of service and to keep all of the access and the services the same. However, can that approach address the magnitude of the deficit? Short term "efficiency" changes usually can only save, at the most, 5 to 10%. More fundamental, and more important system change, can save much more--but usually takes a number of years to accomplish effectively. And, in the current public health system, there are very few resources available to support fundamental system redesign. How do we move ahead with redesign efforts when we anticipate ever fewer supportive resources?

In the end, the choices are all seem like Hobson's choices--options that are not really options at all! Nothing that we really "want" to do. "Forks in the road" that are not what we expected or wanted.

However, no matter what, we move on--not necessarily forward, but onward. Whether or not a conscious and thoughtful choice is made, time makes choices for us. No matter what choice is made, there will be new challenges and new pressures in the future. And, despite our desire to find an outside "savior," there will be none.

Gautama Siddharta, the founder of Buddhism many years ago, framed the reality well with simplicity and strength, "No one saves us but ourselves. No one can and no one may. We ourselves must walk the path." We take that path that seems the best to us, we learn from the mistakes that are inevitably made, and we hope that we can face the next challenge with more skill and more wisdom.

There are many things about the future of health care that will not be "pretty," however, despite the Hobson's choices, we can make progress. For, as Thoreau pointed out, " The constant abrasion and decay of our lives makes the soil of our future growth."

We choose a path in uncertainty, confident that it will make sense in the end and that we will grow enough to make the next decision more wisely.