A Task to Complete David Durenberger, J.D. April 15, 2004 The small plaque that hung by my desk all those years in the U.S. Senate said this: “It is the sign of God that you will be led where you do not plan to go.” It is a paraphrase of what Jesus said to St. Peter, but I always thought it applied to me as well. I was born and raised in the shadow of St. John’s Abbey, the son of a little All-American football player who served as athletic director at St. John’s for 42 years – a Johnnie through and through. Yet here I am now, ensconced in the heart of Tommie-land as the senior health policy fellow in the College of Business.After three terms in the U.S. Senate, I left Washington, D.C., in January 1995 right after the failure of President Clinton’s “managed competition” health reform. From 1979 through 1994, I served on the Finance Committee, where I was responsible for national health financing policy. I also served on the two other major health committees: Health, Education, Labor and Pensions Committee and the Environment Committee. Working with a lot of good people and implementing a lot of good ideas – most of which were not my own – I felt I had accomplished a lot. Yet, my work in health policy seemed unfinished.People ask me, “Of all the places you could have gone, senator, why did you choose St. Thomas?”I tell them, “I have a task to complete, and this is a good place to try to complete it.”I have always benefited from the fact that Minnesota has the best minds in health care and the best spirit of cooperation. Minnesota health leaders have always been on the forefront of change and improvement of the health care system. I wanted to come back home and see if Minnesota might be a better laboratory for health policy change. Whitney MacMillan, retired CEO of Cargill, and his wife, Betty, generously made a commitment to provide an endowment to whichever Minnesota university I determined was the best place for me to continue my health policy work.I chose the University of St. Thomas for several reasons. A major impetus was Father Dennis Dease and his values-based community driven leadership. The quality of the College of Business and its focus on leadership development, particularly in the health care field, was another incentive to bring my health policy work here. Finally, the university provided a neutral forum; St. Thomas doesn’t have a medical school and doesn’t conduct health professions training so I don’t have to worry about protecting any interests as I ask the difficult questions about health care.My work in health policy began in this community 12 years before my election to the U.S. Senate. From 1967 to 1970, I served as Governor Harold LeVander’s chief of staff during dramatic years of policy innovation. There I learned the value of the Citizens League of Minneapolis-St. Paul, and I subsequently chaired its Public Service Options project on employee health plan choice through employer options (the beginnings of the Business Health Care Action Group).During my years of work in health policy, I have learned some important lessons. Our health care problems are system failure problems, not simply financing issues. We can’t solve complex problems such as health care system change at the national level. Like the blind men and the elephant, what you see depends on where you stand. At a time when Republican and Democratic stances are so polarized, consensus is difficult.We can’t fix health care policy through government commissions, in an ivory tower, from the top down, or from outside the professional-patient relationship. We need to address our health care challenges in a way that contributes to the solution: We need to engage the stakeholders in defining the problem and in offering answers. This was the way we solved most of our problems before we became enamored with big government, big interest groups, big experts and big media.Communities or culturally similar regions like the Upper Midwest are the best places to see the future of health care. All health care is local; change is going to begin locally. I call this “inside-out reform.” Inside-out reform will come from example. If we could all agree today what an ideal system is, you’d be surprised to find how many health care professionals and organizations are already halfway there. Yet we can’t agree on what to be because we’re too busy “competing” in today’s dysfunctional marketplace.To make our health care system work, we need to focus on realigning the incentives, on transparency and on accountability. National financing policy change will only happen as communities like ours demonstrate what we should be paying for. And at the heart of any health care reform effort must be change in the professional-patient relationship. Some of the best ideas about reform come from health care professionals and system executives. Health care professionals live in a highly competitive environment because the value of professionals’ contributions to health maintenance or improvement is not rewarded. If inside-out change is to occur, the community must provide an environment that can support those professionals who wish to lead change.One way to do this is through education. Since 1995, through the St. Thomas Center for Health and Medical Affairs (CHMA), I have taught health policy to health professionals. Each year we take a group of students from the MBA in Medical Group Management program, some University of Minnesota graduate students, and health care professionals to Washington, D.C. for a seminar with policymakers. It’s been a fabulous experience every single year and it helps make our MBA in Medical Group Management program the sixth best in the nation. But more was needed.In 1997, with Father Dease and Dr. Frank Cerra, from the University of Minnesota, and with financial support from the Medtronic Foundation, I initiated a program called the National Institute of Health Policy (NIHP). NIHP members are health care, health plan and employer organizations from Minnesota, eastern South Dakota, North Dakota, and western Wisconsin whose goal is to change the health care system from the inside out and thereby to influence national health policy change. The NIHP serves as a critical connection between policy and practice.In our NIHP work, we employ appreciative inquiry to identify what is already working in the system, to envision what could work, and to build from our strengths. We use a method called “community dialogue” to help people find common ground; we bring together leadership from all health care stakeholders in a neutral forum to discuss concerns and we draw upon health services research to frame the issues and to create an environment to enhance meaningful dialogue. Since its inception, the NIHP has provided leadership in health care costs, health workforce policy, and third-party payment for quality. Currently, we are engaged in efforts to see value in real consumer-driven health care and in quality, safety and efficiency of our health care system.Because good national policy must reflect the potential of better local practice, I am also serving as a member of three national policy groups: the Medicare Payment Advisory Commission (MedPAC); the Kaiser Commission on Medicaid and the Uninsured; and the National Commission on Quality Assurance. I also am President of the Medical Technology Leadership Forum.Our health care system is extremely complex and political, and change is difficult. We can’t expect it to change quickly or easily. Every stakeholder has a strong incentive to keep things the way they are. But, coupled with optimism, hope and hard work, we in the Upper Midwest have the talent, expertise and community leadership to show the nation how to transform our health care system.Recently, I had an opportunity to experience the possibility of health care change in the Upper Midwest. Last fall Minnesota Gov. Tim Pawlenty asked me to chair the Minnesota Citizens Forum on Health Care Costs. The goal of the first phase of this effort was to re-envision what Minnesotans want health care to be. Our 18-member panel worked for four months to develop recommendations for change. In early February, Gov. Pawlenty announced his support for the Citizen Forum’s key recommendations for optimal health system performance. He promised to provide the leadership it will take to get it done. Maybe the finish line is finally in sight.Winston Churchill once said that we Americans always do what’s right, after we try everything else. It’s time to do what’s right. And that is why after 35 years – thanks to the University of St. Thomas and more than 30 other financial supporters – I am still trying to do what is right in health care policy.About the author: Senator Durenberger served in the U.S. Senate from 1978-1995. He is the senior health policy fellow and chair of the National Institute of Health Policy at the University of St. Thomas.