Want better health care? Be pushy.

I've been a physician for 35 years. During the most recent 25, I've devoted time to practice improvement and population health initiatives. In part, this involved helping individuals to be healthier. It also involved helping the care delivery system explore how to make care more effective, more efficient and more satisfying to patients (the combination labeled "the triple aim").

I encountered the health care system three times recently in ways that made the triple aim feel more urgent.

First, the July 17 Star Tribune had an article ("Lower costs elude hospitals") about the "Pioneer" ACO program in which the federal government is providing financial incentives for health systems delivering care that meets the triple aim. "After the first year of the program, just 13 of the 32 participating health systems were able to lower health care costs," the story reported.

I'll guess that one issue among the systems that did not succeed is that they tweaked existing processes rather than make bolder moves that would actually represent innovation.

Second, a friend recently noticed a breast lump. She went to her doctor, who did an exam and arranged for a mammogram — scheduled for six days out. My friend had a lump that worried her and was told she could wait six days to have a diagnostic test. Same old system.

Someone told my friend of a clinic that had revamped how it diagnoses breast lumps. She made an appointment, had a visit, a mammogram, a biopsy and a treatment plan before she would have had the mammogram at clinic number one. Transformative.

Third, a colleague recently had a CT scan as part of his work-up for a worrisome lung nodule. On the way out of the scan center, his technician told him the doctor would get back to him in a few days with a report. Same old, same old.

There is a good chance that each patient in the above scenarios likes his or her practitioner. Patients tend to think of medical practice in terms of their relationship with a provider of care. The one-on-one time, the active listening, the deductive reasoning, the ongoing relationship so important to people with medical issues.

But every clinician works within a system. The one-to-one relationship is only one of many processes in the complicated system that is health care. Only active change shifts any part of that system. Nothing changes if everyone is sort of satisfied with how things are going. And things tend to change in the direction of the loudest voice.

If you listen, you notice that the loudest voices in health care are those of doctors, hospitals, insurers and the government. Doctors and hospitals are the primary deliverers of care while insurers and the government do most of the funding.

But it is the patient who is in direct contact with the system. My two friends are patients being offered options that are less than optimal. And patients often feel powerless in such situations. Historically, our health care delivery system is one where patients take what they're given on the assumption that everyone is doing their best. And they may well be "doing their best" — but in the context of how things have always been done.

Transformational change is hard. It requires alignment around a mission; real alignment. Everyone who touches the system must relinquish some control in the name of the greater goal. People in health care don't do well relinquishing control. But the outcomes that could be achieved by a commitment to all three components of the triple aim — commitment beyond the one-to-one relationship — are extraordinary.

Insist on taking your case to a center that has qualified practitioners who are going to organize care around your wishes rather than around "how it's always been done." Use your ability to direct your care as your way to emphasize the need for transformational change. Once you get comfortable with that, pay attention to price, to quality, to service and never accept as an explanation that "it's the best we can do."

Transform how you interact with the care system. Raise your voice!

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