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Thursday
Sep122013

Rational Response #3: Prioritize

The idea of prioritizing is predicated on completion of an inventory (see Rational Response #2). We first need some basic understandings of the infrastructure systems we have committed to maintain:

  • How much do we have?
  • What are the maintenance costs?
  • When do those costs come due?
  • What is the revenue stream to cover those costs?

Once a community has completed an inventory, one thing will be abundantly clear: there is not anywhere near the revenue that will be needed to cover all the commitments the local government has made.

This then brings us to Rational Response #3: Prioritize. I used to talk about this in terms of "triage" but that really doesn't capture this interim step, which is really more of a conversation about core values. If we've promised to spend $1 and we only have 20 cents coming in then we -- the entire community -- have some tough decisions to make.

The inventory will help that conversation get serious because math doesn't lie. Ultimately, the dialog needs to evolve to a ranking system, one that reflects the priorities of the community. Maybe your city will decide that all of the streets that elected officials and their friends live on are the highest priority (essentially, the current system) or maybe your community will come up with a more nuanced and dispassionate approach. Either way, the conversation needs to be broad and deep and the results apparent to everyone.

I'm personally inspired by the rational approach used in the 1990's in Oregon to address a similar problem in health care; not enough money for too many needs. Here's what was done to establish a priority list.

The commission established 17 categories of health problems — for example, acute conditions that can be fatal and for which treatment provides full recovery, acute conditions that are treatable and unlikely to be fatal, chronic conditions that are unlikely to be fatal, maternity and newborn services, and preventive care of proven efficacy.

All diagnoses and their treatments in the medical and surgical armamentarium were assigned to one of these categories, and the categories were ranked according to 13 criteria, including life expectancy, quality of life, the cost effectiveness of a treatment, and whether it would benefit many people.

Treatments that prevent death and lead to full recovery were ranked first, maternity care was ranked second, and treatments that prevent death without full recovery were ranked third. Treatments that result in minimal or no improvement in the quality of life were ranked last.

The diagnosis and treatment items were then prioritized within the categories on the basis of outcomes data, a scale for the quality of well-being, and a consideration of the reasonableness of the rankings.

The interesting thing is that the results of the list were very logical (that didn't make them non-controversial). Vaccines and basic pre-natal care -- very low cost treatments that have significant impact in reducing mortality (and other health care expenses) -- shot to the top of the list. The second bone marrow transplant for the septuagenarian with terminal cancer did not rank as high. These are brutally tough choices, but they need to be made deliberately and publicly.

For me, the infrastructure equivalent of vaccines and pre-natal care would be the parts of the system that are revenue positive. We vaccinate people for pennies and we end up not having to pay later to treat them for a terrible virus. Easy money. If we have a block that is going to cost us $100,000 to maintain over the next two decades but will yield us $500,000 over that same period of time, that's a no brainer. Our inventory will help us identify those.

Conversely, the equivalent of the second bone marrow transplant for the elderly individual with terminal cancer would be those parts that are massively cash flow negative and have zero chance of turning that around. This would be the mile long paved road on the edge of town that serves the mayor's house. The city's never going to collect enough money to make that obligation pay.

These would be the two ends of the list -- everything else would sit in between on the spectrum -- but note that creating a priority list does not mean we're going to take the next step and defund certain parts of the system. That's a whole other conversation. What we're talking about here is just getting a prioritized list assembled based on shared values. When you're done, it will look something like this:

1. Main Street, 1st Ave to 4th Ave

2. Oak Street, 2nd Ave to 6th Ave

...

295. Smokey Hollow Road, County Rd 5 to cul-de-sac

In the next rational response, we'll talk about what to do with this list once it's been created. 

As a final note, and just to head off the classic, knee jerk response, understand one thing...let's not pretend that what we're doing with the status quo is either fair nor equitable. It is clearly not. And let's not also pretend that some state or national standard would make it so. The best shot at a fair and equitable approach we have -- and it's a goal worth pursuing, one I believe in -- is to have these decisions made at a level of community where people know their neighbor and have to look each other in the eye.

It will be messy, no doubt, but any community will be better off owning messy than inheriting stupid.

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