I am thinking about creating a fantasy-consulting league modeled on the fantasy football league. My sense is that the players will be somewhat more nebbish, and the tattoo factor may be less than that in the football league.

Health systems are approaching the eleventh hour with regard to reinventing how they do business. The bad news about the eleventh hour is that nobody will ever warn you when the time is quarter to—you only know the time when it is five after.

If a health system tried to trace the results of its failure to recast patient access to a seminal point the failure would point to their failure to engage, to interact the way people choose to interact with all of their institutions.

Patients leave their health system. They leave it before they are admitted, and they leave it after they are discharged. And people leave it because after trying to accomplish something on the phone with the health system they feel that their time would have been spent better teaching a hamster to tango. And the health system is left with a permanent look of surprise and irony.

One of the curious things about how healthcare is managed is its ability to count and account for things. Supply chain management. The number of bedpans. The number of patients. The number of wilted hibiscus plants by the elevators.

There is also a category of uncountable things, things like leaked patients. Nobody knows when he or she leaked or why they leaked or how many leaked.

For the most part, health systems do not engage people, even though engagement is a priority. They do not have plans to interact. That is because health systems react. Answering the phone is not interacting. It is Pavlovian—stimulus, response. Phone rings, phone is answered; at least some of the time.

This lack of an engagement strategy makes revenue growth for many, many health systems a zero-sum game. One of the teams, Team 1, playing the game is comprised of people from the health system’s marketing and business development departments. They have a budget and tools. In simple terms, their job is to fill the revenue funnel. Get patients. Get new patients; ‘Like us”, ‘Follow us’, ‘Call us’. Millions of dollars are spent trying to get people to buy their healthcare from a given health system.

The membership of the other team, Team 2, playing the zero-sum game is ill defined. Its members include people at the health system’s call center—a euphemism for what is really just a scheduling center. Its members also include people in billing, authorizations, referrals, registration, admissions, and so forth and so on.

The game works like this. Team 1, Marketing, gets a point each time it convinces a potential patient to consider buying healthcare from their health system. Team 2 causes a point to be subtracted every time they fail to engage the potential patient. Team 2 earns bonus points for patient leakage—leaked patients are those who leave the hospital and disappear into a black hole.

In many health systems, patient acquisition, patient retention, patient referrals, and revenue growth are not zero-sum games. They are negative-sum games, games in which both sides lose. Patient revenues are falling, costs are rising, and reimbursements are falling.

The October 2014 issue of Health Leaders Media included an article, “What’s Your Growth Prescription?” The article included a chart showing survey answers to the question, “How will your organization fuel financial growth over the next five years?” The responses, listed in declining order are:

• Expand outpatient services
• Strategic marketing campaign for the existing market—59% plan to do this
• Strategic marketing campaign for new market—41% plan to do this
• Develop or join an ACO
• Acquire or merge with hospitals
• Develop or partner with a convenient care facility
• Acquire or develop a health plan
• Increase inpatient bed capacity

While those may be interesting ideas, none of them does away with the fact that the health system will continue to play the same zero-sum game. Increasing bed capacity without retaining patients will lead to empty beds. Having a strategic marketing campaign will be no more effective than having a non-strategic marketing campaign if the health system cannot engage with the people who respond to the campaign. Acquiring a hospital or a convenient care facility or an ACO or a health plan, without recasting access and engagement will likely pair one zero-sum organization with another zero-sum organization, thereby reinforcing a negative-sum outcome.

Sometimes I am a bit of a pedant when I feel the need to make a substantive argument, and I am afraid that this was one of those times. All of the growth options listed above will require a significant capital investment, and they will take years to become operational.

However, initiatives to improve patient engagement and patient access are measurable, and they can deliver significant short-term results, without a gross outlay of capital. If anyone asked, my plan to grow revenues would focus on recasting access and engagement. And its three tenants would focus on increasing retention and referrals, and a significant reduction in leakage.

I read recently that Vision without execution is hallucination.