Sunday, June 14, 2009

Who's going to do this work?

I've been thinking a lot about Clayton Christensen's comment that the traditional general hospital is not a viable business model, and especially so for general hospitals that are also academic medical centers. I'll have more on the business implications of that conclusion in a future posting, but I want to take a moment to explore one ramification. It occurred to me during a panel discussion with Harvard Pilgrim's Charlie Baker and health care consultant Jeff Krasner (seen here) at the Convergence Forum a few days ago.

People often comment on the fact that a lot of discoveries made in academic medical centers result in new diagnoses, therapies, and devices that add to the cost of health care. And that is true. Our society does not generally conduct a cost-effectiveness analysis on new developments in the field, focusing mainly on medical efficacy and, indeed, business viability. But it is also true that academic medical centers are the place where the creativity of physician-scientists goes to work every day to develop ideas that can really make a difference.

Our Chief of Radiology, Jonny Kruskal, recently told me about a recent example. One of our young radiologists, Ivan Pedrosa, had a hunch about how to deal with the tricky diagnostic problem of pregnant women with pains in the lower right abdomen, which might or might not be appendicitis. Ultrasound does not give a reliable answer, and CT scans are problematic because of radiation. Ivan believed that use of MRI might produce more reliable answers than the former and with less chance of harmful side effects than the latter. Following some experimentation, he and his colleagues were able to prove the hypothesis and publish their results. The study has now been widely circulated (for example, here), and this approach is now expanding as the new standard of care.

Please accept my non-doctor apologies if I don't have the story and the science exactly right, but I think the point is clear. There is a societal advantage to have academic medical centers like BIDMC, as places where many medical advances occur -- often unreimbursed by insurers and the government. That contributes to the lack of viability of our business model, along with the many other factors mentioned by Clayton, but it makes more urgent the question that derives from Clayton's analysis. How do such centers survive and thrive in the environment of disruption he has so ably described?

9 comments:

Anonymous said...

When medical schools invest in training physicians in quality improvement they can make the case for the benefits of enhanced science. Until then, medical schools will produce artisans that may or may not be good for business. As it stands, BIDMC goes the extra (unreimbursed) mile to train residents in improvement science, resulting in better patient outcomes at a cost savings. When will med schools catch up?

Anonymous said...

Mr. Levy, you are right to highlight the need for comprehensive analyses of cost-effectiveness in healthcare policy.

Your reference to a new radiology technique is on point. The notion that innovation adds only unwelcome costs to healthcare is short-sighted.

Not long ago, exploratory surgery was the best option for many patients with hard to diagnose symptoms. Today, however, with the advent of innovative new MRI, CT, and ultrasound techniques, you hardly ever hear about exploratory surgery.

Certainly, new radiological imaging techniques like Dr. Pedrosa's MRI diagnosis of abdominal pain for pregnant women is a much better healthcare outcome than no innovation at all. This method must pose much less risk to mother and child than exploratory surgery and certainly at a fraction of the cost.

Without investment in research like Dr. Pedrosa's, wouldn't we still be doing exploratory surgery-- with all the attendant risks of infection, costs, and other liabilities?

I encourage those leaders shaping the discussion on healthcare reform to consider a cost-effectiveness analysis that recognizes the long-term return on our investment in basic research like Dr. Pedrosa’s.

I think there are ways for us to sustain this investment in research with viable business models for academic medical centers and it is essential that we do so.

Anonymous said...

Christensen also seems to advocate that certain major centers set up solutions shops within their larger frameworks, like your own CVI or Transplant Institute. The problem in Boston is that there are a plethora of centers who seek to do the same thing, creating regional redundancy. Perhaps, however, there will be natural strengths that will flow to a particular institution based on strategic research and clinical investments allowing that center to truly distinguish itself in carefully chosen and nurtured clinical areas.

However, Christensen is likely correct in stating that fewer and fewer centers will be able to "be all things for all people"

76 Degrees in San Diego said...

Why not train the medical students you have in your hospital?

Paul Levy said...

That is not a cost-free activity. It is one of the things that adversely affects our financial results. I'm not sure of your point exactly.

76 Degrees in San Diego said...

See first comment in the list. Trying to change a medical school curriculum is like "moving a graveyard". But, if each hospital location for 3rd and 4th year students could be inclusive of the students in their established quality processes, it would create a "good wave" extending into the future. Is not "quality improvement" part of "medical education"? Someone has to take the first step. Why not lead?

Paul Levy said...

I totally agree, but I have no influence over the curriculum of Harvard Medical School.

76 Degrees in San Diego said...

You are influential. Good ideas are influential. I would just "pass it on"...

Paul Levy said...

Have tried . . .