Friday, September 23, 2011

Margaret answers Howard

One of my regular readers threw down the gauntlet after a recent post:

Hi Paul.  You are very discerning about the problems we face. This last blog of yours is a criticism of what the President has said.  You have also, rightly in my view, urged caution regarding global payments.

What I would appreciate from you is your suggestions for dealing with the rising costs of health care.

First, we have to acknowledge that a large portion of the rise in health care spending in the developing countries is caused by demographic trends.  The elderly are living longer and the baby boomers are reaching the age that requires tertiary care. Both groups, too, are incredibly entitled and want interventions that in previous eras would have been unavailable; e.g., knee and hip replacements.  Looking ahead to the next generation, we see an epidemic of obesity accompanied by its friend diabetes, with high cost sequelae like kidney disease, heart disease, vascular disease, and eye deterioration.

Second, we have created a medical arms race that feeds on and into these trends.  Whether robotic surgery, proton beam emitters, or smaller devices, manufacturers and investment bankers have learned how to create markets for such inventions that take hold well in advance of evidence of clinical efficacy or cost-effectiveness.  Ditto for direct-to-consumer approaches to pharmaceuticals.

Third, we have a regulatory and accreditation system in place for hospitals that focuses on bureaucratic and often picayune "conditions for participation" or "requirements for improvement" that do not address systemic flaws in the way work is done in hospitals.

Fourth, there is virtually nothing in the medical education process that teaches young physicians and nurses about the science of process improvement.  Likewise, the educational process virtually ignores the potential value that patients and families have in creating clinical partnerships that result in less harm and greater efficacy.

Fifth, there is an appalling lack of transparency in our health care system with regard to clinical outcomes.  Such data as are published are stale.  Ditto for cost and price data that might influence both providers and consumers in their choice of diagnostic tools, therapies, and location of care.

Finally, health care is such a large part of our economy that political approaches to these problems inevitably hit the wall of special interests who stand to lose by changes.  The expression, "one person's costs is another person's income," provides a shorthand for the cause of political and administrative gridlock on these items.

One could easily conclude from this list that all is hopeless, that the only way to bend the cost curve is to impose administrative fiats that curtail the amount of money available to the providers in the health care system.  Indeed, commenters on this blog have made such a point.  Sure, it might cause some hardship and rationing, they argue, but at least we will start reducing the rate of increase.

This is the same argument used by tax limitation advocates in the past:  Starve the beast, and the bureaucrats and politicians will finally be held in check.  By definition, this is true, but it can have major unintended consequences.  Proposition 13 in California and Proposition 2-1/2 in Massachusetts both succeeded in limiting taxes in their respective states, but both began a long downward cycle in the quality of public education and other governmental services.

So, Howard, where do we go from here?  First, let's acknowledge that the solution is a long-tailed one.  It will not take place during the period viewed as important by politicians, i.e., the next election cycle.  Neither will it be resolved during the period viewed as important by businesses, i.e., the next financial report.  It will take years, maybe decades.

In Jönköping County in Sweden, arguably the world's exemplar in such matters, the learning process took decades -- and with a political and social environment much less combative than ours.

In my former hospital, where we had an explicit strategy to be a low cost, high-quality, patient-centered environment, the cultural transformation involved took at least five years.  Even then, we felt we were just getting starting in reaching aggressive clinical goals and eliminating waste in our processes.  I am sure that other industry leaders, like those at Virgina Mason, Gunderson Lutheran, and Ascension, would say the same.

But, every journey must start with single steps, and we need to get to work.  Each of the causes outlined above suggests its own remedy.  The variety of causes also suggests that a single, global solution is unlikely to work.  Anyone who says, "All we need is x (e.g., where x is global payments) is barking up the wrong tree.  Incremental change along each front is called for, along with mid-course corrections when that change has unintended consequences. 

All this only happens with a demonstration of clinical and administrative leadership from those in the field, and from the Boards of Trustees who oversee our institutions.  Too many hospital CEOs, chiefs, and board members think they have "arrived" when they reach their high posts -- and then coast thereafter enjoying the salaries and/or prestige of their positions.  Instead, they have to understand that they are facing the challenge of their lives -- fixing an unsustainable health care delivery system -- and progress will only occur when they move past their comfort range and have the intellectual modesty to learn from their patients and from those in other fields that have been through structural change.

In this blog, I have offered success stories in many of the problem areas mentioned above.  I have also offered detailed policy prescriptions where government intervention could directionally make a difference.  As in all other aspects of American life, though, broad and sustained progress will only occur when committed people let their views be known.  It would help if a "barely restrained mob" of patient advocates could find its way to focus on key variables and demand accountability locally and nationally.  But short of that mob, every citizen has right to let his or her voice be heard in their community.  There is no magic bullet that can take the place of that.  As Margaret Mead said,

“Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it's the only thing that ever has.”


Keith said...

So how would you get those entrenched CEO's and their cozy boards to adopt a program of quality improvement and cost containment? It seems the whole process is geared toward increased profitability and expansion of ones empire as the measure of success, thus resulting in situations such as you have in your state of a dominant health care system using its market power to command high prices and use this additonal capital to expand its reach and market share.

So how do we get rid of leadership that seems bent on what I see as wasteful spending for their own profit andd agrandisment?

Anonymous said...

The system is perfectly designed to produce such leaders. And there is little stomach for knocking leaders off balance from the top (e.g. regulation, re-engineering payoffs). Given that the leaders described above are unlikely to experience a religious awakening and volunteer transparency, transparency must come to them. Innumerable patients and family members experience adverse events. Some fraction write long patient complaint letters, a much smaller fraction notify regulating authorities. In any case, they are - and will remain - one off solutions until they become (1) public and (2) aggregated. Where are the 'Patients Like Me' sites where in every community patients and family members bring to light the events that happened to them? No need to name names. Sufficient description (i.e. transparency) would require a more sufficient response!

Anonymous said...

I think your point that the roots of the problem are multifactorial and therefore there will never be one 'magic bullet' is the take-home lesson.
Your post reminds me of the story of the "war on cancer" as described in Mukherjee's magnificent book "The Emperor of all Maladies". Naively, we used to think cancer was one disease with one cure - but we had insufficient knowledge. The book points out that a study in 1986 concluded "the war on cancer had not only failed to show overall progress, but deaths from cancer had actually increased by 8.7%".
" as...our understanding of cancer accumulates depth and complexity, the notion of a war becomes ever more threadbare. Its combatants had been configuring the enemy they needed to fight the war they wanted......."

I fear that the enemy called 'health care costs' is also being configured to fight the war that is wanted, by the various combatants with different agendas. But worse, the consequence is that there seems to be little of the well-intended energy and urgency that was brought to bear in the war on cancer. Apathy may be the cruelest enemy of all, which makes Margaret Mead's quotation all the more appealing.

nonlocal MD