Wednesday, February 04, 2009

When you have a hammer . . .

MIT's Steve Spear makes the point again. "We can provide much better care to many more people than we currently do at less cost and with less strain on providers." How? By engaging in a real effort to reduce harm to patients by redesigning the work flow and patterns in America's hospitals.

Why do so many observers insist, in contrast, that changes in the reimbursement system or other structural changes in the health care industry are the answer? Well, if you are an insurance company or public agency payor and have the "hammer" of insurance rate design, every problem looks like a "nail." You seek to influence behavior with the tool at hand.

If you are an employer and have the "hammer" of plan redesign, every problem looks like your kind of "nail"-- raising co-pays and reducing benefits.

Meanwhile, if you are a union, your solution is to lobby the government for an increase in costs. When you have the "hammer'" of thousands of members, you use your accumulated union dues to engage in a public relations campaign and the implied power of that constituency to pound the legislative "nail."

Doctors, nurses, and hospital administrators know that these methods are crude and poorly constructed to solve underlying problems. For the most part, they mainly shift risk and costs.

Yet, who can blame the others for their attempts to use the tools they have, when the health care professions have abdicated their role in solving the cost problem? The solution, as Spear notes, is literally in the hands of the very people who deliver care.


Anonymous said...

As a physician I agree with your last paragraph. So how do we change that? Some of the reasons are complex. For example some say we order too many CTs in the ER. However the reasons are complex but rational from the viewpoint of the ER doc. On the otherhand, we are too quick to use the latest, expensive drug when it is nothing more than an old, generic drug repackaged.

Anonymous said...

All the parties - stakeholders - you mention are at least one step removed from the most important stakeholder: the patient. Cost control, labor practices, health care practice each involve interests that are not completely aligned with that of the patient. Often they conflict. When do you hear any of these parties arguing that their interests increase their own accountability to quality of care rather than cost? They don't make a claim that they don't have interest in pursuing. Real change in care, and in costs, includes fundamental redesign of systems around the patient. Spears makes this point in Chasing the Rabbit, and patient-advocacy groups, who do not have the power of insurers, government, unions or medical associations, have been clamoring up this steep hill for years.

When care is evaluated by quality - when outcomes are measured and compared across increasing numbers of procedures - we can quit this game of deferring the problem to others. Redesign must first assume the view of the patient, not the provider or insurer.

Anonymous said...

Great post. Physicians receive 21% of healthcare spending, but control a total of ~70+%. There is a chart on this, and more info at

Your point about perceptual hammers and nails is directly on point too. (Yes, pun intended.) There have been several solutions proposed for this medical myopia, including bundling of payments, capitation and medical homes. The last of these is getting increased attention in the policy world, and is being pushed in the real world through some state initiatives. Medical homes may be a way for primary care physicians to retain/recapture some clinical autonomy, while also creating a delivery system structure that is accountable for both clinical and economic outcomes. (See my connection from medical hammers to homes at

Paul - Keep up the perceptive blogging?

Anonymous said...

While changes to way we manage patient care are improtant, the quickest way to reduce health care cost in the US is to junk the ridiculous reimbursement and regulatory system we have.

No other country imposes the degree of documentation we do. Most of the documentation is required to meet either a billing or regulatory requirement that has nothing to do with caring for the patient.

Any health professional will agree that 30% of caregivers' time is spent documenting things that have no relevance to further care, only to billing or regulatory reproting. Our industry employs millions of people in hospitals, physician offices, government and insurers who only get bills out or process bills. Imagine a medical records department that only has to store the record, and not abstract it for billing, regulatory reporting or legal defense. Imagine a patient accounting staff that only has to send out a common bill for service (or none at all), rather than to predertify, recertify, rebill, fight denials, chase self payers, bill multiple carriers, and avoid fraud prosecution for simple mistakes. Imagine.

President Obama, you could do this and cut our costs immediately so that at least we'd be comparable on a cost basis to the other advanced economies.

Anonymous said...

I'm one of the patient stakeholders. The greatest fear that I have is that "health care reform" will condemn many of us to second or third rate health care.

I had elevated PSA (tested only because I pushed the issue with my primary); biopsy only after I pressed for it; found CA on second biopsy (I had to press for the followup about 1.5 years after the first).

My now former urologist notified me of positive biopsy by phone (not face-to-face discussion), told me to pick up a pkg of literature (a paperback book on advanced prostate CA) from his office person, and set up an appointment with someone who was doing a study on seed implants in a nearby town.

I got a copy of the pathology report and sent it to an oncologist (a relative) who told me that the pathology indicated high risk of recurrence with radiation and that I should have a prostatectomy, which I had to arrange on my own with the urology department at a major hospital.

PSA is now undetectable <0.01 six years later, with no thanks to the guy who wanted me as a research specimen without regard to my best interests.

What would have happened to someone without the knowledge and contacts to get what was the best available care? How will health care reform ensure that all patients, from medicare to congressmen, get access to the level of care that is in their best interest?

Anonymous said...

Of course it is good to reengineer work flow and patterns in hospital care. But, hospital care itself is in many ways determined by careful and effective prehospital care for those who have access to primary and specialty care. Go for the low hanging fruit.

Bernard said...

From a hospital point of view, this is one way of reducing costs. For a patient like me, with two chronic illnesses, a far better way to control costs is to cover preventative measures at least as well as outcomes are covered. Allowing me to control my blood sugars effectively (test strips, CGM, and insulin pump) is about $8,000 per year. If I can't do this, then the cost of kidney dialysis (one of many possible outcomes) is $25,000 per year. Where's the sense in covering that outcome but not helping me to avoid it?