Thursday, May 28, 2009

McAllen, Texas = Boston, Massachusetts

Thoughts as I go through the night prepping for my regular colonoscopy (OK, more than you want to know!) which allows me to be up even earlier than usual and make some observations. I can't yet blame the soon-to-be administered Demerol for any incomprehensible wanderings, and I promise not to write the next post until that wears off.

Atul Gawande has yet another beautifully written article in the New Yorker about health care costs, this time focusing on a particular city in Texas that has remarkably high costs compared to the rest of the country. Of course, he need not have travelled so far. The points he raises have been published for years by our colleagues at Dartmouth, and have been discussed by Brent James and others. And the kinds of numbers he cites, although perhaps not as extreme, also typify health care costs here in Massachusetts.

Brent summarized some of these issues in a talk he gave here about a year ago:

-- Well-documented massive variation in practice based on local medical myths.
-- High rates of inappropriate care.
-- Unacceptable rates of preventable care-associated patient injury and death. (Hospitals are actually the #4 or #5 major public health problem in this regard!)
-- A striking inability to "do what we know works".
-- Huge amounts of waster and spiraling prices that limit access.

While Atul focuses on national policy in his article, let me bring the discussion back to strategic planning for hospitals in general and academic medical centers in particular. It seems to me that there are three overwhelming public policy trends in America:

1) A desire to set an annual budget per person for health care;
2) A desire to limit the growth of that annual budget to a rate equal to or less than the overall rate of inflation; and
3) A desire to reduce the amount of harm caused to patients during hospitalizations.

The successful hospitals (and their associated physicians) will be those who learn to live within these broad formulations, and the most successful with be those who wholeheartedly embrace them. Further, they will need to create integrated networks of care -- whether by ownership or strategic alliances -- with people in other parts of the health care delivery system who have similar beliefs. Finally, they will need to engage in process improvement of the type discussed by Steven Spear to squeeze waste out of the system on the "factory floor."

In Massachusetts, there is only one integrated delivery system characterized by ownership of enough entities to engage in this kind of strategic approach, but that system has not yet demonstrated an ability to deliver care at a lower cost. Indeed, just the opposite. For a place like BIDMC, we will have to rely on finding multi-specialty groups, community hospitals, and others who share our vision of success through improving the quality and efficiency of our service, delivering care in the most appropriate settings, and constantly striving to be "the best at getting better."

Many of you have watched our progress here on this blog and on our corporate website as we feel our way along this path. One of our management techniques is transparency. It is based on a philosophy that you can't get better and you can't hold yourself accountable unless you are exceptionally public about what you do wrong, as well as what you do right. As I have noted elsewhere:

Transparency's major societal and strategic imperative is to provide creative tension within hospitals so that they hold themselves accountable. This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care.

In this sense, transparency is a necessary but not sufficient element in bringing about transformational change in an organization. But the actual implementation is not easy. You've seen our stories about BIDMC SPIRIT and Lean process improvement here. We view ourselves as babes in the woods in these arenas, but we view part of our role as an academic medical center to share what we have learned with others. We will also ruthlessly borrow good ideas from others in our quest to do better for our patients but also for ourselves as an organization facing the three policy imperatives set forth above.


Telephone Triage said...

Just that you are thinking so much for other peoples good and well being is a wonderful thought.

e-Patient Dave said...

Great thoughtful discussion.

As a Minnesota native, I know the Gopher State will be alarmed to learn that Atul has moved the hayfields (including Mayo) to the north. Last I checked, the northern part of the state had iron ranges and Mayo was south of MSP. :-)

=== For those who just can't get enough colonoscopy stories, mine ("Runnymede") is here. Stunningly, I tried to lighten up the process.

Craig Melin said...

As a Massachusetts hospital CEO, and a current PhD candidate at Dartmouth, I believe your comments are on track with what policy is saying, but nonetheless I come to a different, though related, set of three guidelines that I believe are the right three for healthcare organizations to aggressively pursue(concept: what does policy say vs. what does it mean we should do?):

Increase Quality
Increase Safety
Increase Value
, all the time pulling out cost as quickly as is reasonable while protecting the three goals

The differences in frameworks are several:
1) Inclusion of Quality: I know BIDMC actually pursues this, but there is more to quality than reducing harm -- the quality changes in practice that healthcare systems, including BIDMC, are broader than reducing harm, they also seek to achieve the best outcomes
2) Use of the word value (to the patient) instead of the specifics of budget per person and rate of inflation:
a) Healthcare is already too expensive.While acknowledging that payment may move to per patient and that no one wants healthcre costs to inflate, our percentage of GNP is also too high. Focusing on value could well mean pulling cost down lower than existing rates -- unless we believe the nation really values our national care outcomes (mediocre) at the national rate (highest internationally)
b) In addition, building value ties to the patient rather than to our best guesses as to the national system's next iteration and is consistent with lean's focus on the customer -- the need to pull out non-value added steps (waste). We can all work on pulling cost out immediately without waiting for national paths to be set on payment per population.
c) finally, building value has both a numerator and a denominator. sometimes we improve value by increasing the outcomes vs pulling down the cost for a particular process -- and staff can much more easily engage personally on the mix of issues in the value equation, rather than focusing on cost alone.

Thus the prescription of increasing quality, safety and value, while pulling cost out, for our organization, and perhaps for others, is the actionable agenda. Leaving organizational goals at the level of interaction with policy(a task typically relegated to senior leaders), when we don't yet know the details of those policies, could make it hard for front line staff to improve on opportunities that already exist in our organizations. However, regardless of the way in which the policy is ultimately specified, leaders who lead their organizations to tackle quality, safety, and value will be giving guidance to all staff on what we can do to improve the care and health of our populations in a way that will fit future societal demands.

Charlie Kenney said...


Really interesting post. Your mentions of the work by Brent James and Steve Spears is great -- I suspect that at some point in the years to come when the US health care system is transformed their work will be fully recognized as an essential part of the quality movement (among many others of course).

It strikes me that your three trends suggest important movement in the direction of the Triple Aim as defined by Don Berwick and his IHI colleagues:
- Improve overall population health
- Enhance patient care experience (quality, access, reliability)
- Reduce (or at the very least) control per cap cost of care.

I suspect this is what the healthcare promised land will look like. And it feels lately as though significant momentum is building in this direction.

Gene Lindsey, MD - President and CEO, Atrius Health said...

Atrius Health, including Harvard Vanguard, believes in Peter Orszag’s concept that the path to fiscal responsibility runs through health care. Atul Gawande’s article is a great piece of narrative non-fiction that dramatically makes Orszag’s point and is yet another vote for the fact that “unsustainable” does really mean “unsustainable.” Atrius Health also embraces the Institute for Healthcare Improvement’s “triple aim” which calls for a focus on the patient’s experience of care, the population’s health and the per capita cost of health care. We also believe that if we focus on the Institute of Medicine’s 6 aspects of quality which are patient centeredness, safety, efficiency, effectiveness, equity, and timeliness of care, we will not only reduce the cost of health care, but we will also improve all aspects of quality and make it easier for our patients to be healthy. We accept the analysis that offers the road to recovery through a process of elimination of overuse, under use and misuse of medical care. Most importantly we have internalized the President’s call for responsibility and accepted it as a professional an organizational challenge. In his inaugural address the President said:

What is required of us now is a new era of responsibility -- a recognition, on the part of every American, that we have duties to ourselves, our nation and the world, duties that we do not grudgingly accept but rather seize gladly, firm in the knowledge that there is nothing so satisfying to the spirit, so defining of our character than giving our all to a difficult task. This is the price and the promise of citizenship.

Under the leadership of Paul Levy, BIDMC has also accepted the challenge of doing something real that is a step toward a true transformation of health care. In spirit and in deed, BIDMC under Paul’s leadership has also accepted the President’s challenge to act responsibly. They are giving their all to a difficult task using a blend of quality tools, LEAN process improvement techniques, and unconventional and brave tools like total transparency and a focus on a community of care. We applaud his call for the physicians in the wider community to come together, integrate their activities into effective partnerships and take on a collective responsibility to move from talking to acting together like the doctors Gawande highlights in Grand Junction to improve the health of our patients. Acting together and moving back to the values that brought us to medicine will allow us to improve the quality and cost of the care we all desire. By so doing, we would take an enormous step toward healing our economy. It is great to hope that we can both improve our economy and, for the first time, grant all of the citizens of this great country equal access to the high quality of care that we are capable of giving them.

Anonymous said...

On another note, Demerol has been removed from many hospital formularies; there are better choices for many reasons. Did you really get Demerol, or something else?
ps having had 3 of those suckers myself, I am glad for you that your prep is over. (:


Anonymous said...

Actually, it was fentanyl, this time.

Anonymous said...

Ah, good. I will get to your main point in a minute, but as an aside, here is an illustration of how rigidly enforced medical guidelines cannot be applied to all patients:
You may be aware that many outpatient centers are going to routine use of propofol for endoscopies, requiring the presence of an anesthesiologist. This drives up costs and therefore insurance companies are discussing whether to refuse to pay for use of this drug instead of the usual fentanyl.
It so happens that fentanyl makes me barf for 12 hours after my endoscopies. So, what will happen to patients like me when insurance companies decree that use of propofol will not be reimbursed, huh? Interesting to generalize this question to many other situations.
Now, I wish to address the role of physicians in the quality/value aspirations described in your post. My recent experience with an elderly relative's 3 hospitalizations in 2 hospitals within one month exposed a truly shocking level of dysfunction among the various physicians involved in his care. There appeared to be little to no communication (much less any coordination) between any of the docs, between docs and staff, and between docs OR staff with the patient or family. These are good hospitals in a large metropolitan area thought to have many good physicians.
Any attempts to improve care and decrease costs MUST have all the physicians completely on board - a known problem area. Increasingly, I believe the docs must be an integrated part of the care system - with the same consequences for poor performance as anyone else.
And no, I don't just mean an affiliated group practice - I mean either salaried, or a clinic model, or a bundled payment from Medicare, or something. Without this I fear the hospitals will be spitting in the wind. Now all my colleagues can shout me down.

nonlocal MD

Anonymous said...

You raise a key question. For academic centers, can an independent faculty practice be sufficiently aligned to achieve the overall objectives. For community hospitals, ditto, whether an affiliated group of doctors can be so aligned. I, too, welome comments on this from your colleagues.

Stephen Hsu said...

Excellent post and resulting commentary here! The title is what caught my eye as I've experienced hospital vs. payer relationships in both rural and urban environments. In neither case does the hospital significantly win out, so it's always challenging for me to put the cost-cutting edge on the hospital side versus the insurance side.

If only the managed care system had some elements of the stock market in its veins. Imagine what a great investment The Biggest Loser would be! The healthier the contestant / patient, the more money made and the more money saved. And then there'd be a bubble, and then a crash, and then a scandal...

In any case, great post.

Charlie Kenney said...

Dr. Gary Kaplan tackled the issue of physician alignment head-on when he sought to apply Toyota lean to the Virginia Mason Medical Center. He worked hard at it recognizing how absolutely essential it was to have docs fully on board. He received important help and guidance from Jack Silversin of Cambridge who helped work through a physician compact. Without that compact it seems unlikely Virginia Mason would have had anywhere near the level of success they have achieved.

PookieMD said...

As to the hospital in Texas,with the over the top costs, and "high rates of inappropriate care," I wonder, what is the malpractice rates? Over testing and over treating goes hand in hand with defensive medicine.

Anonymous said...

I don't think the Texans can blame defensive medicine. After tort law amendments in Texas, lawsuits and insurance premiums have dropped dramatically. Further, as the article points out, rates of utilization and the level of medical costs vary widely from city to city in Texas.

Anonymous said...

To Pookie MD;

I recommend taking some time to plow through the Dartmouth material yourself. I was unaware of this ongoing study until a couple years ago when I started reading health blogs. They have done a pretty careful job in controlling for all potentially confounding variables. One of the fairly inescapable conclusions is that the amount of medical care in a given area correlates pretty closely with the local supply of physicians - more docs, more care.
Scary stuff.

nonlocal MD

Anonymous said...

I come to this site after reading Dr. Lindsey's latest weekly note to Vanguard/Atrius staff. I have written to Senator Kennedy on an ongoing basis about health care cost/coverage. I am a 72 year old,still working for health care coverage. Eventually I will have to go on Medicare. Here is my issue: I want the same care and coverage as Senator Kennedy. Will this ever happen? I doubt it in my lifetime. I have read Atul's article re health care cost in Texas and I have followed Don Berwick for years. I believe that Primary Care docs should be involved in every aspect of a person's health care, I believe this Primary Care doc is the only one who can sort through all issues for the confused patient and I believe that health care should be a right and affordable (like Senator Kennedy's coverage) for all! These are my thoughts as a patient

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