Monday, February 07, 2011

Teach the doctors, please!

If you read the Boston newspapers, you would think that the most important thing going on in health care is a proposal to move from one kind of insurance payment scheme to another. Reporters seem willing to accept relatively unsupported and undocumented assertions that global payments are working. You have to be persistent to find these sentences in this story:

But other doctors and health care executives cautioned against drawing definitive conclusions from the insurer’s early results. They have not been independently reviewed and may not be easily reproduced statewide.

If it is working, why do reporters not demand more transparency to demonstrate it? Why this instead?

Blue Cross did not release specific performance results for doctors groups.

Why no mention in these stories of alternative approaches being taken by other insurers?

Why hold off, too, on this really important statement until after the page turn and deep at the end of this story?

Both supporters and critics of global payment agree that any mandate should be flexible, and phased in slowly, so patients and providers can adjust. Thomas A. Croswell, chief operating officer of Tufts Health Plan, suggested a five-year transition.

Much is often made of Atul Gawande's superb writing about the use of check lists and other quality and safety process improvements. If you read carefully, though, you will see that he seldom mentions progress in the medical schools with which his and other Boston hospitals are affiliated. While we wait five years or more for the new pricing regime, why don't the insurers, the state government, and other stakeholders put pressure on the region's four medical schools to introduce and emphasize the science of process improvement in their curriculum?

Local readers might be interested to know that the process improvement world is alive and well in other regions, irrespective of insurance payment regimes. Two of the heroes in this arena, Brent James and Bob Wachter, recently had a conversation about how to teach quality and safety improvement.

Dr. James gave some history of his efforts at Intermountain Health. Dr. Wachter asks:

[Y]ou and others have written about the culture of medicine being so individualistic. It sounds like we came into this with a culture that you would expect would create tremendous variation from doctor to doctor.

Dr. James replies:

Looking back, that's absolutely true. Of course it came to be called the craft of medicine, a cottage industry, where it's based on purely personal expertise, personal perfection, if you will. Speaking as somebody out of a surgical background—that concept is so central to what it means to be good, I mean for your patients, the best you can be. You don't want to lose that personal dedication. But you start to extend it a step further. Where it ended up for us was a form of Lean.

And later, he relates:

We did other things that were really important. The first is that we built firmly on the foundation of medicine. By that point, we'd understood that there's a whole bunch of jargon with improvement, but you didn't have to use any of it; you could describe the whole thing in the language of medicine. So rather than asking the natives to learn quality improvement jargon, we spoke the language of the native. The second thing was that in order to graduate you had to complete a successful improvement project. Our aim was to get hands-on experience that was real. And boy did that ever turn out well.

Here is an article about a system clinical safety and effectiveness (CS&E) course taught at the University of Texas. An excerpt:

Unfortunately, most front-line caregivers complete their professional training with almost no exposure to even rudimentary QI concepts or methods....

The University of Texas MD Anderson Cancer Center began such a course in 2005 ... and its success led us to implement courses in four of the six health campuses in the University of Texas system....

The purpose of the CS&E course is to provide physicians, other key clinicians, and administrators the skills and knowledge required to lead breakthrough change initiatives. After initial success at UT MD Anderson Cancer Center, all presidents of the UT System health care institutions approved a proposal in 2007 to develop and implement CS&E programs on their own campuses. A UT CS&E Steering Committee with representatives from each campus was established to provide oversight for the course expansion, and in 2008 the University's Regents provided funding from the UT System's malpractice liability reserve fund.

We are very quick to find a rivalry between Texas and Boston in other fields. Let's start one here, where lives hang in the balance.


Anonymous said...

Your post sounded a bit familiar, so I searched your blog for similar posts and found no less than 5 dating back to 2008. There are probably more. Here's part of my comment on one from last May:

" Of the 23 medical schools listed in the Leape report as those beginning to implement some of the recommended changes in education, Tufts is the only Massachusetts representative.
Boston has proven itself to be a thoroughly complacent and self-satisfied place when it comes to the introspection necessary to improve medical care delivery, present company excepted.........Health care delivery science will evolve outside of Boston's hallowed but calcified walls."

I have little doubt that the high costs admitted to by the Partners group may be related to lack of a coherent program of physician engagement and system improvement in health care delivery, and that the recent stellar financial results reported by your former hospital BIDMC may be related to those same improvements - accompanied by superior patient outcomes.

What will eventually cause change in Boston? Well, it's simple - after their current unfair financial advantages expire, they will be behind the curve on costs, outcomes and efficiency, because all other hospitals will have already educated their physicians and made these changes. Someday, to their shock, we will see an exodus of patients from Boston for excellent medical care - not an influx. So be it.

nonlocal MD

e-Patient Dave said...

Paul, you may be onto something here, something I never noticed (as nonlocal did) until I fully understood the subject of practice variation. I knew in my gut it was a culture issue but didn't understand the source.

If I'm right (that you're right), then indeed the door is WIDE open for any other part of the country to walk right in and steal the groceries.

Anonymous said...

I'd like to see some reporter go a step further and ask what seems to me to be an obvious question: Why does how you pay for healthcare (fee for service or capitated) change the quality of the delivery of the healthcare? If you go to a good restaurant, the quality of the food is just as good fixe prix or a la carte.

(I am saying this as somone that has been capitated for 30 something years and have no complaints. But I don't understand the logic.)

-- Dennis Byron