Thursday, March 03, 2011

Time for the wisdom of the crowd

On the post below, "nonlocal MD," a regular contributor, asks:

I would next like to see a series on how you think all this could be done better, perhaps drawing on your international experiences.

And Barry Carol says:

As I understand it, the German population is generally satisfied with their healthcare and health insurance system. However, people can opt out and access more comprehensive private insurance if they want to and can afford to. About 10% of the population chooses the private system. One way or another, the wealthy and upper middle class will always be able to trade up creating, in effect, a two tier system. Personally, I don’t have any problem with that as long as what’s available to the bulk of the population is widely perceived as “good enough.”

Here is my reply, to you and to her:

Dear nonlocal,

It is not a question of doing better: It is the political imperative at work. My purpose in writing about all this was to describe the natural sequence of events.

As Barry suggests, people are generally content with this kind of system. The broad base of the population, the voters, gets security and a plan that is "good enough." The wealthy buy the "upper tier" plan.

It's the same as coach and first class on airplanes; Ford and Lexus in cars; McDonald's and luxury restaurants.

For years, we have rationed primary care in the US based on income. Now, like Europe, it will be reversed: We will ration high-end care based on income.

An underlying problem remains: There is little about the new order here in the US nor the European system that has dealt with the need to improve quality, safety, transparency, and promote continuous process improvement. And so demographic cost pressures will continue to build on both sides of the Atlantic. Governments and other payers will try to use the hammer of rates and regulatory changes to accomplish the kind of process improvement that can truly create better value for the population. That will fail. Those changes should come from the medical profession, but that profession has been recalcitrant and engaged in denial. We have seen that over and over: "The data are wrong" or "Our patients are sicker."

Changes are most likely to come as a result of strong advocacy from patients who are more and more empowered because of the internet and social media. In health care, the future is Egypt -- if and when the patient advocacy community gets its act together.

Places like Institute for Healthcare Improvement and the Joint Commission will finally succeed at their jobs when they facilitate the engagement of those thousands of people throughout the country. But you can not "own" those individuals or prescribe the approach that should be taken: You have to cede control of the agenda to let the wisdom of the crowd come through.


Anonymous said...

Addressing only the first part of your post, I say wait a minute - whether you sit in first class or coach in an airplane does not affect your chances of surviving a plane crash. This is the crux of the problem with a 2 tiered health care system - what is 'necessary' care and what is 'concierge' care?


Anonymous said...

Now have had the chance to digest the second part of your post; you are so right. No one, and I really mean no one, will be able to effect the needed changes except patient organizations - because they are the one group who has no competing agendas/constituents/back-scratching obligations. But they need to 'get their act together' fast - time's a'wastin.


Tricia Pil, MD said...

You’re right, Paul, change is most likely to come from the patient advocacy community. But we need help. Well-intentioned as Nonlocal’s comment was, it’s simply not true that patient advocates do not have "competing agendas/constituents/back-scratching obligations." Of course we do—anytime you bring two or more people together on any issue, and especially one that is as emotionally and politically charged an issue for patient advocates as health care safety, quality, and access-- there will be differences of opinion on directions, aims, and priorities. We can overcome these differences and form a unified coalition, but we need resources and guidance to form a solid organizational infrastructure that will support productive discourse and ultimately effect the change we all want to see. In that respect, the patient advocacy community is not the only one that needs to get its act together.

Kerry OConnell said...

Regarding the first part of your post capitalism seldom produces the best of anything. It is great at producing mediocre quality, high profit, goods and services that are available 24/7 within a mile of every American's home ie: Walmart, McDonalds, and Starbucks. Healthcare has been headed down this path for at least the last 30 years. The rich don't buy American and will likely find their Healthcare needs met elsewhere. Perhaps we will evolve into Good,Better, Best facilities based on what we are willing to pay and our tolerance for crippling medical errors. Regarding the second part, like Egypt, consumer activists can stage loud demonstrations demanding better care but our bottom line choice will always be either to take a large risk with the system we have or forego treatment and live with your condition the best you can. A whole lot of us wish we had taken the last option.

Anonymous said...

Non-local, actually, sitting in first class increases your chances of being killed in a plane crash.

e-Patient Dave said...

Paul, as you know, I agree with the idea that healthcare will change when its customers get uppity, and probably not until then. I've been ASTOUNDED at how unscientific the bulk of the industry is, believing their schooling many years ago means they're up on the latest today, and resisting all evidence of things like practice variation. Whatever most MDs are taught in school, it certainly doesn't include the humility of scientific uncertainty and continuous learning.

I know a smart, gentle woman whose physician fired her this past week because the radiologist evaluated a scan for the wrong thing, and she had the audacity to ask that it be read again, for the right thing.

What's needed is awareness of how badly some hospitals and doctors suck. (You know I've never spoken that way before, but in the past 3-6 months I've reached that conclusion.) I spoke with a guy this week who's recently been digging into hospital quality data and says the real estate market will go through a massive readjustment if people start adding that issue into their home shopping, along with school quality and crime rate. Because, he says, the data are just stunning about which hospitals have far higher rates of medical errors and readmissions, and choosing one town over another can substantially affect your family's safety if you ever need a hospital fast.

And, he says, that data is well documented for all demographics (not just in Medicare), but it's owned by a private company and is only sold to insurance companies - not available to consumers. That's a kind of poisonous "information asymmetry" that I'd like to see end. How can ANYone justify withholding that information from the innocent souls who walk in the front doors of different hospitals, putting themselves, their children, their families at far greater risk at one door than at another?