Wednesday, November 24, 2004

Is $41.4 Billion Enough?

Massachusetts Governor Mitt Romney has announced a program for reducing the number of people in the Commonwealth (estimated to be in the range of 450,000 to 650,000) who do not have health insurance. Details have not yet been announced, but the preliminary indication is that there will be four main elements. One is a stripped-down, presumably more affordable health insurance package that excludes things like treatment for substance abuse, chiropractic services, and rehabilitation. Second is a group of carrot-and-stick incentives for employers to offer health insurance coverage. Third is an effort to get all those eligible into Medicaid. Fourth is the funneling of patients seeking free services into an “aggressively managed system of care.”

There is also some rhetoric about electronic medical records, reducing paperwork, hiring more nurses, and the like.

All of this is to be done with no increase in taxes.

Predictably, the liberal health care gurus (of which Boston has an abundance) are pooh-poohing this proposal by a Republican governor as being ineffective. They say that in order to achieve anything approaching universal coverage, the Commonwealth will have to put up serious money.

The Governor’s response is that the $41.4 billion Massachusetts is already spending annually for health care ought to be enough. Referring to that number, Ronald Preston, his Secretary of Health and Human Services, asked “How can you be contemplating spending a whole lot more money no matter who pays for it?”

Sounds to me like a reasonable question.

Wednesday, November 17, 2004

If Doctor Doesn’t Know Best, Then What?

It hasn’t been so long ago that a good patient was one who followed doctor’s orders. Doctor knew best.

Whether doctor always knew best can be debated, but the belief that he did has been a bedrock assumption underpinning the organization and operation of the health care system. The doctor, without external interference, decided what was to be done for the patient and it was then the responsibility of the rest of the health care system to see that it got done and that it got paid for.

Now the magazine AARP, in the lead article of its November/December 2004 issue, urges its readers not to accept uncritically the decisions of cardiologists who tell them that they need to have heart surgery as treatment for their clogged arteries. The article reports “neither bypass nor angiography has been shown to prevent heart attacks.” It suggests that these procedures are appropriate in only a limited number of cases – many fewer than are now being done. Patients who are advised by their doctors to have them are urged to seek a second opinion and are given a three-step formula to use in evaluating the advice received.

Of course, this sort of thing has appeared in the media before. But seeing it in AARP brings its implications sharply to mind. AARP claims the largest circulation of any American magazine and is aimed at the seniors who are the main users of these two procedures.

If we can no longer assume that doctor knows best, then who should decide what should be done for patients? The patients themselves? Insurance companies? The government? Provider organizations like hospitals and large group practices?

These are important questions. Any serious thinking about redesigning the health care system has to address them.

Leaving these matters up to individual patients doesn’t seem very practical. Attempts by managed care companies to do it set off a public revolt.

So as a practical matter we are left with provider organizations. Actually, there has already been movement in that direction. Clinical protocols and care pathways are examples. These standardized approaches to the treatment of particular conditions represent institutional rather than individual decisions about what is to be done for patients. To the extent that they are based on evidence and followed in a disciplined way, they result in better outcomes and lower cost.

Unfortunately, all if this is happening in a rather haphazard way. It needs more strategic thought and the process of doing it needs to be speeded up.

Saturday, November 13, 2004

Economies of Scale

Some McDonald’s restaurants are “outsourcing” order taking. So when you shout at the little box on your way to the carry-out window, you give your order to someone in a remote location who is answering for several restaurants.

McDonald’s is exploiting the concept of economy of scale, one of the most misunderstood economic ideas around. Cost reduction resulting from economy of scale was one of the main justifications for the hospital merger mania of the 1980’s and 90’s. It was almost always false. More often than not, those mergers caused diseconomies of scale with costs going up, not down.

The idea of economy of scale is attributed to Adam Smith, the legendary 18th century Scottish philosopher who wrote the book Wealth of Nations. Using a pin factory as an example, he observed that if each worker performed one of the separate functions involved in pin making, they could together make more pins than they could if each made a complete pin by himself.

Of course, you had to make enough pins to fully occupy several workers, which has led to the erroneous conclusion that the increased efficiency was due to volume – thus the term “economy of scale.” In actuality, however, the efficiency was due to the specialization of labor that the volume permitted.

In the case of McDonald’s, it seems that workers who took orders also had to prepare food. Information technology allowed order taking to be consolidated off-site, thereby making it possible for workers to do it full time. The result has been higher sales (order-taking specialists are better salespersons) and faster, more accurate service (because full-time order takers are more proficient).

Health care providers have done a lot of specializing. Recent examples are hospitalists (doctors who work full-time caring for inpatients) and intensivists (doctors who work full-time providing intensive care).

But hospitals never said they merged in order to become large enough to afford hospitalists and intensivists (actually, most of them were big enough for that already). Instead, they claimed that their overhead departments like purchasing and payroll could “absorb” the extra work without growing proportionally. If that were true (and it usually wasn’t), the economies were more than offset by the added bureaucratic effort needed to manage the larger and more complex operation.

Health care providers need to learn to exploit economy of scale in the same way that McDonalds has. For example, a large hospital with a busy Emergency Department could have Physicians Assistants or Nurse Practitioners specialize in the care of stroke patients. Thoughtfully applied, that sort of innovation could make a significant contribution to both quality improvement and cost reduction.

Thursday, November 11, 2004

Kindergarten Games in Health Care

The November 1, 2004 issue of AHA News, the weekly newsletter of the American Hospital Association, carried an article entitled “Redesign the clinical process to enhance patient care.” The authors were Carol Haraden and Pat Rutherford, two Vice Presidents of the Boston-based Institute for Healthcare Improvement.

The article concluded with an example of a “simple” work redesign that improved health care. It seems that using clippers rather than razors to remove body hair before surgery avoids the small razor nicks that can harbor infection.

Not only does that make sense, there is evidence to support it.

So ordinary people might think that the hospital would just decide that clippers would replace razors and that would be that.

Not so. As the authors point out, such decisive action “might annoy staff.” So they played kindergarten games. They put clippers in convenient locations and gradually moved razors farther and farther away until they disappeared altogether.

And we wonder why improving the quality of health care is so difficult.

Thursday, November 04, 2004

A Glimmer of Progress

The October 28, 2004 issue of The Boston Globe carried an article about medical errors that had been committed by house staff at Brigham and Women’s Hospital and attributed to fatigue following long hours of continuous duty. The article was a report of a study conducted by Brigham and Women’s researchers and published in the prestigious New England Journal of Medicine.

The numbers were not trivial. One chart showed a total of about 100 medication errors per 1000 patient days. A little simple math will tell you that his means that if you had been an inpatient in that hospital, the chances of your being subject to a medication error during the period of the study were about one in three.

Not so long ago, a study of this kind would have been impossible. Supervising house staff was a province of clinical departments that no one would have dared to invade. And if information of the sort was somehow developed, the public report would have taken the form of an exposé. The hospital would have reacted defensively, saying that the information was being misrepresented, its significance was being exaggerated, corrective action had already been taken, etc. etc.

But those days seem to be on the way out, and happily so. What happened in this case is that Brigham and Women’s suspected it had a patient safety problem, confirmed its suspicions with a formal study, and made the results public. It also reported the steps it was taking in response to the information it had uncovered.

Having had something to do with the creation of that institution some 30 years ago, I can perhaps be excused for taking some pride in the leadership it is showing.

One such incident does not create a redesigned health care system. But successful redesign can only take place if old and outdated attitudes are abandoned in favor of new and progressive ones such as those that have taken root at Brigham and Women’s.

Given the prestige that Brigham and Women’s enjoys in the field of health care, it is an encouraging sign.

Wednesday, November 03, 2004

The Health Care State of Affairs

The November 2, 2004 issue of The Boston Globe carried an article written by freelancer Judy Foreman that neatly captures one aspect of the current state of affairs in health care.

The headline of the piece: “Doctors should return test results faster,” accurately described the theme. Patients become both anxious and annoyed when they have to wait for inordinately long periods to get the results of medical tests – particularly when there is suspicion of a life-threatening condition.

Foreman interviewed a number of lab and x-ray people who pointed out that in the modern digital age, there is no excuse for these delays. Information can be moved with the speed of light. Radiologists don’t even have to wait any more for the old films to be delivered. Computers allow them to be called up instantly.

So here is an opportunity for a health care institution that seriously wants to make productive use of information technology. It could provide same-day reporting to patients of all test results – something that would not have been practical before computers. With a little vision and determination and some IT staff time, it could be done without waiting for federal grant support or national standards.

But, of course, health care providers don’t have the organization or the discipline to pull it off, which explains why they have been so slow to exploit IT.

At the end of the article, Foreman offered her own suggestion, which was to give patients a tracking number like UPS does. It seems not to have occurred to her to hold health care providers responsible.

So I sent her an e-mail with my own suggestion, which was that hospital trustees hold their high-paid CEOs accountable for seeing to it that the problem got fixed. I suggested, further, that she interview some trustees, find out why they don’t do that and report the results in a future article. Her reply was “Good idea. Thanks.”

We’ll see. If she doesn’t, that will tell us something more about why the state of health care is as it is.

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