“Any system produces exactly the results it was designed to produce,” or so goes the saying. If we don’t like the results we get, we need to re-examine the system and not simply individual inputs.
In the US, healthcare’s systemic complexity has gone from that of a grandfather clock to nuclear reactor over the course of the past 100 years. If we really wish to improve the results of US healthcare, we need to look at the totality of the system, the multitude of inputs and outputs.
EMR’s, reimbursement rates, pre-authorizations, universal coverage and each of the many hot-button topics swirling around the question of healthcare reform are all important inputs that effect quality, cost, access, but I’m very much a hands-on person and I want to know what these have to do with the physical points of distribution of healthcare… our doctors’ offices and hospitals?
We know that a hammer sees every problem as a nail. And I concede that my predisposition as a recovering architect is to see the problems inherent in the physical instruments of our healthcare delivery… namely hospitals.
Not too many years ago in the US when water consumption for plumbing fixtures was regulated (as in maximum gallons-per-minute for shower-heads or gallons-per-flush for toilets) there was a period of several years when new showerheads drizzled and new toilets required multiple flushes. Why? Because plumbing manufacturers looked at the new requirements and simply limited the input (water) without considering how it would impact the overall function of the system.
I wouldn’t encourage you to read anything beyond my systemic analogy into my comparison between our healthcare system and toilets, but what I would encourage you to do is to look at the distal ends of our healthcare system and realize that changes in funding, structure, benchmarks, policy and other inputs may not have the desired effect if we ignore the delivery vehicle of healthcare.
For medical professionals, the notion of evidence-based care is an ingrained part of the discipline. Clinical studies, peer review, government oversight, all of these are a part of a methodical process for vetting theories of more effective treatment and care.
The architectural profession, on the other hand, has long been characterized by larger-than-life egos, with black turtlenecks and rimless glasses. It is only within the last 10 years or so that healthcare architects have broadly embraced the notion of evidence-based design for healthcare… that the changes we implement to the design of hospitals for the purpose of improving care should actually be tested instead being assumed to be self-evident.
I don’t mean to indict my beloved profession, because it’s not as if architects haven’t had a multitude of concerns with rapidly morphing building technology, codes and professional requirements. My point is that if we want the input changes to have their desired effects, we need to make sure that the means of delivering care will be capable of supporting those changes. We need to rethink the bricks-and-mortar of our hospitals.
Most of my work is in the realm of medical imaging, a discipline that was hit particularly hard by changes to CMS reimbursement brought about by the Deficit Reduction Act. In an effort to cut federal spending on advanced medical imaging, Medicare and Medicaid reimbursements were slashed for CT and MRI exams.
The system of providing CT and MRI services to the American public was established based on the initial introduction of very expensive machines with very narrow clinical applicability. To support the promise of more effective diagnoses and treatment, reimbursement rates were set high in order to cover the inordinate cost to the provider.
Over the years, new clinical applications were found for these technologies, so utilization ramped up and – with a year or two lag-time – payors began to incrementally reduce reimbursement rates. As long a providers’ revenue gains were two years ahead of the payors’ reimbursement cuts, CT and MRI were financial gold-mines for the provider. This incremental spiral was halted, dead in its tracks, when the DRA cut a huge proportion out of technical reimbursement for these exams all at once.
The medical imaging industry, like my illustrative toilet manufacturers, has begun to realize that their system simply can not perform as desired based solely on changing the input (reimbursement). The results that the medical imaging industry is currently seeing, contraction and consolidation, are a direct consequence of a system structured on a foundation of low volume and high reimbursement. Medical imaging is now, belatedly and very painfully, reconsidering the entire system for delivery of care.
When we start radically altering the inputs for our entire healthcare system, as opposed to just a single sub-specialty within it, imagine this structural pain spread throughout.
I don’t propose this as an argument against structural change, nor do I have the Pollyanna perspective that change doesn’t have to be painful at all. We need to change and that change will inflict pain.
I do think that the beltway debates about systemic changes should be paired with discussions on strategies to re-think our hospitals and points of care. Preemptively thinking about the changed expectations of our delivery of healthcare may, in fact, provide valuable considerations for the discussion about changes in the policy of healthcare. At a minimum, the forewarning of the trickle-down effects of policy changes to the point of care could help to soften the blow to our established (and possibly soon-to-be anachronistic) hospitals.
Tobias Gilk is President and MRI Safety Director for Mednovus, Inc.
By the same author: Pharma vs. Devices – FDA, Supreme Court and Liability Whiplash