A Declaration of Independence Is Only the Beginning

A Declaration of Independence Is Only the Beginning

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flying cadeuciiOn April 29, Dr. Daniel Croviotto published an editorial in the Wall Street Journal, “A Doctor’s Declaration of Independence,” in which he argued that it is time to “defy healthcare mandates issued by bureaucrats not in the healing profession.”

Dr. Croviotto does a good job of articulating his frustration with the increasingly burdensome bureaucracy and regulations placed on care. Many physicians and nurses share his frustration. I once did, until I saw a way out of the cynicism and frustration – a way that can improve the quality and lower the cost of care for all Americans.

No matter how misguided we think the federal government is in its electronic health record mandate or other requirements, simply defying mandates as Dr. Croviotto proposes is not  likely to accomplish much. Those who signed the Declaration of Independence knew it was only an initial step toward ridding the country of tyranny. They had to create a new vision for a better, more effective government.

Similarly, the medical profession needs to move beyond cynicism to create a vision for a better, more effective healthcare system.


Modern healthcare enjoys one of the most intelligent, educated and committed work forces of any industry in the world. However, they are trying to deliver care using a system that was developed over 100 years ago. While that system has carried us a long way, it is not designed to deal with the complexity that characterizes modern care.

Healthcare is long overdue in implementing a care management system that is better designed to deal with complexity and increase reliability. “Managed care” means managing the processes of care, not managing physicians and nurses.

We need to leverage clinicians’ skills and expertise to implement care processes that are efficient, reliable and waste free.

To get there, though, physicians will need to give up the traditional craft-based approach to medicine. For the last 100 years or so, medicine has consisted of an individual physician putting the healthcare needs of an individual patient before any other end or goal. The physician draws upon his or her clinical knowledge to develop a unique diagnostic and treatment regimen that is customized for each individual patient.

Unfortunately, healthcare has simply become too complex and costly to rely on this craft-based approach to deliver the right care to the right patient at the right time, every time. Doing so only introduces variation and unnecessary costs that contribute to the estimated $700 billion in medical waste each year.

Instead, clinicians must adopt a profession-based style of practice in which groups of peers, treating similar patients in a shared setting, develop standard, coordinated care delivery processes using standard evidence-based protocols. Individual clinicians can then adapt this standards-based style of practice to specific patient needs.

And organizations can use information systems and analytics to track the cost and quality of care against specific procedures, measure their effectiveness, and inform improvements.

What I’m describing is akin to the application of the Lean process improvement methodology that Toyota and hundreds of other businesses have used to eliminate waste and drive value. Just as it did for manufacturing, the Lean approach can help medicine produce less expensive, less complex care with better patient outcomes.

In fact, it already has. Under the visionary leadership of Dr. Brent James and others, Utah’s Intermountain Healthcare has demonstrated two decades of success using Deming’s principles of continuous process improvement to drive quality, patient safety, waste reduction and cost savings. Similar results are being achieved by other leading-edge healthcare organizations.

The Virginia Mason Hospital and Medical Clinic in Seattle began implementing Lean principles in 2002. Since then, Virginia Mason has demonstrated it can save capital, use staff more efficiently, reduce inventories, improve productivity, save space and improve care quality. These improvements have resulted in tens of millions of dollars in savings.

Eventually, all healthcare organizations, regardless of payment models and federal mandates, will need to emulate these improvement pioneers if they want to survive the transformation of healthcare.  We need to leverage the incredible progress of the past century and design a new system that is more effective, more efficient and more capable of creating optimal outcomes for patients and communities.

We need to move beyond skepticism and frustration to an era that will be characterized by hope, excitement and promise.

We have the necessary skills. The only question is whether we have the will.

John Haughom, MD,  former senior vice president of clinical quality, safety and IT for PeaceHealth, is a senior advisor to Health Catalyst and the author of Healthcare: A Better Way: The New Era of Opportunity.

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44 Comments on "A Declaration of Independence Is Only the Beginning"


Guest
Sep 23, 2014

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Charles Kenney
May 9, 2014

This article is chock full of good thinking. In particular, this struck me as right on the money: “Modern healthcare enjoys one of the most intelligent, educated and committed work forces of any industry in the world. However, they are trying to deliver care using a system that was developed over 100 years ago. While that system has carried us a long way, it is not designed to deal with the complexity that characterizes modern care.”

So what will/does the new system look like? For one, it has to be physician-led. Physicians have the clout to challenge the status quo. And as Dr. Haughom notes, we would be smart to draw upon lean tools and methods to reduce waste and become more patient-centered. The lean approach has proven to reduce the burden of work and enable physicians to focus more on patients — both individuals and populations (see Virginia Mason). Too many physicians work in bureaucratic, dysfunctional environments that do not foster their ability to care for patients in the best way possible. If we can reduce the burden of work on physicians and enable them to focus on patients — individually and collectively — we are likely to have both more engaged and happier doctors and healthier patients. Dr. Jack Cochran and I write about this in our new book THE DOCTOR CRISIS.

http://www.bostonglobe.com/arts/2014/05/04/book-review-the-doctor-crisis-how-physicians-can-and-must-lead-way-better-health-care-jack-cochran-and-charles-kenney/JG2YPCAexXSpEqRcCi4FbI/story.html

Guest
John Haughom, MD
May 9, 2014

Thank you very much for your thoughtful comments. They are appreciated. I will look forward to reading your book. I am just in the process of completing a book as well. It focuses on the need for engaging clinicians in data-driven improvement. The full book will be out in June, but you can download much it at this link. The book is free. Title: Healthcare: A Better Way. The New Era of Opportunity.

http://www.healthcatalyst.com/ebooks/healthcare-transformation-healthcare-a-better-way/

Guest
Balboa
May 8, 2014

We’ll come full circle if physicians come up with a new cost efficient system. It was after all the providers who drove up costs astronomically under the FFS model. That is what led to tighter regulations and ushered in the managed care model in the 70’s-80’s.

Guest

Hmmm, maybe… But. I am just old enough to remember folks in my medical school in the 80’s telling me about how things were going to change in health care as more professional businessmen are invited to “improve the level of management” in health care.

Trouble is health care is neither entirely a sacred calling, nor a business. It is both. It always has been and always will be. And MBAs miss one and some policy makers wish for the other. Only docs have a superficial but instinctive understanding of how to balance both.

Guest
Balboa
May 9, 2014

Very interesting. It’s funny that you should say that. I have a friend in pharmaceutical manufacturing who says that people with MBAs come into management all the time and yap orders to the floormen about how to do their jobs better when those same MBAs have never stepped a foot on the floor.

That same company has quality issues and horrible culture with no integrity of work. They only care about meeting metrics and the numbers, which sounds very familiar with the current conversation in management.

I agree that doctors are the ones with the insight to make meaningful changes but the vision has to be extremely clear to convince the politicians, the payors, the people.

Guest
Joel Hassman, MD
May 7, 2014

Incredible how people just pontificate, rationalize, minimize, deny, project, and just ignore things just to satisfy selfish , limited, and destructive impulses just to win, place, and show. It is a pony show, to utilize the horse race times of the month.

Infantile and immature defenses are just what the dysfunctional doctors ordered, eh? Most if you just don’t get it, health care is not a business, but the most sacred and valued service a culture needs and deserves of those committed to the principles that defined it.

But, the antisocial element pervasive in profiteering had succeeded in dividing and conquering. Welcome to the worst addiction of America. And why addiction is practiced so well by antisocials. Frankly, through some of the most regular commenters here, textbook examples of the sublime and determined.

How do some of you live with yourselves at the end of the day? Thank god for mirrors, I guess!

Guest
John Haughom
May 7, 2014

While I agree with Dr. Hassman’s thoughts, I might say them differently. From my first day in medical school, I have viewed being a physician as a tremendous privilege. I have never stopped feeling this is true. We all hold a very privileged position and owe it to the patients we serve to act that way. One quote that I did not use in my book (but will in a future iteration) reflects these sentiments. Recently, a young rising star physician leader shared this quote with me. It was written about 75 years ago by Tinsley Harrison, MD, who wrote Harrison’s Textbook of Medicine. This was in the introduction to Harrison’s book.

“No greater opportunity, responsibility or obligation can fall to the lot of a human being than to become a physician. In the care of the suffering, she/he needs technical skill, scientific knowledge, and human understanding. She/he who uses this with courage, with humility and with wisdom, will provide a unique service for her/his fellow beings, and will build an enduring edifice of character within herself/himself. The physician should ask of her/his destiny no more than this; she/he should be content with no less.”

Guest
John Haughom, MD
May 7, 2014

May we all live up to this vision and standard.

Guest
Ben Rush MD
May 7, 2014

Effective Care, Population Health, Quality Metrics are rushing headlong into the onrushing freight train of Personalized Medicine and Genomics. Which Megatrend will dominate?

Guest
John Haughom
May 7, 2014

Great comment! Actually, I believe both will dominate. We are long overdue in measuring our quality and being transparent about it. As you suggest, genomics offers amazing new possibilities for personalized treatment. It is a “both-and” rather than an “either-or.” Chapter 8 of my free book mentions these amazing impending genetic possibilities. Future clinicians will have diagnostic and therapeutic tools that we never dreamed of.

Guest
William Palmer MD
May 7, 2014

Dear Government Healthcare Policy Makers:

Dig back into Econ 101 and recall the Principal-Agent theory.

Do you believe that a person’s physical and mental health are his or her’s most precious possessions? …and that they often enclose the most intimate secrets? and desperate needs?…and that if anything in the world deserved a principal-agent relationship, this particular bond would fulfill that need….and that it would be perfectly akin to the attorney-client and the preacher-church member relationship?

Do you agree that we need this in health care? If you do not, and believe we are selling a commodity, I beg you to talk to some patients or remember when you were one.

Accordingly then, harken: We do not intend to conduct ourselves in any manner other then to improve our patient’s well-being as best we can. It’s called beneficence. You remember it in the Hippocratic Oath. Our canonical role is to help the patient. [ We did not vote on or approve the recently added item of Justice in the Oath.]

We are not here to be actors in your theories about health care or in saving money. That is not our purpose and if patients do not feel we follow a loyal agent’s role, we _and you_ will have no patients. To conspire with others and with hospitals to save money–sending our patients back and forth to members of this club–and hence derive bonuses from skimping on the care of our patient seems to us as a diluted form of kickback. This was well understood in days of yore, but seems to have been forgotten.

We don’t mind saving money and praise this activity but we cannot be ultimately, and in the end, loyal to both purposes.

You can save money by global budgets or by monopsonic purchasing, by intalling market forces, perhaps by regulations, lotteries. Go for it. This is your role and we need to strum against this extrinsic resistance of yours. We appreciate this role of yours. By doing this we remain good agents. We need therefor to, sometimes, tussle with you to try to get what our patients need.

Society needs robust advocacy and we understand this, but we must first be a true agent to our patient.

Guest
Jun 29, 2014

Thank you, doc.

Guest
John Haughom
May 7, 2014

While I understand the frustration and concern with so-called “policy makers,” the reality is that these policy makers are only filling a void to address serious challenges that we (clinicians) need to fill. Healthcare faces very real quality, safety, access, waste and cost challenges. All of these challenges can be addressed by clinicians changing the processes of care and the delivery system in a way that benefits the patients we serve. A growing number of smart clinicians are figuring that out. Like them, I believe we are the “smart cogs” as described by Deming and others. Hopefully, we are not the “lazy cogs” of Taylor’s Scientific Management theory. As I said in my editorial response to Dr. Croviotto, non-compliance with government mandates (no matter how misguided) or waxing eloquent about policy makers is unlikely to change anything. We will only get more of the same. The problem is not them. It is us.

Guest
Jun 29, 2014

Deming, as in W. Edwards Deming? The guy who said “Cease dependence on inspection to achieve quality. Eliminate the need for inspection on a mass basis by building quality into the product in the first place.” Boy have we taught HIM a lesson! American Medicine is a performance art piece giving Deming the finger for his ideas. Inspection IS the purpose of production – the end-user or consumer is irrelevant! We work for the Lord of the Clipboard
We are the cogs of Taylor, of Ford and of Aldous Huxley, all of whom were familiar with this romance of Modernism with Fascism. Read Brave New World – it was an essay thinly papered over as a novel. Nowadays, we’ve even got Soma on the formulary!
Today’s vision is – “Towards the happy consensus of all.” We will achieve it!

Guest
Perry
May 7, 2014

“The person using the tool is different. If there is a poor outcome, do not blame the tool. The issue is with those using the tool.”

Very true, but you have to remember:

You need the right tool for the right job.
Not everyone is equally adept at using all tools.

Guest
John Haughom
May 7, 2014

Perry… Precisely. After 20 years in this game, I know that some know how to pick the right tool and some know how to implement it well (not always the same folks). The key is keeping one’s focus on the end goal (facilitating clinicians and better patient care) and understanding the care processes and environment you are implementing the tool in. You also need to invest in education. Some people (clinicians) know how to use tools (EHRs) well. Others do not. If they do not, the issue is again not the people but those who are implementing the tool who do not understand the need for education. As i indicate in my book, healthcare arguably has the most intelligent, well educated and committed people in the world. However, that does not mean they necessarily know how to use the tools and data. We need to help them see the answer. Thanks so much for your thoughtful comments.

Guest
CatC in Mich
May 7, 2014

When I was handed an exit bill and 1-page ‘patient summary’ of newly entered EHR data (after 25 yrs annual appts at the same complex), half the items were totally wrong — conditions that never happened or weren’t mine! Entered by their disgruntled Admin staff, my records are now garbage, then I was told I’d have to pay for an appt to fix their ‘errors’. Why didn’t the practice contract a reputable data entry contractor with the normal 1/1000 error rate to enter/verify their 25,000+ patients ? I hope no one is injured or killed by this company’s negligence (in Lansing MI). Btw, their promised patient portal is still unavailable 3 years later so I still can’t verify if my corrections were ever made.

In the meantime, my maintenance drug of >10 got dropped by BCBS, so I requested a similar scrip … That new drug raised my BP so high I ended up in the ER for 3 days. So who would drs rather be controlled by – Feds or insurance companies???

Guest
John Haughom, MD
May 7, 2014

As I pondered your insightful response, I have one additional comment. EHRs are only tools. Very powerful and complex tools, but basically tools nonetheless. Imagine another tool – a paint brush. Some people pick up a paint brush and can barely paint the side of a barn well. Others pick up the same paint brush and paint things like the ceiling at the Sistine Chapel and people admire it for centuries. The tool is the same. The person using the tool is different. If there is a poor outcome, do not blame the tool. The issue is with those using the tool.

Guest
John Haughom, MD
May 7, 2014

Thank you for your comments. You do a very good job of highlighting one of many issues. My 93 year old mother died a few months ago. Over the last ten years of her life, my brother and I split up the responsibility of helping her. I took on helping her with her healthcare decisions and my brother agreed to manage her healthcare bills. Wow. Did I make the right choice. While my Mother’s health issues were complex, they paled in comparison to figuring out her health bills! This is a process issue that needs to be solved and will be solved. Many reasons for it, but it will be solved.

With respect to your other thoughtful comments, who would you rather work your health decisions out with? A highly trained, committed physician and nurse, or a non-clinical bureaucrat? I have tremendous respect for countless non-clinical executives, operational leaders, bureaucrats and others I have encountered in my life. However, I do not want any if them managing my care. My health decisions are too personal and important. I want the best trained minds working with me.

Guest
MD as HELL
May 7, 2014

Your canned retort is missing my point. I did not say have clinicians design the system (although they probably should). I said design a system that doctors would actually want to use.

I also think your quaint condescending reference to craftsman versus professional is very self serving and egotistical. Doctors have always done piece work. They have done it quite professionally. Only after the non-physician problem solvers got involved did the wheels fly off.

Bring back common sense and give the patient back the money to hold.

Guest
Jun 29, 2014

Hear, hear! I am frustrated and baffled by the appearance of this statement:
“To get there, though, physicians will need to give up the traditional craft-based approach to medicine. For the last 100 years or so, medicine has consisted of an individual physician putting the healthcare needs of an individual patient before any other end or goal. The physician draws upon his or her clinical knowledge to develop a unique diagnostic and treatment regimen that is customized for each individual patient.
Unfortunately, healthcare has simply become too complex and costly to rely on this craft-based approach to deliver the right care to the right patient at the right time, every time.”

This is a manifesto of Fordism in medicine. Many of these ideas were cast out of the business schools, with loathing, after the World War. THE World War, in 1920 or so. How come we have dredged up these dreary Modernist zombies and set them in search of brains?
Modernist thinking says one size fits all, and it’s cheap. Postmodernist thinking goes towards bespoke product. Modernism talks about shoe size; postmodernism produces $100 shoes custom to the size of your feet.
If one wishes to see Modernist healthcare, there’s some in Haiti, and Ghana and Togo. Those who have the money to pay for the quaint old system of craftsman medical care have it, and plenty of it. but the other 95% of the population goes to the pharmacy. All of the drugs are direct-to-consumer (see what patient empowerment they have in Togo and Haiti!) and the consumers make their educated choices. They don’t have iApps to help them; they don’t have shoes. But they DO have freedom of choice!
Healhcare in Haiti is as six-sigma-lean as the patients themselves are. Skeleton-lean, you’ve got to admire that. Ghana itself is actually moving to increase their public health coverage and is doing and admirable job of it – actually putting their citizens first.
We are hearing the soft and crappy politics come in once again. You know, these issues of improving primary care, removing impediments and empowering patients are clearly well documented from the 1990’s. Some of them have failed miserably, atrociously. A fix is tried, it does not work – and the politicians rebrand it and trot it out a few years later as the New Fix to the problems caused by the Old Fix.
The old profession of “Doctor” will be exterminated in the same way “Nursing” was murdered twenty years ago. Of course, there will always be a serf to hang the sign on – there are still Nurses. Look what fifty years of out-of-the-box motivationally-driven change have done to the nursing profession!
Once the Goose that Lays the Golden Egg is killed and the postmortem proceeds, once all the profits come rolling in when doctors are eliminated, then – we’ll have a New New Fix! Good luck with all that.

Guest
John Haughom
May 7, 2014

I am sorry for any confusion. I am sure it is because I did not respond effectively. In truth, I believe I got your point, but my response did not reflect it correctly. The best system of care delivery is one in which clinicians eagerly want to practice. Even more, it is a system that clinicians want to take care of them and their loved ones. Based on experience, I can tell you that this is possible. Over the past 15 years, i have been in countless rooms where I see great clinicians see a new future, and it is always inspiring, exciting, and powerful. The energy in these rooms is electric and incredibly fun to experience. I can sense your passion and your frustration. I have felt the same. I would encourage you to read my book (it is free) and then let’s discuss it. I know it can — and it will — be different, my friend.

Guest
May 7, 2014

“Healthcare is long overdue in implementing a care management system that is better designed to deal with complexity and increase reliability. “Managed care” means managing the processes of care, not managing physicians and nurses.”
__

Well, originally (e.g., Ira Magaziner, HillaryCare) is was about managing the money. Not all that much has changed.

Guest
John Haughom
May 7, 2014

Bobby… Thank you for your comments. Actually, it is changing. My book highlights many instances. There are now dozens of organizations that are taking just this approach, and they are experiencing great outcomes. The current edition of Health Affairs illustrates another one. Check out “From a ‘Solution Shop’ Model to ‘Focused Factory’ in Hospital Surgery: Increasing Care Value and Predictability’ in the current Health Affairs. This is an example of clinicians moving from craft-based medicine to profession-based clinical care and making a real difference for patients. This is an example of the system I would like to care for me.

Guest
MD as HELL
May 7, 2014

Another “Good ship lollypop” bureaucrat.

Design a “system” that doctors want to be patients in and you might have it right. I have yet to see it.

We are not all identical like a Camry is a Camry. Some of us are Lexuses. Some of us are Yarises. Different tires, different fuel pumps, different ages of a fortunately age old design. Amazing that some examples from the same assembly sline go 20,000 miles and are lemons while others go 300,000 miles and are still going strong. Why is that? Why is that OK at Toyota?

The ideal system will keep well people away from healthcare infrastructure. It also will not bother the individual who wishes to be left alone.

The intrusive overtones of all systems is offensive to me as a person and a physician. Healthcare should be a commodity and a service, not servitude.

The final common pathway is the craftsman in the room with the patient. If the system is still intruding or blocking or dictating or restricting or conspiring, then it is no system I would use as a patient nor be part of as a physician.

Guest
dee
May 7, 2014

Brilliantly stated, but the intruders will always object. Patient + Doctor = medical care. Patient owned by 3rd parties + Employed Doctors controlled by the 3rd parties = healthcare and tyranny.

Guest
John Haughom
May 7, 2014

How better to design that system than ask clinicians to do it for you? Who else should do it? Having each individual clinician do it will not work (it isn’t now). Groups of clinicians acting on behalf of the patients they serve can. There are now dozens of organizations that are taking just this approach, and they are experiencing great outcomes. My book describes many examples. The current edition of Health Affairs illustrates another one. Check out “From a ‘Solution Shop’ Model to ‘Focused Factory’ in Hospital Surgery: Increasing Care Value and Predictability’ in the current Health Affairs. This is an example of clinicians moving from craft-based medicine to profession-based clinical care and making a real difference for patients. This is an example of the system I would like to care for me.

Guest
May 7, 2014

Not so sure…
It seems we have a good workforce that is shackled by a regulatory system that chokes their ability to innovate and a system of incentives that commoditizes complex and relationship-based care.

But that would be a much longer post to characterize and support.

Guest
John Haughom
May 7, 2014

Dino… I have been a practicing physician for 39 years. I spent 16 of those years in active practice building a robust practice (internal medicine and GI). I loved it. I still have my license, but I maintain it by giving my care away for free in clinics for the poor. In 1993, a visionary CEO was good enough to convince me to become an executive leading quality, safety and IT in a multi-state health system. 15 years ago, that same CEO (a nurse) and I founded a clinic for the poor which now supports care for over 15,000 patients. Most recently, I have been gifted with my current role focused on working with my peer clinicians to change healthcare for the better. My first step in that process was to write a book called “Healthcare: A Better Way. The New Era of Opportunity.” It is available for free at this link: http://www.healthcatalyst.com/ebooks/healthcare-transformation-healthcare-a-better-way/ Feedback welcome.

Guest
John Haughom
May 7, 2014

Dino… I agree. We need to harness the knowledge, expertise and passion of clinicians to solve issues. That includes an incentive system that rewards them for this work. Externally imposing solutions – such as regulations — will never work. At least that is my belief. And, I believe the evidence favors this view. Sometimes regulations are necessary. But they must be used judiciously. Non-thoughtful regulations impose barriers to solutions rather than offering solutions. There are not many non-clinical bureaucrats that understand the complexity of care.

Guest
May 7, 2014

I am an avid WSJ reader, and I read Croviotto’s lament and found most of it silly. His “threat” to retire in10 years was particularly pointless. He’s 58; of course, he’s likely to retire within 10 years.

The fundamental dysfunction with our healthcare system, particularly with providers is this: in the modern healthcare era, let’s say since 1965 when Medicare (and Mediciad, but it wasn’t the real driver of financial dysfunction), the focus has been on revenue generation not clinical excellence. The FFS system and the embrace of enterpreneurship as a primary medical value and the subordination of care safety and efficacy to that value, has created a system (I hesitate to use that term) in which making money for simply doing is viewed as an entitlement.

Guest
John Haughom
May 7, 2014

Thank you for your thoughtful response. The “entrepreneurship” that you refer to is largely driven by the “pay for doing things” (FFS) that you mention. Over my 43 years in healthcare, i have met and worked with many thousands clinicians. Based on my interactions, I believe that at least 95% of them get up each day wanting to be the best they can be for patients. We need to tap into that level of commitment by developing a reimbursement system that rewards clinicians for outcomes rather than doing things.

Guest
Peter1
May 7, 2014

“…in which making money for simply doing is viewed as an entitlement.”

Maybe a little harsh for all caregivers, but for once I agree with you.

“These improvements have resulted in tens of millions of dollars in savings.”

Passed on to patients?

“the Lean process improvement methodology”

I’d argue that single-pay achieves this, not corporate for profit health care.

Guest
John Haughom
May 7, 2014

Again, thank you for your thoughtful reply. I am always intrigued when I see folks focusing so much on the payer system. The quality, safety, waste and cost issues associated with healthcare will never be successfully solved by a payer. As in other industries, only the front line healthcare workers — clinicians — know enough about the process of care to address these perplexing issues. I have never met a payer who has the knowledge to do so, and I have worked for them. Whether it is a single government payer or multiple commercial payers, or some combination, I fail to see how that will solve the problem. The evidence is on my side on this issue. If you look at other countries that do have a single payer including Canada, the UK and other industrialized countries, they also have quality, safety and cost issues. The single payer system has not solved it.

Guest
Cynthia
May 7, 2014

No doubt that hospital costs are the reason why overall health care costs are so outrageously high. This is largely because hospitals can: 1) tack on a so-call “facility fee” to each and every hospital bill, and 2) charge Medicare and other insurers for test and procedures at rates that are four to five times higher than what non-hospital affiliated clinics and surgicenters can charge for them. Take way hospital facility fees and make hospital charges for test and procedure more in line with what non-hospital providers can charge for tests and procedures and then you’ll see hospital costs drop significantly. Most of these hospital facility fees and extra charges aren’t used to provide better or more care at the bedside anyway; they are instead used to pay for a fat and bloated management structure and for far too many worthless ivory-tower jobs in nursing education. At least that’s true in academic hospitals.

Guest
John Haughom
May 7, 2014

Cynthia… Thanks for your response. I am not sure I agree completely with your view of hospitals. I spent 20 years of my career as an SVP of Clinical Quality, Safety and IT in a multi-state hospital system. This experience taught me that the leaders of hospitals face a very tough picture. To use an analogy, hospitals are like a university athletic program. The typical university makes a lot of money off of their football program and a little off of their basketball program. Essentially every other athletic program either breaks even (a precious few) or loses a lot of money (the majority). Hospitals are the same. They make a lot of money off of surgery, cardiac care and often women’s care, but massively lose on everything else, especially psychiatric care. Yet, patients desperately need all services, not just a few. Most hospital systems do not have “bloated” management ranks, and the vast majority work very hard to meet the needs of communities. We need to collaborate with them, not disparage them. Thanks again.

Guest
Peter1
May 7, 2014

” If you look at other countries that do have a single payer including Canada, the UK and other industrialized countries, they also have quality, safety and cost issues. The single payer system has not solved it.”

Thanks for responding. So many authors here write and flee.

Health care is never “solved” only managed. single-pay may not have solved the cost, but they do it for about half – a missing component here.

Right now I’d settle for a 30% reduction.

Guest
Peter1
May 9, 2014

“There is good data to suggest that an established, trusting PPR reduces costs by 30% or more!”

Dino, how then is the U.S. system better equipped to accomplish this over the Canadian system?

Guest

Peter, I never suggested that a single payer interferes with the physician-patient relationship (PPR) but rather that single payer is the wrong place to look for savings. On the other hand all payers need some degree of accountability, so they are potential partners in the relationship.in moving from Canada to the US, I traded in a provincial government for an insurance company and either can be more or less competent or intrusive,

There is good data to suggest that an established, trusting PPR reduces costs by 30% or more! wW are not gatekeepers, but if I’ve known you for a couple of years, You might be more likely to believe me when I tell you that MRI won’t change anything.

Systems theory suggests that change, revolutionary or incremental, always begins with acknowledging that the status quo has good reasons to exist and making decisions within that framework. Single payer will never happen in the US for reasons too numerous to enumerate here, but we can achieve the same goals in a systemically relevant way.

Guest
Peter1
May 8, 2014

“You?”

Born Canadian, raised in Toronto, lived there most of my life under single-pay. Now live in U.S. for about 20 years.

So, how does communication between doc and patient get compromised by Canadian single-pay? You see your doc not your bureaucrat when you need care.

Guest
May 7, 2014

My life:
Educated in Canada under a single payor. University faculty. Chief Medical Officer. Primary Care Activist (who just started a foundation to provide primary care to cover “Obamagaps”) hainvg practiced in two provinces and four states with an emphasis on underserved populations.

You?

Guest
Peter1
May 7, 2014

“Ya but single payer is a bonehead way to reduce costs, since it does not focus on effective communication between provider and patient.”

Really? What do you base that “insight” on?

Guest
May 7, 2014

Ya but single payer is a bonehead way to reduce costs, since it does not focus on effective communication between provider and patient. It is only in that context that useful, well-informed and low-cost decisions can be satisfactorily made.

It’s not for nothing that managed care tried to turn PCPs into gate-keepers… it was noted that people with long-standing primary care relationships cost the system between 30 and 50% less overall. However like bonehead, reactionary bureaucrats they did the typical knee-jerk and forced it on the public as a depersonalized transactional product. No wonder it didn’t work.

I will go so far as to say there is absolutely no way to reduce health costs or achieve the triple aim without re-investing in our primary care infrastructure. At least not without a lot of disgruntled doctors and pissed off patients. That’s all UR achieves.