Of Healthcare and Toilets

Tobias Gilk “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

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8 replies »

  1. Now, US healthcare system and toilet system both have improved a lot.

  2. I believe the initial post brings out an important issue being there are many factors and variables which, in their totality, result in escalating costs, unnecessary spending and inefficiency. While Tobias focused his discussion diagnostic imaging, the same dialogue could be had with any clinical discipline.
    Living in the world of healthcare strategy and real estate, I witness facilities being designed (ranging from physician offices to hospitals) by professionals who lack an understanding of health care from an operational perspective. Moreover, they are not designing facilities for the delivery of care over the next 15-20 years. To further complicate matters, we often have administrators and managers leading design processes and replicating what they already have in place; this just perpetuates the issues and challenges we are facing today.
    In the past I have told my staff to focus their energy on managing issues that are within their control. Using the MRI analogy, we should be focusing on throughput and increasing volume to a point where the magnet is running at capacity.
    Hospitals that have multiple magnets should evaluate whether there is sufficient demand for two magnets or whether an alternative diagnostic resource might generate greater revenue and improve patient care.
    Over my career I have seen that many of the challenges our industry faces are self-imposed and can be mitigated if managed accordingly. As administrators and care providers, we must stop being victims and start managing issues that are within our control. Five years from now we will be looking back and saying if Ford can do it, then why can’t we.

  3. rbar, I think you make important points. On the one hand cheaper MRIs are good for individuals/insurance making payments IF hospitals pass the savings in equipment on (will they)- but opening up more usage to make up for less cost does not do anything for overall system costs. This is the failure of private non- universal budget healthcare – it turns a savings into a revenue stream and we still end up with over utilizatiuon. When we all used roll film we were frugal with picture taking, but since digital pics make over use cheap (and disposable), we don’t think twice about taking a zillion useless pics just cause we can.

  4. Interesting link, Peter, thank you.
    What we should never forget: when there are market based changes in medicine, are they good for the potential patients (that’s what health care is for, after all)? No doubt that cheaper MRIs can be a good thing, but the question is: will we end up MRIing everything? In some areas of the US, we may come close to that already (regardless of cost). But is it worth the expense and effort?
    By my own experience, the answer is: an MRI is helpful in the appropriate clinical situation … and then, it should be a high quality exam (a lot of the weaker magnets, esp. from open MRIs, deliver px that are plagued by artefacts), interpreted by both a qualified radiologist and a clinician.
    If you do it otherwise, you end up with costly (regardless of the MRI price) and potentially harmful nonsense: inappropriate furter testing (f/u MRI and other testing), inaccurate diagnoses (MS for nonspecific white matter changes in the brain), bad treatments (surgeries for disc prolapses that cause nonradicular pain).
    We need competition for clinically appropriate high quality MRIs, not just for pictures. That’s where the health care market needs steering. But who should do the steering? Medicare?

  5. Peter- You’ve hit the nail on the head. The greatest need of hospital facilities (and, specifically, the people who design and operate them) will be innovation as we begin changing the system inputs. What I’ve not seen as a companion to the healthcare reform debate (but would very much like to) is a parallel ‘innovation incubator’ intended to develop multitudes of solutions for effective and efficient care delivery… prototypes that hospital designers can use as jumping-off points.

  6. Resistance (or refusal) to reducing healthcare costs while achieving better outcomes has got to be a function of American mentality. When reimbursments are cut the health industry whines and looks for a workaround (and lobbying)to keep the money flowing while Europeans and Japanese move on and INNOVATE to get more from less.
    I am reminded about how Japanese MRI manufacturers designed and built cheaper systems to accomodate radically lower MRI payments. Is it any wonder that Chrysler and GM are declaring bankruptcy after decades of refusing to change in a changing world.

  7. I think the post is a little opaque – “Medical imaging is now, belatedly and very painfully, reconsidering the entire system for delivery of care.” Who exactly considers what? Can “imaging” “consider” anything, let alone the health care system?
    Superfluous medical imaging is probably one of the biggest cost drivers in US health care. And it’s not only the superfluous scan for back pain alone, but the follow up costs – further tests for incidental or ambiguous findings, surgical interventions for irrelevant findings …
    As I said here before, a good full coverage plan probably could be at least 10% cheaper, if not a multiple of that, if some simple and existing EBM guidelines would be followed. And it’s not only the doctors’ fault; an important subset of patients shares the blame: “A thorough doctor orders a lot of tests”, “I want to look what is going on where it hurts”, “it is so good to know that body part x is OK”, these are the prevailing attitudes that make cost explode. And personal injury lawyers, who, with hindsight reasonning, determine that there was reason to image body part X on visit date Y and that it would have made a difference.