Is excellent good enough?
As physicians, we are trained to diagnose and treat disease. We dedicate ourselves to searching for cures and perfecting procedures that will restore the health of our patients. Over the last 50 years, we’ve made some remarkable progress. We’ve reduced the death rate from heart disease by 32.5% with a better understanding of primary and secondary prevention and advances in treatment. We’ve made similar progress in cancer care with better treatment options through radiation, surgery, chemotherapy, and genomics. We’ve changed an HIV diagnosis from a hopeless death sentence with limited treatment options to a manageable, chronic condition.
These truly excellent accomplishments in medicine have been life-changing for millions of people. But is excellent good enough?
While we have made great strides in clinical care, the American dream is faltering. Americans are more obese, more medicated and more in debt than at any other time in the history of our nation. One-third of our nation’s total health-care spending, about $750 billion per year, is wasted on unnecessary treatments, redundant tests, and uncoordinated care . Health Care Reform will have limited impact on this waste. While the rate of increase of health care spending has slowed in recent years, the United States still spends 2.5 times more than most developed nations on health care . U.S. health care spending is on track to reach $4.8 trillion in 2021, almost 20% of our gross domestic product .
There is an old saying that every unsustainable trend, by definition, comes to an end. The U.S. healthcare system has been on an unsustainable trajectory, consuming more and more of our national income while failing to deliver the kind of care that Americans need and deserve. But although every unsustainable trend eventually ends, how it ends is up to us.
The healthcare system has the potential to collapse under its own weight, requiring Americans to pay even more for healthcare, forcing draconian and blunt cuts in the kinds of services available, and putting high quality healthcare out of reach for the poor and the sick.
An alternative future is one in which payers pay for value, providers become more efficient and patient centered, and consumers become increasingly engaged in caring for themselves. In this future, healthcare becomes an important force for improving the health of the American public.
What will determine which path our healthcare system will take? While the fate of our healthcare system will be influenced by policymakers in Washington DC and the state capitals, it will ultimately be decided by each of us – providers and patients who are involved in the daily work of delivering and engaging in healthcare.
The journal Healthcare: The Journal of Delivery Science and Innovation is an effort to nudge us toward a better, sustainable path for our healthcare system. The mission of the journal is simple: to play a meaningful role in fostering real change in the healthcare delivery system. The journal wants to be a venue for sharing the best ideas for delivery science, payment innovation and smart use of health information technologies. The journal was conceived by Amol Navathe and Sachin Jain, who have been thinking long and hard about compelling new approaches to bring about change in the healthcare system. It took years of persistence to line up a terrific publisher, put together a top notch editorial board and recruit some of the nation’s best minds to lead individual theme areas. And it paid off handsomely. Today, June 26th, Healthcare officially launches with its premier issue, and what an issue it is.
The two introductions are short, pithy and worth reading over and over again. The first is by Don Berwick, the former Administrator of the Centers for Medicare and Medicaid Services but even more importantly (at least to me), the man who has done more to promote quality and safety than anyone in recent memory. Don frames the issues in ways that only he can, reminding us that we can have the best healthcare system in the world – we have all the pieces – but we have to learn how to put it together.
Everybody hates curbside consults – the informal, “Hey, Joe, how would you treat asymptomatic pyuria in my 80-year-old nursing home patient?”-type questions that dominate those Doctor’s Lounge conversations that aren’t about sports, Wall Street, or ObamaCare. Consultants hate being asked clinical questions out of context; they know that they may give incorrect advice if the underlying facts and assumptions aren’t right (the old garbage in, garbage out phenomenon). They also don’t enjoy giving away their time and intellectual capital for free. Risk managers hate curbside consults because they sometimes figure into the pathogenesis of a lawsuit, such as when a hospitalist or ER doctor acts after receiving (non-documented) curbside guidance and things go sideways.
There is some evidence to support this antipathy. A recent study published in the Journal of Hospital Medicine examined 47 curbside consultations by hospitalists, in which formal consults by different hospitalists (unaware of the details of the curbside encounter) were performed soon thereafter. Conducted by a team of researchers from the University of Colorado, the study found that the information given to the curbside consultant was incomplete or inaccurate roughly half the time, and that management advice offered via the two forms of consultation differed 60 percent of the time. (In those cases in which the consultant was given inaccurate or incomplete information, the advice differed more than 90 percent of the time!) This is not the first warning about the dangers of such consults (see also here and here), and it won’t be the last.
For the next three months, the Supreme Court will mull the constitutionality of the new health care law. At stake is the government’s requirement that its citizens buy private health insurance. But whatever the outcome, it’s a foregone conclusion that some fundamental change must be instituted in the financing of health care delivery.
Today, enormous sums of taxpayer money are spent on the administration of health care programs such as Medicaid. Those administrative costs could be sharply reduced and the savings put to what is really needed — providing health care. With the information technology available today, public agencies should consider eliminating their function as a government-run insurance operation and focusing their resources on paying providers to deliver care.
Consider Medicaid, the shared federal and state program for the poor. When Medicaid was created, it was designed to replicate the private insurance function. But the basic purpose of insurance is to protect the policy holder’s assets against a catastrophic event causing risk of personal bankruptcy. Because the very nature of qualifying for Medicaid requires recipients to first spend down their assets and then earn an annual income below a certain percentage of the federal poverty level, what assets is the policy protecting? The person doesn’t need health insurance. He needs health care.
When the government created Medicaid as a look-alike insurance product, it developed an oversight operation that has not kept up with what technology can do to make a system run more efficiently. And unlike private insurance, it built a system requiring monthly updates of each of its 50 million recipients’ eligibility, including filled-out and faxed-in monthly reports, income receipts, etc.
To be a patient today is to be treated as a consumer. But treating patients as typical proactive, in control, well-informed consumers can backfire. Asked to take on increasingly complex decisions and digest ever-larger amounts of information, patients find themselves placed — often by design — in the driver’s seat. High-deductible insurance plans aspire to make the cost implications of care more transparent and implicitly shift decision-making to members. The “empowered patient” movement encourages patients to become hyper-informed and to take control over their care. But providing greater information, access and autonomy — so often successful in consumer settings — does not necessarily drive better care or experience. Consider these cases:
- An unexplained black-out sent a 61-year-old Boston woman to the emergency room and set off a flurry of visits to specialists to uncover the cause. Each doctor needed records of the diagnostics from previous visits. Hospital policy, however, required that patient data be released only to the patient, meaning she had to return to the hospital prior to any new specialist visit. Requiring her to control the information flow burdened her in the midst of a medical crisis.
- After years of struggling with her weight, a New York mother underwent bariatric surgery. She was inundated with information from her medical team about how she would need to change her behavior. Guidelines around when, how, and what to eat or not eat — the rules were overwhelming and constraining. Before long her weight had jumped again. For this woman, an excess of information (along with an assumption that she was prepared to absorb it) was part of the problem, not the solution.