Boston surgeon Atul Gawnde and Don Berwick, the president of the Institute for Health Care Improvement, understand that we can create a sustainable, universal U.S. healthcare system only if we reduce costs. And they recognize that by spending less, we can, in turn, lift the quality of care. As Berwick puts it: “The best health care is the very, very least healthcare that we need to gain the long and full and joyous lives that we really want.”
Talk to virtually anyone who has studied the problem in depth, and they agree. While many uninsured and underinsured patients receive too little care, a great many well-insured patients—including Medicare patients—receive too much of the wrong kind of care. Gawande explains: “Our system neglects low-profit services like mental-health care, geriatrics, and primary care, and [is] almost giddy in its overuse of high-cost technologies such as radiology imaging, brand-name drugs, and many elective procedures.”
It’s remarkable how those who have investigated reform agree. It’s not that we don’t know what to aim for. We’re just not at all sure how to achieve those goals in a profit-driven health care system.
Gawande and Berwick argue that we’re not going to find out until we enact legislation. Congress cannot sketch out a solution on paper. The only way to realize reform is to pass a law—and then engage in the very messy process of trying it out on the ground.
Reading the Minds of Millions of Americans
To predict, with any certainty, which reform strategies will work and which won’t requires reading the minds of the millions of patients, health care providers, hospital CEO’s and manufacturers involved in our health care system. Which incentives will change how they think and how they act? Which will they ignore?
This is a huge country. Ideas that work in some areas won’t find an answering chord in others.
How many patients will respond to rational appeals to self-interest? Economists are virtually the only social scientists who believe that men normally act in their own self-interest. Sociologists, anthropologists and, of course, psychologists know better. The fact that we are often irrational in our response to seemingly logical ideas makes us unpredictable. Interesting. Amusing. Great material for a novel. But as difficult to forecast as the weather.
If we hope to “bend the curve” of health care inflation, the web of relationships that connects patients, doctors and hospitals will have to be transformed. And no one can do this except the individuals themselves. Patients, nurses, doctors, and hospital CEO’s must begin to look at each other through a different lens. This takes us into relatively unknown territory: the human mind.
In short, “bending the curve” means changing the social model—i.e., moving minds. For example, hospital CEO’s need to recognize that they are not running revenue centers. They are running cost centers. Their goal, under reform: to trim hospital bills. This means reducing revenues. How do we bend their minds?
“We have our models, to be sure,” Gawande writes. “There are places like the Mayo Clinic, in Minnesota; Intermountain Healthcare, in Utah; the Kaiser Permanente health-care system in California; and Scott & White Healthcare, in Texas, that reliably deliver higher quality for lower costs than elsewhere. Yet they have had years to develop their organizations and institutional cultures. We don’t yet know how to replicate what they do. Even they have difficulties. Kaiser Permanente has struggled to bring California-calibre results to North Carolina, for instance.”
This doesn’t mean that there is something wrong with Kaiser’s structure. It just means that it’s not a “master plan.” Nothing could be. There is no “Toyota” diagram of efficiency for healthcare. Healthcare isn’t about producing automobiles; it’s about repairing human beings. This means that an enormous number of cultural traditions and religious beliefs come into play. As Gawande points out: “Each area has its own history and traditions, its own gaps in infrastructure, and its own distinctive patient population.”
I am not suggesting that we should accept regional variations that expose some patients to over-treatment, while expecting taxpayers in other parts of the country to pay for it. Reformers must take a close look at individual hospital systems, and the web of doctors who refer patients to those hospitals, finding ways to steer them toward the sustainable, affordable, effective care that their patients need.
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Last week, Berwick offered a definition of optimal care that every corner of the country needs to keep in mind when he suggested that “The best health care is the very, very least healthcare that we need,” and explained: “The best hospital bed is empty not full. . . The best CT-scan, the one we don’t need.”
The health care industry, like all businesses, wants to grow. But as a society, we cannot afford to foot the bill for a system in which each player strives for higher revenues and fatter profits. As Berwick puts it: “We have to escape from the tragedy of the commons—and the instinct to simply grow what we have, to do what we do”.
That said, different strategies will work in different regions. Accountable care organizations may not work in the corridor that runs from Boston to Washington, where so many physicians work in small practices. Very likely they will have to find other ways of pooling resources.
This is why reducing the cost of care does not admit to a single solution. The most meticulous master plan, carefully “scored” and laid out on paper, is meaningless, unless it moves hearts and minds–and thus transforms our extravagant, inefficient and extraordinarily solipsistic health care system.
The only way to find out what will work is to enact reform. This is why Gawande believes that “We will have to proceed by trial and error with a ‘hodge-podge’ of pilot projects.
Turning to history, Gawande offers an analogy, arguing that U.S. health care reform can be compared to agricultural reform. “In 1900, more than forty per cent of a family’s income went to paying for food. At the same time, farming was hugely labor-intensive, tying up almost half the American workforce. We were, partly as a result, still a poor nation. Only by improving the productivity of farming could we raise our standard of living and emerge as an industrial power. We had to reduce food costs, so that families could spend money on other goods, and resources could flow to other economic sectors.”
At the time, he argues, the cost of food was overtaking the economy, just as the cost of health care is encroaching on GDP today.
Comparing Health Care Reform to Agricultural Reform?
I have some reservations about how well the analogy works. But analogies and similes (X, is like Y) always involve a stretch. That’s why I prefer metaphors and symbols ( X is embedded in Y; it’s implicit, not explicit.)
Nevertheless, from 1903 (when Gawande’s story about the history of U.S. agriculture begins), to the middle of the 20th century, there is no question that county extension agencies helped improve farming practices. Sometime after that, I would argue, corporations began to take over agriculture. And the government began to serve corporate interests.
That said, Gawande is right to argue that earlier in the 20th century, “the government shaped a feedback loop of experiment and learning and encouragement for farmers across the country.” If a comparative effectiveness panel began disseminating guidelines for best practice, while simultaneously soliciting feedback from physicians, nurses and hospitals, it could create a similar learning loop for medicine.
Engaging the farmers was not always easy. Like physicians who bristle at the idea of “evidence-based medicine,” or “cook-book medicine,” farmer’s resisted progress—what they called “book farming.”
Here, Gawande underlines another lesson that we need to remember as we embark on health care reform: Doctors, nurses, hospital administrators and other healthcare professionals will have to re-form health care at a grass roots level. They must “own” the process. Otherwise they won’t believe in it. He quotes Seaman Knapp, an early pioneer in agricultural reform: “What a man hears he may doubt, what he sees, he may possibly doubt, but what he does himself, he cannot doubt.”
In August, I wrote about ten U.S. communities that have discovered that it is possible to change how care is delivered, making it both
less expensive and more effective.
They didn’t have to ration care to reduce costs. They don’t have to pay more to achieve better care. How did they do it? Local health care providers got together and decided that, instead of competing, they would unite. Most of these communities moved away from fee-for service care. One began pooling fees. Finally, they began “counting”—keeping track of the medical resources they were using—with the aim of reducing waste.
Whatever happens in Washington in the next month, these communities are already in the vanguard of reform. Berwick believes that the government can declare that universal coverage is the law of the land. This would mean that, as a civilized society, we have decided that we cannot deny anyone humane, effective care. Government can lay out rules that oversee health care for all: the sick cannot be penalized for being sick; everyone must participate, or pay a penalty. And Washington can figure out how to funnel funding to universal care.
But, as a society, Berwick points out, we cannot afford unlimited care. If universal care is going to be sustainable, the system must change from within. That’s why it has to happen on the ground.
In his keynote address, Berwick offered his audience an opportunity: “I challenge us to end the “Tragedy of the Commons” in health care. I challenge us to prove Garrett Hardin wrong.”
I submit that Garrett Hardin was wrong. It is not inevitable that human beings must be short-sighted and stupid. We are not doomed to “tragedy” or “ruin.” In some parts of the U.S., as well as in other countries, people have learned to think collectively about health care.
“It isn’t easy,” Berwick admitted to his audience. “Positive collective action, even in small communities, and especially in health care, is fragile. It could all just fall apart. But, it can work. I know it can work because, sometimes, some places, it does work.
“But,” he added, “I’m very mindful of who you all are. You are doctors and nurses tending patients, operating managers trying to keep 6 West going or clear the waiting lines. You’re QI directors coaxing the operating room into using a checklist, or executives getting ready to tell the Board some bad news. And, I think, you’re wondering, ‘What can I do from my limited perch to govern the Commons better? I’m already over my head.’
“I am really not sure,” Berwick added. “But, I have a strong feeling that it can – it has to – start with you. Command and control solutions seem weaker every day . . . Maybe someone smart enough and courageous enough in Washington can write a few rules that change the odds . . . But, the odds of real reform, ‘re-form,’ remain zero – the Commons is doomed – unless the action is closer to home – closer to you.”
Berwick then offered some suggestions:
- “Adopt an aim. Here’s one: Over the next three years, reduce the total resource consumption of your health care system, no matter where you start, by 10%. Do this without a single instance of harm, rationing of effective care, or exclusion of needed services for the population you serve. Do it by focusing not on the habits of health care as it is now, but by focusing on what really, really matters.
- “Develop, fast, because there isn’t much time left, your own institutional structures – the ones you will need for local rule-making to better manage your Common Pool Resource. Do not wait for external rules to be made, or to change; do it yourself.
“One such structure might be, for example, a Community-wide board – the collection together of all the health care Boards with shared stewardship of the whole.
- “Develop, fast, because there isn’t much time left, monitors, so that you can track the use of the common resource, and find out who is sticking to the rules you write, and who is breaking them “And, when people do break the rules – opportunists, free riders – create undesirable consequences for them, if you can, and ways to isolate them, if you cannot. Collective action is very fragile. You will need militia.”
it is an interesting and optimistic scenario, but the comparison with agriculture seems a bit of a stretch. we’re talking about a period prior to food and drug laws when there was virtually no regulation and certainly no credentialling that excluded most potential competitors. then we were talking about a lot of small farmers with minimal market power. here the focus is a few very centralized, rich players who have ample market power.
I think he’s right about the comparison with agriculture. I put up a post last week with Gawande’s article and the first comment was this:
►Jeez, if there was ever an legitimate argument against government intervention in health care, this is it.
To learn more about how government intervention influences our food safety and supply, I recommend reading “The Omnivore’s Dilemma” and “In Defense of Food” by Michael Pollan and watching the documentary “Food Inc.”
In short, government intervention has consolidated the industry with subsidies (not “winnowing out unproductive farmers”, as Gawande suggests), preferentially pushed crops, significantly contributed to an obesity epidemic, and encouraged the use of chemicals and genetically modified foodstuffs.
I support a significant (if not complete) role for the federal government in health care. But I sure hope Mr. Gawande’s argument isn’t used to sell it.◄
The best I could do was this tepid response:
► Good points. But it’s hard to tease out how much of that intervention is truly government and how much represents corporate welfare similar to that dimension of “health care” for drug and medical device industries, trial lawyers and insurance companies.
In addition to what you mentioned, the dark underside of the agriculture revolution includes hybrid seeds with impressive yields that must be replaced annually with part of the return since there is no more “seed corn.” And the overuse of herbicides and other “modern miracles” is having a catastrophic impact in many developing countries. It’s a very long list. The list of unintended consequences grows longer each year.
I think his main point is that broad policy goals have a greater long-term impact than micromanaging. Food safety and supply (appropriate mix) are important but different from costs as a percentage of GDP.◄
Despite all that, I still think the point is well-taken. The challenge is to get people to think in paradigms instead of anecdotes.
Hi Maggie,
Long time reader, rare commentator.
At first, I thought Dr. Gawande’s article was an ingenious analogy and it gave me much hope. But then, a different reality dawned on me and gave me significant grief.
The fundamental difference I see between the agricultural model of reform Dr. Gawande presents and the healthcare model of reform that is currently underway is the end result for producers (i.e. farmers v. health care providers…physicians, hospitals, pharmacists, etc). Farmers reformed to become MORE profitable. As farmers changed techniques, their land became more productive and they made more money. As their operations became more efficient, they made even more money. A social good was achieved in the process, low food prices and a freed up labor force, but that was not the driving force on the ground. It was always profit.
In seeking healthcare reform, we are asking just the opposite of healthcare providers. As they get more efficient, they LOSE money. The entire goal of healthcare reform is, as you’ve said repeatedly, to use less of the system and in the process, achieve better patient outcomes. By definition, this is a profit killing endeavor. And, therein lies the rub.
There is already too much money in the system as a whole. The healthcare system consumes 16% of the GDP. To be competitive with other nations in the long term, we must shave off at least 4-5 percentage points. That means wringing as much as $800B OUT of the system. That’s $800B healthcare providers will never see again… every year on a going forward basis.
The bottom line in healthcare reform is some providers are going to be poorer at the end of the day… a lot poorer. And that is why they fight so hard.
The problem with the current legislation is that we continue to have a sick care non-system that, to the extent that it has any design, is designed to service the for-profit insurance and pharmaceutical industries. In particular the insurance industry will continue to profit, with increased government subsidies, by covering those who are least at risk, while the taxpayer pays for those who are sick and old. Any public option we get from THIS congress will be subject to adverse selection. Furthermore, allowing only UNEMPLOYED people between age 55 and 65 to “join” medicare is just another way to shift the cost of those who are next-most expensive to the taxpayer. We need one risk pool, everybody in, nobody out, THEN start our “experiments”.
I think the analogy between farming and medicine is very tortured. The story of agriculture over the past 100 years has been one of tremendous technological advancement: tractor for mule, combine for scythe, chemical fertilizer for manure, insecticides intead of picking weevils. (Not that I am necessarily endorsing chemical fertilizer and pesticides) The result has been that 1 farmer can now produce as many bushels of corn as were produced by 100 farmand workers.
Similar technological changes have occurred in medicine, a CBC and differential that used to take an hour to do by hand (anyway it took me an hour when I was a med student)can now be done in seconds. A CT scan of the head that took an hour on an EMI scan (Electronic Musical Instruments – started by the Beatles) in 1978 now takes about a minute. etc., etc.
The problem is that medicine doesn’t have a finite end point. As medicine has “advanced”, expectations have increased. It is as if we used to eat one bushel of corn, but now we are eating 100 bushels of corn. And of course much of the valuable part of medicine – the “cognitive” part – can’t be readily mechanized.
If Berwick’s suggestions are the best we have, then we are in serious trouble. Berwick’s suggestions are akin to asking the Arabs and Israelis to gather in a circle and sing Kumbaya. Or playing the Youngbloods (“come on people now, smile on your brother every body get together try to love one another right now”) over a stereo system at the Afghan/Pakistan border.
What government needs to do is to create incentives (financial and otherwise) for health care organization, physicians, nurses, etc. to act in the nations best interest.
Berwick’s exhortations are not only so general as to be useless, but almost laughable in their naivete.
I agree with Concerned_FP’s analysis regarding Dr Gawande’s interesting article.
Also, re “Medicare…private insurers…will follow in cutting fees and refusing to pay for unnecessary treatments.” I think we agree that refusal of payment for a treatment that a patient understands her trusted physician considers vital for her sick child isn’t an adequate solution to the problems of unaffordable insurance and medical bankruptcy. I agree that integrated care systems make more sense, and I also doubt they will be widely developed without a rearrangement of financial incentives. I don’t see the current private insurance companies doing this. You said further that, “Accountable care organizations may not work in the corridor that runs from Boston to Washington, where so many physicians work in small practices. Very likely they will have to find other ways of pooling resources.” Do you think that if the financial incentives were to adequately favor integrated groups, even in that corridor new groups would develop, forcing solo practitioners to merge with a cost-effective group to survive? Or is the entry cost too great for new organizations, short of the kind of total overturn of the health care system that the President rejected?
I take issue with the often-used implication that patients are demanding all these high risk/high tech treatments and that “we” (patients)have to realize that we can’t have everything we want. I think this is a cop-out; patients don’t provide care, nor can they overhaul healthcare; Especially when we can’t even get basic outcome data or access to costs in order to evaluate the quality of care that’s available & how it will affect our insurance premiums.
Take a trip through New England; every small town has building cranes expanding hospitals, building cardiac surgery & cancer centers, and even bariatric and cosmetic surgery centers.
If you want to reform healthcare and start controlling costs, start honing in on and regulating hospital CEO’s. They and their boards are the ones putting profit at the top of the agenda. At the expense of qualty and higher costs, they are using a ‘build it and they will come’ mentality to build their empires.
It is obscene and there’s no end in sight. I don’t recall any ‘town hall meetings’ asking patients whether they want or need a new cardiac surgery center when there’s already 3 or 4 others within an hour north or south.
We need some heavy handed healthcare regulation of the kind that Congress just passed for Wall Street executives.
Follow the money and you’ll arrive at the best solutions.
jim, hootsbuddy, concenred FP, phochfeld,
jim– I agree that in some waus the analogy is stretched. Though I disagree that our healthcare system is compoised of “a few very centroalized rich players.”
Our fragemented system is made up of thousands of small doctors’ practices and small hopsitals. Fragmentaion is a major problem, as it was in agriculture.
Hootsbuddy–
Good to hear from you.
It occurred to me, too, that one could take the agricutlure example and turn it against the idea of government involvement in health care reform.
That’s why I suggested that the anology might work best if you thought in terms of agricultural reform from 1903 until 1950 (or maybe until WW II)–beofre coporate inteest began to take over. . . Government did bring some sound science to farming in the earlier decades of the 20th century.
What went wrong (and this is a very broad generaliation) is that corporate intersts captured the regulators.
I agree about paradigms vs. anecdotes..
Finally I think the Gawande article works even if you remove the agriculure analogy. It would some revision and refocusing, but I don’t think he really needs the anaology to make his argument.
Concerned FP–
I know there are many thoughtful readers out there who don’t usually comment. It’s good to hear your voice.
I see your point, but here is the difference between argruiculture and medicine.
When govt’ set out to help reform agrictulure, most farmers were “dirt poor.” As farming became more efficien tthey moved inot the middle class, and in some cases, into the upper-middle class.
By contrast, today those who profit from our health care industry (most physicians, hospital excutives, most of Pharma’s employees etc.) are already statistically upper-middle class (earning more than $75,000 or $80,000) and many are wealthy. Those at the top of the health care ladder are very wealthy.
As we try to squeeze waste out of the system, those at the top of that ladder are going to become somewhat less wealthy.
But primary care physicians, nurse practioners, hospital workers at the low end of the pay scale are not going to see their incomes cut.
Of course you are right many specialists earning $600,000 a year, hospital executivevs who are paid millions, Pharma CEOs, etc. will fight any reform that puts a dent in their revenues.
But some professionals look beyond their own income to the system as a whole, and are frustrated to see the waste, the lack of collaboration, etc.
This is why towad the end of the article, Gawande and his colleagues are talking about whether they could do a better job of reforming their corner of the health care world if they went on salary.
Chances are some of them would make less than they do now. But all of them are well enough paid, they they could afford a cut if that’s what it took–and they are willing to entertain the idea.
Many doctors now working on salary know that they could make more in private practice charging fee-for-service. But they prefer the working conditions, the collegialitiy and the collaboration of being part of a larger organization like Kaiser or Mayo or Cleveland Clinic.
At a certain point on the income ladder, many people realize that they have “enough.” They don’t feel compelled to always strive for “more.” This is particularly true if they take great satisfaction in their work for its own sake.
And if they are capable of looking beyond their own noses, and recognize themselves as part of a larger society.
If you read Don Berwick’s writing (begin with Escape Fire) you will find that he has been involved wtih many people in the health care world who take that larger view.
Finally, when I talk to doctors from other countries they often express surprise that so many American phsyicians seem so caught up in the drive to make more money
In our society, we have made wealth a measure of self-worth to such a degree that some people never feel that they have “plenty” or “enough”–their lives become a rat-race, always searching for “more” . . .
These are not the people we need or want in the health care professions.
pochfeld–
I agree, we need everyone in no one out.
I would add only that some hosptials and doctors must be included in the group profiting from a money-driven system.
Hi Maggie,
I can’t tell you what a thrill it is to have you respond to my posting. I’m a big fan. Thanks.
I wish all physicians felt the way you do about their profession. If they did, I don’t think we’d be in this mess. At the end of the day, significant portions of the profession approach their jobs as just that… jobs. A means to put food on the table, to send the kids through college, to buy the nice house, car, etc. Treating patients is just the way they make money. Part of it isn’t their fault. I think the training of medical students and residents, who both routinely work 80+ hours per week for years on end, saps most of the energy required to care. In your 80th hour, the last patient on your list is just a box to be scratched off, not a person to be cared for. Any doc who tells you otherwise is just fibbing. We all know how it really stands. After all, we’re only human.
The question becomes, why work 80 hours per week (including at the Mayo, Cleveland Clinic, Kaiser, et al)? In Europe, residents work a maximum of 60 hours per week. In some countries, it’s no more than 50. Countless studies have shown that being overtired is similar in cognitive effect to being drunk, and yet we staff our hospitals with these docs, and expect them to make good life and death decisions after having been up for 24+ hours straight. Truck drivers are required to sleep for 8 hours per day. Airline pilots have similar rules. And we wonder why there are 100,000+ deaths per year as a result of negligence in the hospitals. The folks in charge of these decisions, how we train our medical students, residents, and care for our sick, are physicians.
I’m not sure the leadership required to fix the system will ever come from within it. It requires a different perspective. Ultimately, I believe the change will come from government imposing its will on the healthcare system, and not for the sake of the people’s health mind you, but for the sake of its competitiveness in the world. When healthcare costs start to significantly affect our economic competitiveness on a large scale, the government will act. As crazy as it sounds, I don’t think the US has felt enough pain yet from the healthcare system to make the hard decisions.
Concerned FP–
Just saw your last comment.
Some people I respect very much agree with you– we won’t change the U.S. healthcare system until it implodes.
I hope that’s not true.
And I do think that there are a large number of health care profesionals like you, who see it as far more than a job.
If they saw other doctors, nurses etc. as willing to join with them, I think a fair number would step forwrd to put patients’ interests first and reform the system from within.
Health care reform needs a “movement” on the ground, and I think it should be led by health care professionals.