So why hasn’t the health care system in the US been fixed? Could it be that there are those in the system that really don’t want the system to change despite their public rhetoric? Or is it that no one really is focusing on issues that will result in meaningful change? Maybe they really don’t know how to fix it.
There has been a great effort to develop a value-based health care system. The message has been that if we focus on value, defined as quality/cost, then the system will be improved. This makes intuitive sense. Patients will receive better care at a price that is affordable in a system that is sustainable. But despite now years of talking value there is no clear evidence that value is improving. No one seems to have the blue print for a value-based health care system. In fact, in keeping an open mind is it possible that current initiatives may be making things worse?
The essence of health care is the patient-physician relationship as mentioned in a previous post (Relationships Over Transactions). It is the hard target for health care value. How does one optimize the patient-physician relationship to maximize value? Simple. Optimize and protect a physician’s time and hold the physician accountable for utilizing that time in a manner that is beneficial to the patient and the profession. Doing so allows for better preparation and execution. Value will be maximized when a well prepared physician practicing evidenced based medicine engages a patient in a non-hurried manner so that a genuine professional and personal relationship is developed.
It seems as if the current environment is doing just the opposite. An electronic medial record is a good thing but not when it is focused on documentation instead of care and occupies 20% of a physician’s day. The insurance industry has certainly cut some of the bloat out of the system but the pendulum has swung too far in the opposite direction and physicians and staff spend a great deal of time getting care approved at the expense of preparation and execution of value-based health care. The list of care “process and procedures” grows exponentially and most have nothing to do with improving value. Process won’t fix health care (Quality, Evidence and Avedis Donabedian). Compliance training is another enormous time vacuum. Someone please provide the evidence that a physician’s time is not better spent preparing for and executing patient focused health care. In general HCR does not believe that business-oriented initiatives are good for health care but it may be time for a Toyota lean approach to eliminate what is likely an enormous amount of wasted physician time.
Is this not obvious to everyone? One really has to question the motivation of any person or organization that doesn’t believe that this is worth at least a discussion.
The chasm between providers and non-providers in health care may be deeper and wider than anyone can imagine. The differences in priorities, cultures and motivations are astounding.
Take for instance a recent article in the Harvard Business review titled “Making Appointments Fast and Easy Must be Health Care’s Top Priority”. The piece was submitted by Jonathan Bush the CEO of athenahealth, a provider of health care services such as EHRs and billing. In the article Mr Bush asserts that fast and easy appointments should be the focus, or keystone habit, of every health care system in the US. The author begins with a subtle trashing of the “Triple Aim” which originated from the Institute for Health Care Improvement in 2008. The Triple Aim suggested that the focus of health care systems should be to 1) Improve the patient experience, 2) Improve the health of populations and 3) Reduce the per capita cost of care. The Harvard Business Review article even contains a seemingly sarcastic association between the Triple Aim and “motherhood, apple pie and the Stars and Stripes”. The contrast between Mr Bush’s (a non-provider) quick access keystone habit and The Institute for Health Care Improvement’s (providers) goals are striking and revealing. Mr Bush’s push is to get patients into a broken system as quickly as possible. The Institute for Health Care Improvement implies that the focus should be on fixing the system first.
Can there really ever by alignment between providers and non-providers? Probably not. Consider the training, job description and motivations of all involved. Providers are trained to provide health care to patients in need. They are trained to review complex scientific literature and make decisions for patients. Their loyalties are first to their patients. Non-providers, such as those in the health care services industry, are business people who are trained to make money and their entire motivation is a bottom line. Their loyalties are first to the corporate bottom line (See Self Serving Interests). It is not surprising that a health services company would focus on quick access. It’s what they do. They can sell quick access via their services. It is how they improve their bottom line. It also provides non-providers with a metric that they can manage in an era where their cash cow wRVU metric is rumored to be obsolete. Both metrics, quick access and wRVUs, measure and drive utilization – nothing more. Nothing to do with quality or value.
There is no question that access is important. There are certain conditions which require immediate access for better outcomes. On the other hand there are a lot of medical conditions that are emotional emergencies but do not require immediate care. And yes patients have come to expect on-demand care for even the most trivial conditions. However, forcing non-urgent conditions into immediate care helps no one. This expectation of immediate care is better addressed with educational initiatives. As mentioned in a comment following the article most patients, if properly educated, are likely to understand that their care will be better, less rushed and likely more affordable with the appropriate timing.
So the Harvard Business Review article exposes the chasm between providers and non-providers with respect to how to improve the health care system. It’s time to educate patients (i.e. the paying customer) and let them help define the future of health care. Do they simply want the quickest access possible to a dysfunctional system? Or are they smarter than that and willing to wait (when appropriate) for quality?
As one looks for reasons as to why the health care system is so dysfunctional no one is without at least some degree of blame. HCR believes that beginning of the end was accelerated at Harvard in 1985 when William Hsiao and colleagues contrived the resource based value unit or RVU. At that moment the health care system was handed over to corporate interests, strategies and tactics. At that moment there was a metric to manage. However this metric had nothing to do with health care quality. Nothing. At that moment people who know nothing about providing care to human beings were handed the keys. The goal was to control cost. Instead the greed of corporate interests saw the cash cow and simply drove output. Physicians were coerced to see more patients and work faster to maintain what they felt was fair compensation for their services. Physicians became little hamsters on the wheel and the patient-doctor relationship began its death spiral. EPIC FAIL!!!!
And the beat goes on. Health care is currently managed by administrators and insurance executives who thoroughly enjoy data. Of course they do. They have never been in an exam room with a patient. They have never read, nor would they understand, a medical journal. We are on a path that could make it worse instead of better. We are focusing on Big Data instead of Big People and Big Culture.
“We can not solve our problems with the same level of thinking that created them”
– Albert Einstein
Just ask yourself this question. If an electronic medical record or big data can cut the cost of health care (and they certainly may) will that savings be passed along to the patient/consumer Probably not. The same business motivations that managed the RVU debacle will simply siphon the savings off to their pockets. It’s what they are trained to do – make money.
The center of the health care universe will always be the patient-doctor relationship. As mentioned here before it is also the hard target for quality and value initiatives. Decades of corporate driven health care have replaced the patient-doctor relationship with the doctor-patient transaction (Relationships Over Transactions). A quick, impersonal, mostly authoritarian and more recently technology-focused transaction. It’s what administrators and managers do so why did we expect anything else when we handed over the keys?
A healthy relationship, as in patient-doctor relationship, is built upon a foundation of components such as trust, respect, communication, patience and empathy. In a service-based relationship the communication aspect is the most important and communication requires time. None of these components are required for the current doctor-patient transaction. A recent blog post entitled “Is Lack of Time Really Why So Many Physicians Are Poor Communicators?” asserted that poor physician communication is a learned behavior taught in medical school. There was an implication that the authoritarian approach to patient interaction is part of the training. HCR believes this to not be the case. It is true that physicians in training spend a great deal of time learning about the science of the body in health and disease. And it is also true that the individual human aspect of health and disease is often overlooked. The question is: does a focus on science necessarily lead to poor communication? It is probably a safe bet that no where in medical school are students taught an authoritarian approach to patient interaction. It is also a safe bet that no where in medical school are students taught to spend as little time as possible with patients. Rather, HCR believes that the current state of the patient-doctor relationship (transaction) is a direct result of the system and environment in which physicians work and practice.
Physicians, and more importantly current and past physician leaders (A Call-Out to All Physicians In Leadership Positions), are guilty of weakness and complacency. They have slowly and overtime conceded to the business school model of health care where volume trumps quality. And driving volume means less time with each patient. The only way for that to happen if for weakened physicians to completely take over the interaction and transform a relationship into a transaction. The authoritarian nature of the transaction is a coping mechanism rather than a methodology taught in medical school.
HCR believes that most physicians leaving medical school sincerely wish to do the right thing and practice their profession with pride. HCR believes that mid to later career physicians would thoroughly enjoy recapturing their autonomy and practicing medicine without a useless administrator beating them up for their numbers each month. So yes HCR believes that more time will matter (What If Physicians Had More Time?). It will signal a return to a patient-doctor relationship rather than a transaction. With more time greater things are possible. Physicians will have more time to discuss options. More time to discuss risks and benefits. More time to listen. More time to make sure patients understand. How could health care not be better for all? Except the MBA’s.
What will the US healthcare system look like in the future? Are we getting reform right and how, and more importantly when, will we know?
In the financial world a leading indicator has been described as a factor that can be observed and measured that predicts how the economy as a whole is going to change. The Conference Board looks at factors (referred to as “Global Business Cycle Indicators”) such as manufacturing orders, new building permits, unemployment, stock prices and others to predict the near-term future of the economy. Are there any such indicators for the healthcare reform movement? Possibly.
Maybe one can find a leading indicator of reform and improvement by looking first for a lagging indicator of what is wrong with the system. HCR believes that everything wrong with healthcare currently manifests as a brief and impersonal interaction between patient and physician. Physicians, lacking both the courage and energy to advocate for their patients and profession, have acquiesced to the external forces that now control the healthcare system. It is a system that has been recently driven by the non-providers whose only interest is a monthly P/L statement. They threaten providers with decreased salaries if productivity (read number of patients not quality of care) decreases. The administrators do not have the knowledge base to assess or improve quality. So they template everything. Oh they will talk about quality and the patient experience but they don’t have the knowledge to improve either and in reality their own survival is tied not to quality but to the bottom line. In the rare instance that an administrator talks quality it is disingenuous and futile. Administrators place no value on the intellectual and academic components of the profession of Medicine. They would prefer that physicians spend all of their time seeing as many patients as possible because they can measure and manage the number of visit. The value of reading and education not important even though they claim to be on a quality march. And they frown on physicians spending a minute more than the 10 minutes that they allocated on their template. Thus as the healthcare system deteriorated the length of time that physicians spent with patients diminished.
So maybe there is something to this. If the lagging indicator of everything wrong in healthcare is a short patient visit then maybe a leading indicator of improvement will be a prolonged and non-hurried patient visit. Oh, and also an exponential growth in unemployed healthcare administrators.
Honestly. Why do patients and physicians allow this nonsense to happen? One hopes that calm, rational, educated and caring people can make health care better through a slow adaptive process. At times however it does seem as if a patient-physician led coup will be necessary. It’s difficult to understand if the non-provider leaders in health care just don’t understand the human aspect of health care or if they don’t want to understand the human aspect of health care because it would expose how unimportant they really are to success if quality is the priority.
The goal of health care providers is to interact with other human beings to improve their health. The goal of health care administrators is to make numbers work. Health care administrators shuffle money, objects and people so that everything looks good on paper. More often than not the goal of the provider and the goal of the administrator are at odds.
A real-life example from a newly created health care system created by the blend of provider and payer with the intent of building an integrated delivery system that will compete in the anticipated future of health care where there is a focus on value, quality and cost. The new system has to date been mostly led by the payer. All decisions to date made by people whose job it is to make things look good on paper. And their answer for everything seems to be to create and manage templates. There is probably no greater example of the philosophical chasm between provider and administrator than the concept of templates. Templates completely remove the variability of the human interactions in health care. Human interactions are the essence of health care. Human interactions are also notoriously difficult to measure and manage.
One example of template-mania involves physician scheduling. The newly created health care system will be creating a centralized call center for scheduling. This is staffed by entry-level administrative types who will insert callers into a master data base of physician schedules. The goal of this initiative was to assure patients timely access to physicians and this was discussed in a previous post (“Fixing the Four Ring Problem. Driving Uniformity and Mediocrity”). Timely access over quality and experience? Timely access is an important, but not the most important, component of quality care. There are already bad examples of this template-driven and centralized scheduling system. Patients arriving at physician office without the necessary prior studies requiring a second visit. Patients getting put onto a resident-run clinic. Patients calling for a specific surgeon for a specific procedure and being told the surgeon does not do the procedure when in fact he/she does.
They love to template space as well. To an administrator an office is a small tin can into which you should fit as many sardines as possible. The noise and disruption are not important. It looks good on paper. Could they do their job as well if they shared the space. The clinical spaces are where the revenue is generated. In reality shouldn’t all the administrators be compressed into cubicles in a room that takes the least amount of space away from patient care?
Do we really need more high-priced VP’s in health care whose only skill is to manage a template of time or space? You honestly can’t manage health care with templates and expect quality health care and a great patient experience. Let’s fire the template jockeys and hire more nurses.
When does the patient-provider coup begin?
Is there a single fix for health care? Probably not. It’s a really broken system that involves a lot of money, a lot of waste, and lot of unnecessary people, processes and rules that consume precious resources with no return. The much-needed complete overhaul frightens many because the overhaul involves the people factor. And the CFO doesn’t know how to talk to the board of directors about the people factor. It’s difficult to measure the impact of a healthy culture and health relationships on a month to month basis.
More than any other industry health care is about people and their relationships. People and relationships are more important than big data. More important than any new processes or procedure. More important than new penalties or incentives. More important than the patient experience as it is currently being described. Healthcare needs to focus on people and their relationships. The patient-physician relationship. The provider-provider relationship. The provider-payer relationship.
The physician-patient relationship is ground zero for healthcare. A high-value location with the potential for the biggest impact. It is where the greatest improvements in quality can be made. It is where cost control begins. It is the ultimate component of the patient experience. Unfortunately, corporate medicine based on business principles has replaced a physician-patient relationship with a physician-patient transaction. Volume driven healthcare with the focus on simply getting as much done as possible. And the two most important stakeholders in healthcare, patients and physicians, have allowed it to happen. Patients have lowered their expectations and physicians have cheapened the profession. Re-establishing and optimizing a physician-patient relationship is a must for value-based healthcare that focuses on quality and succeeds at controlling costs. The physician-patient relationship is the foundation of healthcare. Transitioning from transaction to relationships will be problematic in that relationships require time and in the current system the value of time is not appreciated by anyone but patients and physicians. Is it wrong to assume that healthcare will improve if we give patients more time with their physician? More time to listen. More time to educate. More time to discuss the risks, benefits and costs of all options. More time to develop a relationship.
The provider-provider relationship also needs to be addressed. A culture of collegiality focused on patient care is imperative. Everyone has an important role to play. One can’t administrate the culture. It is about getting the appropriate people in key positions and allowing them to be role models for the new culture.
Lastly, providers and payers must establish a better relationship. The current business speak describes the concept of alignment. This will require both sides overcoming years of mistrust and antagonism.
The transition from transactions to relationships won’t be easy. Administrators and payers currently focus on volume. Physicians have been rendered powerless. It may require a revolution that starts with the paying customer, the patient, to simply demand more.
So a physician recently was working through the never-ending and ever-growing list of compliance training. None of which has ever been shown to make health care better and all of which takes up precious time. This compliance supports a self-serving industry. Nothing more.
One of the compliance learning courses was intended to help providers develop a culture of health care safety. The material in this course discussed toxic cultures and how they can lead to health care errors and patient harm. So far so good. Focus on culture. Somehow the discussion then lead to a recommendation to eliminate the hierarchical structure in health care. A dangerous statement.
Now, for the record when any member of HCR interacts with the health care system there will be a preference for the hierarchical health care system. The hope is that a well-trained, well-educated physician is at the top of this hierarchy making all of the health care decisions. He/she will work very closely with a team of providers (nurses, therapists, etc. but not managers or administrators) each of whom will have a job to perform. Patient care will be discussed openly and each provider’s feedback and opinion is valued and important. But there will be a hierarchy and the patient’s physician will ultimately make decisions and assume responsibility for those decisions.
The hierarchy is not the problem. The hierarchy is a necessity. There is a reason that it takes a long time and a lot of hard work to become a physician. Any team needs to have a leader and that leader needs to be the person that is irreplaceable to the team. In the health care system that person would be the physician. The self-proclaimed and self-serving experts and advocates love to compare industries. One “pundit” suggested that the hierarchy in health care should be eliminated making a comparison to the cockpit of an airplane. The bizarre analogy was that if a pilot is going to fly a plane into the ground the existing hierarchy might prevent someone from intervening. Seriously? In this scenario the hierarchy is likely not the problem. The problem is the pilot. If a pilot is making potentially disastrous decisions and not receptive to suggestions from colleagues then he/she should simply not be flying. This does not mean that the hierarchy is inherently bad. For the record again, when any member of HCR is on an airplane the expectation will be that a hierarchy is in place and that a well-trained and well-adjusted pilot is at the top of the hierarchy.
No, the hierarchy is not the problem. A hierarchy is a necessity. No hierarchy usually means anarchy. It’s the culture within the hierarchy that is the problem.
Does everyone who collects a pay check in health care really understand the mission and their individual role? Rhetorical. It seems that over the recent decades the health care system has been more about the industry itself and less about what it was designed to do. A lot of self-serving interests.
“An organization begins to die the day it begins to run for the benefit of insiders and not the benefit of the outsiders.” -Peter Drucker
Just in case anyone has forgotten. The mission is to deliver health care to patients. Financial success is important to sustain this mission but the bottom line must be secondary. Competing with the health care system across town is important but if you focus on the mission you will win the competition.
The engine of health care is the interaction between patients and their physicians. The physicians guide and drive the care. And the best health care occurs where the best doctors practice. All others in a health care organization are support personnel. If you have never been face to face with a person asking for help for a potentially life-threatening illness then your job is to support the person who does that job. If you have never been in an operating room attempting to correct a life-threatening problem then your job is to support the person who does that job.
This is not about elitism. This is more about reality, good business principles and how to create a successful health care organization. Everyone in a health care system presumably was hired to do a job that was important to patient care. Every employee, from hospital CEO to parking lot attendant, needs to simply realize why patients walk in the door and who they walk in to see.
Health care has become bloated. The system has become incredibly complicated and unfortunately there is no clear answer as to whether or not the complexity has any benefit. Or if the small amount of benefit is worth the cost. The reality is that there are a lot of people making a living in health care performing and providing services which probably contribute little to value for patient care either at an individual or systems level. We can not ignore the fact that there is a lot of money in this system and that not everyone may be in the health care system for the same reason. Not meant to be judgmental.
As we move toward trying to improve this broken system there are so many “stakeholders”. Patients, physicians, other providers, hospital and insurance administrators and managers, medical device and pharmaceutical companies, politicians and the list goes on. Everyone has an opinion on how to make things better. Most have never had direct contact with a patient. And everyone has interests to protect. It is a difficult issue to discuss but how do we eliminate interests that are simply self-serving? The path of least resistance would be to simply ignore this issue. Just avoid any potential conflict and keep on with business as usual. However, these are tough times for health care. Tough times require tough people to make tough decisions.
The mission will not be easy. The rhetoric is intense. As is often the care the most intense rhetoric is often used to distract from a lack of substance. How are we able to separate genuine good intentions from purely self-serving and economic motivation? Everyone gives the appearance of taking the high road. Is it genuine? Is the message to the public from each stakeholder the same message that is given to shareholders and others with a financial stake? In other words are the motivations and intentions of all of the accessory personnel (essentially anyone who doesn’t come in contact with a patient) aligned with the motivations and intentions of physicians and other providers?
In a previous post HCR proposed that all reform initiatives be scrutinized to the same degree as medical practice (Evidence Based Medicine, Evidence Based Reform?). We are not in a position to be throwing money at new ideas that someone thinks is a good idea because it works in another industry. With quality and cost as the primary metric each and every new idea needs to be scrutinized. Forget the sales pitches and the hype. Ignore the rhetoric. Someone needs to be able to see through all of the smoke and mirrors that are simply protecting self-serving interests. And we should not invest in anything that is going to result in a trivial incremental change. Chances are it won’t be worth the cost.
While we are at it we should also look at the current system and begin to trim the excess using the same principles. In a previous post HCR proposed having everyone account for their existence and paycheck (Tell Me What You Do Again and Why It’s Important?).
Is it wrong to questions people’s motives? Absolutely not. Is it difficult to question people’s motives? Yep. But it’s just a reality that we have to address in health care sooner rather than later.