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.
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?
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.
Health care version 1.0, run by physicians and other providers, did not work due to an unrestrained utilization of resources. Health care version 2.0, run by corporate forces, also has been a failure. For the past several decades the focus in health care has been about the business of health care. A model of corporate medicine has emerged and proliferated and it only works well for those whose job it is to manage the bottom line. Now we are told (finally) that the future of health care is value. And we are told that the numerator and denominator of value are quality and cost respectively. In theory this will be a transformational change in health care that will require a complete overhaul in operations. But unfortunately nothing is happening at the front lines. Most likely because those currently in charge know nothing about quality but rather are business people. A meaningful change in health care will begin with a substantive change in leadership.
- CCO: Chief Cultural Officer. The most important person in the C-Suite. The CCO will be the relentless agent of change. The CCO will establish the environment where quality care happens. A Donabedian disciple of quality who realizes that structure and process guarantees nothing. Care will always be patient focused. Care will always be evidence based. Sets the standards and acts as a role model for providers at every level of the organization.
- CAO: Chief Alignment Officer. The CAO will serve as the intermediary between quality and cost. Understands the importance of the bottom line which is second only to great care. Will interact with and align the providers with the payers and others whose job it is to maintain the bottom line. Will share information between the two sides on an ongoing basis so that the value equation is maximized.
- CPO: Chief Practice Officer. Possibly the most difficult job on the list. The CPO will be responsible for transforming the practice of medicine. The current model will be deconstructed and rebuilt. The medical staff will first and foremost be dedicated to evidence based practice and will be provided with all of the time and resources to do so. All unnecessary and ineffective processes will be eliminated so that providers can use that time for better purposes. It’s not about compliance anymore. The future will be about a medical staff that is self-motivated to be the best that they can be and doesn’t need high-priced babysitters to follow them around checking boxes on paper. The CPO will make sure that their medical staff is functioning at the highest possible level. The CPO will also assure that they medical staff will make every decision based upon the patient’s best interest. Always.
There will be additional new and innovative positions designed to completely change health care. These positions will all be held by physicians who have demonstrated a selfless commitment to patients and the profession. They must be innovators. Incremental change won’t work. Lastly, they must be courageous. For several decades health care has been shaped and managed by non-physician administrators who now will need to be displaced. Someone will need to help them see how little they actually contribute to the process of delivering health care. They won’t go quietly. There will be an incredible amount of self-preserving rhetoric. Keep the focus on patients, quality and care and the good guys will persevere.
The new C-Suite will meet regularly with community members to receive feedback and assure that the new model is meeting the needs of the people that they serve.
So hopefully a complete change at the leadership level will result in the transformational change in health care that is necessary: The transition from the emphasis being placed on volume to the emphasis being placed on quality with the result being value. This isn’t bad news for everyone currently in the C-Suite. Will keep the CFO. Someone needs to understand how to depreciate equipment 🙂
They don’t understand. They can’t understand. They probably would rather not understand. Health care administrators and managers and insurance executives can’t understand what it is like to provide health care face to face with another human being.
The training of health care administrators, managers and insurance executives is based on spending two years in business school studying topics such as accounting, finance, marketing, human resources and operations management with some electives in an area of concentration as well. The goal of this training is to eventually sell something to someone. The product is irrelevant and the focus is always on the bottom line. Any human interaction is a means to an end.
In comparison, physicians spend a minimum of seven years in training (often more) and in general all but the first two years involve daily contact with other human beings who have a potentially serious health concern. The goal of this training is to deliver quality health care. Human interaction and relationships are the foundation of the profession.
To a business school graduate the product doesn’t really matter. The unit of production is irrelevant. Make as many as you can as cheap as you can and sell them at the highest possible price. Time and people are expenses that ideally are minimized. No time for a relationship in this model. The mentality is that health care can and should be sold and delivered just like any other product or service. In fairness, health care was in need of efficiency however this grind has passed the point of diminishing returns. Cost cutting at the level of care delivery is now compromising the ability to deliver quality health care. And sadly patients and physicians have accepted the current model.
Physicians are well aware that health care can not be managed like any other abstract unit of production. Health care is based on a relationship between a patient and a physician and relationships take time. In addition, the relationship time is usually different for each patient. The training is long and difficult for a good reason.
Alignment is a hot topic right now. Physicians, other providers, hospitals and insurers must all be working together to deliver value focused health care. The adversarial and antagonistic atmosphere that exists must be eliminated before the health care system will improve. Two years of business school, or even a 20 year career in an administrative suite, can not begin to allow a health care administrator or manager to understand what health care is like on the front line of health care delivery. Therefore, HCR is proposing that all administrators, insurers and managers be required to spend time with physicians and other providers. A busy day in the office or operating room. Administrators need to see close-up the human interactions that are such an important part of quality health care and that can not be streamlined like an assembly line. And they need to watch it all as if the patient was one of their own family. Would an administrator who spent the day with a busy oncologist really wonder why he/she can’t see 5 more patients a day after watching him/her spend 45 minutes with a young mother just diagnosed with cancer?
And maybe to be fair health care administrators and insurance executives can have a “Bring Your Doctor to Work Day”. Guess is that providers would be able to review with them all of the people and processes that cost money and do nothing to make care better.
With little fanfare or media coverage the 2013 Fantasy Health Care Draft was held this past weekend. There was great excitement as a sold-out crowd watched every citizen in the United States fill the 10 roster spots for their personal health care teams. The eligible draftee pool was deep. Included were insurance executives, hospital and health care system administrators, politicians, health care quality leaders, drug company and medical device executives and many others who walk around hospitals in nice clothes. Oh, and their were physicians and nurses as well. The draft order was derived via a lottery system. Parents made roster choices for their children under 18. Each draftee could be on multiple rosters as the number of citizens far out numbered the draftees. As expected, there was a significant amount of pre-draft maneuvering to obtain a higher position in the draft order. Based on some early surveys the people of the US apparently spend a great deal of time doing research in the hopes of assembling a winning team.
The expectations were high for the potential draftees in the newly created accountable care organization executives. Also expected to do well were those who have never practiced medicine a day in their lives but who tell those who do provide care how to do it better; the health care quality people. The festivities began with a video presentation of the history of the health care system in the United States. This was followed by another video that demonstrated how the Affordable Care act has been terribly politicized. Finally at 9:00 am the first citizen came to the microphone and made their first roster addition. It was a primary care physician. One after another the people of the US came to the podium and 313 million people later every first round choice was a primary care physician. As the draft moved through rounds 2-10 the anxiety among the non-provider draftees became evident. The citizens of the US filled their rosters with various specialist physicians, nurses and other providers such as chiropractors, physical therapists, nutritionists and even EMS personnel.
At the conclusion of the draft after no non-provider personnel were drafted a formal complaint was filed on behalf of all non-providers questioning the integrity of the draft and the sanity of the American public. A full investigation will be carried out and a report is expected within the next few months.