The Cost Conundrum by Atul Gawande, New Yorker (The Power of a Checklist was published there in 2007 by the same author)
I talked to Denis Cortese, the C.E.O. of the Mayo Clinic, which is among the highest-quality, lowest-cost health-care systems in the country. A couple of years ago, I spent several days there as a visiting surgeon. Among the things that stand out from that visit was how much time the doctors spent with patients. There was no churn—no shuttling patients in and out of rooms while the doctor bounces from one to the other. I accompanied a colleague while he saw patients. Most of the patients, like those in my clinic, required about twenty minutes. But one patient had colon cancer and a number of other complex issues, including heart disease. The physician spent an hour with her, sorting things out. He phoned a cardiologist with a question.
“I’ll be there,” the cardiologist said. Fifteen minutes later, he was. They mulled over everything together. The cardiologist adjusted a medication, and said that no further testing was needed. He cleared the patient for surgery, and the operating room gave her a slot the next day.
The whole interaction was astonishing to me. Just having the cardiologist pop down to see the patient with the surgeon would be unimaginable at my hospital. The time required wouldn’t pay. The time required just to organize the system wouldn’t pay.
The core tenet of the Mayo Clinic is “The needs of the patient come first—”not the convenience of the doctors, not their revenues. The doctors and nurses, and even the janitors, sat in meetings almost weekly, working on ideas to make the service and the care better, not to get more money out of patients. I asked Cortese how the Mayo Clinic made this possible.
“It’s not easy,” he said. But decades ago Mayo recognized that the first thing it needed to do was eliminate the financial barriers. It pooled all the money the doctors and the hospital system received and began paying everyone a salary, so that the doctors’ goal in patient care couldn’t be increasing their income. Mayo promoted leaders who focussed first on what was best for patients, and then on how to make this financially possible.
No one there actually intends to do fewer expensive scans and procedures than is done elsewhere in the country. The aim is to raise quality and to help doctors and other staff members work as a team. But, almost by happenstance, the result has been lower costs. [actually the Deming Chain Reaction]
The Mayo Clinic is not an aberration. One of the lowest-cost markets in the country is Grand Junction, Colorado, a community of a hundred and twenty thousand that nonetheless has achieved some of Medicare’s highest quality-of-care scores. Michael Pramenko is a family physician and a local medical leader there. Unlike doctors at the Mayo Clinic, he told me, those in Grand Junction get piecework fees from insurers. But years ago the doctors agreed among themselves to a system that paid them a similar fee whether they saw Medicare, Medicaid, or private-insurance patients, so that there would be little incentive to cherry-pick patients. They also agreed, at the behest of the main health plan in town, an H.M.O., to meet regularly on small peer-review committees to go over their patient charts together. They focussed on rooting out problems like poor prevention practices, unnecessary back operations, and unusual hospital-complication rates. Problems went down. Quality went up. Then, in 2004, the doctors’ group and the local H.M.O. jointly created a regional information network—a community-wide electronic-record system that shared office notes, test results, and hospital data for patients across the area. Again, problems went down. Quality went up. And costs ended up lower than just about anywhere else in the United States.
This approach has been adopted in other places, too: the Geisinger Health System, in Danville, Pennsylvania; the Marshfield Clinic, in Marshfield, Wisconsin; Intermountain Healthcare, in Salt Lake City; Kaiser Permanente, in Northern California. All of them function on similar principles. All are not-for-profit institutions. And all have produced enviably higher quality and lower costs than the average American town enjoys.
Hopefully those that have taken decades to get around to dealing with the health care crisis will listen to these success stories. I can’t understand how people keep saying we can’t afford to create a better health care system. We have the most costly system by far and we have worse result than most other rich economies. It seems we should expect better results for less money. The only way to get as bad results as we do for the huge cost is to keep doing what we are doing (or I suppose choose some option that does even worse than are very bad current system – though that seems a bit unlikely).
Related: Lots of posts on how to fix the health care system in the USA – Measuring the Health of Nations – Change Health Care – articles on improving the health care system – Our Failed Health-care System
Great blog. What is intriguing here is that we as physicians have focused here on the needs of the customer first. Financial incentives and disjointed fiscal incentives exacerbate thesse problems, but the only way to overcome them is to develop a professional culture of mutual trust and respect, the core underpinning of the Toyota Production System. This reflects not only mutual trust and respect for our external customers (patients, payers, hospitals, etc), but our internal customers as well (Why did the cardiologist respond so quickly to his/her colleagues pull for assistance?) Developing a culture first is the key to successful Lean, TPS, Six-sigma type initiatives.
Even more intriguing is the question whether this is only possible in environments where financial incentives are removed as a variable. There seems to be a lot of evidence that this is true (Virginia Mason, Park Nicollet, Mayo, Geisinger), but is it necessary? This seems to me to be somewhat analogous to the question of whether TPS can be implemented in a union environment. Toyota seems to have answered this in NUMMI. Other enterprises with which I have worked are union and the cultural change model appears to be working.
I would challenge our healthcare organizations that employment of physicians is not a necessary step in attaining a continuous improvement, customer first, no defect downstream, mutual trust and respect culture. What is necessary is a committment to cultural change–in the direction identified above by senior administrative and professional leaders. After all, all culture is expertiential. If we don’t demonstrate the culture we desire, every day in all the little things, then we will infact demonstrate the culture we have and get the culture we display. Don Berwick once quoted,”Every process is perfectly designed to get exactly the results it gets.” This couldn’t be truer for our culture. We get exactly the results we display for our employees.
I would greatly appreciate dialog with those who see cultural change as the first process in Operational Excellence rather than a tools based approach that is arguably short lived at best.