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Quote of the Month
"A great leader's courage to fulfill his vision comes from passion, not position."
John Maxwell
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10 Steps to Better Health Care
By
ATUL GAWANDE, DONALD BERWICK, ELLIOTT FISHER and MARK McCLELLAN
We have reached a sobering point in our national health-reform debate. Americans have recognized that our health system is bankrupting us and that we have dealt with this by letting the system price more and more people out of health care. So we are trying to decide if we are willing to change - willing to ensure that everyone can have coverage. That means banishing the phrase "pre-existing condition." It also means finding ways to pay for coverage for those who can't afford it without help.
Both of these steps stir heated argument, not to mention lobbyists' hearts. But what creates the deepest unease is considering what we will have to do about the system's exploding costs if pushing more people out is no longer an option. We have really discussed only two options: raising taxes or rationing care. The public is understandably alarmed.
There is a far more desirable alternative: to change how care is delivered so that it is both less expensive and more effective. But there is widespread skepticism about whether that is possible.
Yes, many European health systems have done it, but we are not Europe. And evidence that places like the Mayo Clinic in Minnesota or the Cleveland Clinic are doing it is likewise dismissed because their unique structures (for example, their physicians work on salary rather than being paid for each service) make them seem as far from Middle America as Sweden is.
Yet in studying communities all over America, not just a few unusual corners, we have found evidence that more effective, lower-cost care is possible.
To find models of success, we searched among our country's 306 Hospital Referral Regions, as defined by the Dartmouth Atlas of Health Care, for "positive outliers." Our criteria were simple: find regions with per capita Medicare costs that are low or markedly declining in rank and where federal measures of quality are above average. In the end, 74 regions passed our test.
So we invited physicians, hospital executives and local leaders from 10 of these regions to a meeting in Washington so they could explain how they do what they do. They came from towns big and small, urban and rural, North and South, East and West. Here's the list: Asheville, N.C.; Cedar Rapids, Iowa; Everett, Wash.; La Crosse, Wis.; Portland, Me.; Richmond, Va.; Sacramento; Sayre, Pa.; Temple, Tex.; and Tallahassee, Fla., which, despite not ranking above the 50th percentile in terms of quality, has made such great recent strides in both costs and quality that we thought it had something to teach us.
If the rest of America could achieve the performances of regions like these, our health care cost crisis would be over. Their quality scores are well above average. Yet they spend more than $1,500 (16 percent) less per Medicare patient than the national average and have a slower real annual growth rate (3 percent versus 3.5 percent nationwide).
Caveat: Because we relied on Medicare data for our selections, it is possible that some of these regions are not so low-cost from the viewpoint of non-Medicare patients. But overall data strongly suggest that most of these regions are providing excellent care for all patients while being far more successful than others at not overusing or misusing health care resources.
So how do they do that? Some have followed the Mayo model, with salaried doctors employed by a unified local system focused on quality of care: these include Temple, where the Scott and White clinic dominates the market, and Sayre, where the Guthrie Clinic does. Other regions, including Richmond and Everett, look more like most American communities, with several medical groups whose physicians are paid on a traditional fee-for-service basis. But they, too, have found ways to protect patients against the damaging incentives of a system that encourages fragmentation of care and the pursuit of revenues over patient needs.
The physicians and hospital leaders from Cedar Rapids told us how they have adopted electronic systems to improve communication among physicians and quality of care. Last year, they decided to investigate the overuse of CAT scans. They examined the data and found that in just one year 52,000 scans were done in a community of 300,000 people. A large portion of them were almost certainly unnecessary, not to mention possibly harmful, as CAT scans have about 1,000 times as much radiation exposure as a chest X-ray.
"I was embarrassed for us," said Jim Levett, a cardiac surgeon and the head of a large physician group. More important, the area's doctors and clinics are turning that embarrassment into change by seeking out solutions to reduce the expense and harm of unnecessary scans.
That number of scans in Cedar Rapids may seem shocking, but there is nothing surprising about it. Nationwide, we do 62 million CAT scans a year for 300 million people. So Cedar Rapids's rate was actually better than average. But all medicine is local. And until a community confronts what goes on in its own population - to the point of actually seeking the data and engaging those who can solve the problem - nothing will change.
The team from Portland told us of a collaboration of doctors, state officials, insurers and community leaders to improve care. For more than four years, physicians have been tracking some 60 measures of quality, like medication error rates for their patients, and meeting voluntary cost-reduction goals.
Asheville, after gaining state support to avoid antitrust concerns, merged two underutilized hospitals. In Sacramento, a decade of fierce competition among four rival health systems brought about elimination of unneeded beds, adoption of new electronic systems for patient data and a race to raise quality. Sacramento also went from being one of America's high-cost areas for health care to being among the low-cost elite.
In their own ways, each of these successful communities tells the same simple story: better, safer, lower-cost care is within reach. Many high-cost regions are just a few hours' drive from a lower-cost, higher-quality region. And in the more efficient areas, neither the physicians nor the citizens reported feeling that care is "rationed." Indeed, it's rational.
Many in Congress and the Obama administration seem to recognize this. The various reform bills making their way through the process have included provisions to protect successful medical communities by incorporating payment approaches that reward those that slow spending growth while improving patient outcomes. This is the right direction for reform.
There is a lot of troubling rhetoric being thrown around in the health care debate. But we don't need to be trapped between charges that reforms will ration care and doing nothing about costs and coverage. We must instead look at the communities that are already redesigning American health care for the better, and pursue ways for the nation to follow their lead.
Atul Gawande directs the Center for Surgery and Public Health at Brigham and Women's Hospital in Boston and is a staff writer at The New Yorker; Donald Berwick is the president of the Institute for Healthcare Improvement in Cambridge, Mass.; Elliott Fisher directs policy-reform efforts at the Dartmouth Institute for Health Policy and Clinical Practice; and Mark McClellan is the director of health care reform policy at the Brookings Institution. All are physicians.
August 13, 2009
Op-Ed Contributors
NYT
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"The most powerful weapon on earth is the human soul on fire."
- Field Marshal Ferdinand Foch
"One person with passion is better than forty people merely interested."
- E. M. Forster
"The achievement of excellence can occur only if the organization promotes a culture of creative dissatisfaction."
- Lawrence Miller
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GOT PASSION?
Quality improvement takes something, something special which all too often is in short supply in the executive suite of your local hospital. What could it be - physicians, nurses, equipment? Well, it could be any of those things, but the shortage I'm worried about is passion, a shortage of passion!
In my work I have seen hospital board members become complacent, sometimes even about concrete things like a replacement hospital and clinic. In one conversation with a physician leader he said something like: "this new facility is desperately needed, it's a once in a lifetime opportunity." Then he paused and said: "I don't think it will ever happen." He certainly didn't have the passion to push the issue. In this case he was correct, but fortunately only for a few years. Hospital and physician leadership changed and the new facility was completed 5 years later.
In the last several years I have witnessed a more distressing passion shortage... a shortage of passion about clinical and service quality. Too often leadership of healthcare organizations seem satisfied with not being any worse than "the other guys."
Quality improvement and quality management requires more than data gathering and analysis, it requires leadership, behavior modeling, transparency and a real passion about providing great care and great customer service - not just most of the time, but every day, for every patient!
Front line staff and all employees want to work in and for high quality, high service organizations that deliver consistent, compassionate care that they can be proud of. They also want leaders who are passionate about delivering that kind of care.
"Every man is proud of what he does well; and no man is proud of what he does not do well. With the former, his heart is in his work; and he will do twice as much of it with less fatigue. The latter performs a little imperfectly, looks at it in disgust, turns from it, and imagines himself exceedingly tired. The little he has done, comes to nothing, for want of finishing."
- Abraham Lincoln
September 30, 1859 in Address before the Wisconsin State Agricultural Society
Passion for the best possible outcomes must reach all the way to the board room. Board members must do all they can to help create transparent organizations where the question is "how can we make it better?" not "how do we punish errors?" Board members must have a clear understanding of where their organization ranks in comparison to world class providers. They must also understand their organization's improvement plans. Does the hospital have a systematic, measurable, organization-wide approach that involves all employees and physicians? What issues are currently being worked on? What are the biggest challenges we face?
When I meet one-on-one with healthcare front-line staff I often hear that one of their concerns is that there is a lack of accountability in their organization and lack of accountability is one form of a lack of passion. They are generally referring to their fellow employees, but lack of accountability may also apply to the board of directors. As we all know, the Board is ultimately responsible for the quality of care. If only that realization created passion! Let's get some and soon!
Ken
PS Thanks to all of you who emailed me about the August topic: healthcare reform. I received more emails than anything else I've talked about in the last 18 months. To continue that discussion I encourage you to review this month's articles. Perhaps they will generate some passion in you!
PS #2 Do read the final article "Congress Deadlocked" from the Onion. It was written as a joke, but I think it's all too true.
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A 12 Point Plan for Health Care Reform
As a former executive with a major health insurer in Wisconsin, I have thought for many years what I would do if I was asked to reform health care in the United States. In my role as a communicator and lobbyist for this organization, I've explored the points-of-view of providers, insurers, legislators, regulators and patients. I've concluded that any reform legislation need not be 3,200 pages. There are plenty of "best practices" to explore and incorporate in any reform plan. Also, much of this need not be legislated. Just rely on the best resources of the private and public sectors in using common sense in attacking reform.
I don't think we need to "blowup" the current system. It does need work, and is not perfect by any means. My 12-point plan is based on years of observation of how the system works and how it could be improved. I've worked in upper management of a major health insurer and two of Wisconsin's larger hospitals. During the past 20 years, I've also consulted with many fine funders and providers of health care, and have been a patient myself. Some of my points may be considered unconventional, and not in the mainstream of thinking of current health insurers. For what it is worth, here are my thoughts.
First, revise medical liability laws to make them more realistic so more medical students are attracted to the primary care specialties of family practice, pediatrics and internal medicine.
Currently, malpractice insurance for these specialties is excessive, and may deter students from pursuing these specialties.
Second, to improve competition and lower prices, remove the current provision that we may only purchase health insurance licensed by the state in which we live. Set national standards for health insurance and let us purchase plans anywhere in the United States.
Third, self-insured (ERISA) plans do not have to include state mandated benefits, although many do. Let the individual or employer purchasers have the same freedom to select a plan free of some or all of the state's mandated benefits such as chiropractic, AODA, birthing services, acupunture, etc. Premium costs could be reduced substantially.
Fourth, go back to a community/age-rated system popular with some plans 30 or 40 years ago. Premiums would be based on the community's providers actual charges. Comparisons could be made to other communities' charges by employer and individual purchasers. These purchasers couldput pressure on local providers to accept best practices and qualitiy initiatives from the lower-cost communities to reduce costs
Fifth, insurers must remove the pre-existing condition provision and include that risk in the community/age rating system of determining premium. This could provide incentives for communities to initiate and support well city/community health programs aimed at reducing utilization.
Sixth, hospitals need to develop a better triage system for people, especially the uninsured, who present themselves for care at emergency rooms. Only true emergencies should be treated there. Work with all levels of government to set-up 24-hour clinics down the hall or next door to treat the non-emergent patients at a much reduced cost. Today the cost of care for these patients is often passed on to the people who have insurance, thus raising their premiums.
Seventh, many of our non-insured are illegal immigrants. Have the State Department explore ways to work with the offending countries who allow their citizens who enter our country illegally to take more fiscal responsibility for their lack of emigration enforcement. Perhaps a substanial reduction in foreign aid to those countries could be rerouted to help pay for illegal immigrant health care. This is a very controvertial area, so much thought needs to be considered in how to do this. The current system is not working.
Eighth, develop a better tax incentive program which encourages all individuals to purchase health insurance. Have the tax benefit based on the annual income of the health insurance purchasers, with better tax benefits for lower income individuals.
Ninth, develop premium lowering incentives for people who show marked improvement in their health like weight loss, lower blood pressure, blood sugar, smoking cessation. Do not continue to punish people for past health care sins with higher premiums if they make positive changes.
Tenth, another "must do" for reform is the development of an easily transportable and easily updated electronic medical record system. This alone, could save hundreds of millions of dollars in duplicative or unnecessary tests each year. (A friend of mine is in the process of trying to patent and market these flash drive-type devices for your keychain or in a credit card format).
Eleventh, as a condition of getting health care coverage, each individual should have to register his or her advanced directives for end stage of life health care. The family anxiety and waste in the area are staggering. This would go a long way to provide ethical health care in the final stages of a person's life.
Twelfth, take personal responsibility for your own health and the health of your loved ones.
The resources are all around you. Take advantage of them and you will lead a longer, healthier and happier life.
Alan L. Gaudynski
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Paging Dr. Reform
By David Ignatius
Thursday, August 20, 2009
Reading the transcripts of President Obama's "town hall meetings" this month on heath-care reform is painful. He's preaching the right gospel, but the parishioners are getting restless. The harder he tries to sell his program, the louder and angrier the debate gets -- and the more the general public tunes out the politicians.
It reminds me of the polarizing Iraq debate of several years ago. Forgive the analogy between war and health care, but maybe Obama needs the medical equivalent of a Gen. David Petraeus -- that is, a professional who can break through the political chaff and describe a strategy for reform that can unite the country.
I have a nomination for the medical commander role, and it won't surprise anyone who follows this issue: Dr. Denis Cortese, the chief executive of the Mayo Clinic. He's already doing what the nation needs -- that is, providing high-quality health care at relatively low cost. Every time I listen to Cortese explain what's wrong with the system, I have the same reaction: Let him and other smart health professionals lead us out of the political morass.
Talking to Cortese this week, I heard two themes that cut to the heart of the debate. First, he thinks Obama has made a mistake in moving toward the narrower goal of "health insurance reform" when what the country truly needs is health system reform. Imposing a mandate for universal insurance will only make things worse if we don't change the process so that it becomes more efficient and less costly. The system we have is gradually bankrupting the country; expanding that system without changing the internal dynamics is folly.
Second, Cortese argues that reformers should stop obsessing over whether there's a "public option" in the plan. Yes, we need a yardstick for measuring costs and effectiveness. But we should start by fixing the public options we already have.
Cortese counts six existing public options that should be laboratories for reform: Medicare, with its 45 million patients and a fee-for-service structure that all but guarantees bad medicine; Medicaid, with an additional 34 million beneficiaries; military medicine, through which government doctors deliver state-of-the-art care; the Department of Veterans Affairs, which has improved performance at its hospitals by embracing new technology; the "Tricare" insurance plan for military retirees; and the Federal Employees Health Benefits Program.
Adding a new public option for insurance, as congressional reformers are demanding, would be useful. But it's not necessary now, and it is creating a poisonous debate that's undermining the more important reforms -- which are in the delivery system, not insurance.
If liberals really want to show they are serious, they should begin with our existing single-payer behemoths, Medicare and Medicaid. Cortese argues that the White House should mandate that, within three years, these programs will shift from the current fee-for-service approach to a system that pays for value -- that is, for delivering low-cost, high-quality care. If doctors performed unnecessary tests that ballooned costs, their compensation would be reduced. And doctors would be compensated by regional formulas, to encourage them to work cooperatively in local networks where they could all make more money by practicing better medicine.
What difference would such Medicare reform make? Take a look at estimates prepared by the Dartmouth Institute for Health Policy and Clinical Practice (which developed the national "health atlas" that was the basis for the widely read New Yorker article by Dr. Atul Gawande). At current spending rates, Medicare will run a $660 billion deficit by 2023. But by cutting the annual growth in per-capita spending from the current national average of 3.5 percent to 2.4 percent (the rate in San Francisco, for example), Medicare could save $1.42 trillion and post a big surplus.
This "pay for value" approach would amount to a cultural revolution in American health care. It would take our bloated system and make it cheaper and better. The adjustments wouldn't be easy, and the medical profession would balk unless respected doctors such as Cortese led the way.
Obama has been campaigning furiously in this crazy summer of bogus debates about "death panels," but he's losing traction. Reformers aren't helping by drawing a false line in the sand over a "public option" when we already have one, in Medicare, that provides a laboratory for systemic change. I hope that Obama understands that his health plan is in mortal danger -- and that it's time to call for the doctor.
davidignatius@washpost.com |
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Congress Deadlocked Over How To Not Provide Health Care
WASHINGTON-After months of committee meetings and hundreds of hours of heated debate, the United States Congress remained deadlocked this week over the best possible way to deny Americans health care.
"Both parties understand that the current system is broken," House Speaker Nancy Pelosi told reporters Monday. "But what we can't seem to agree upon is how to best keep it broken, while still ensuring that no elected official takes any political risk whatsoever. It's a very complicated issue."
"Ultimately, though, it's our responsibility as lawmakers to put these differences aside and focus on refusing Americans the health care they deserve," Pelosi added.
The legislative stalemate largely stems from competing ideologies deeply rooted along party lines. Democrats want to create a government-run system for not providing health care, while Republicans say coverage is best denied by allowing private insurers to make it unaffordable for as many citizens as possible.
"We have over 40 million people without insurance in this country today, and that is unacceptable," Sen. Orrin Hatch (R-UT) said. "If we would just quit squabbling so much, we could get that number up to 50 or even 100 million. Why, there's no reason we can't work together to deny health care to everyone but the richest 1 percent of the population."
"That's what America is all about," he added.
House Minority Leader John Boehner (R-OH) said on Meet The Press that Republicans would never agree to a plan that doesn't allow citizens the choice to be denied medical care in the private sector.
"Americans don't need some government official telling them they don't have the proper coverage to receive treatment," Boehner said. "What they need is massive insurance companies to become even more rich and powerful by withholding from average citizens the care they so desperately require. We're talking about people's health and the obscene profits associated with that, after all."
Though there remain irreconcilable points, both parties have reached some common ground in recent weeks. Senate leaders Harry Reid (D-NV) and Mitch McConnell (R-KY) point to Congress' failure to pass legislation before a July 31 deadline as proof of just how serious lawmakers are about stringing along the American people and never actually reforming the health care industry in any meaningful way.
"People should know that every day we are working without their best interests in mind," Reid said. "But the goal here is not to push through some watered-down bill that only denies health care to a few Americans here and a few Americans there. The goal is to recognize that all Americans have a God-given right to proper medical attention and then make sure there's no chance in hell that ever happens."
"No matter what we come up with," Reid continued, "rest assured that millions of citizens will remain dangerously uninsured, and the inflated health care industry will continue to bankrupt the country for decades."
Other lawmakers stressed that, while there has been some progress, the window of cooperation was closing.
"When you get into the nuts and bolts of how best not to provide people with care essential to their survival, there are many things to take into consideration," Rep. Michele Bachmann (R-MN) said. "I believe we can create a plan for Americans that allows them to not be able to go to the hospital, not get the treatment they need, and ultimately whither away and die. But we've got to act fast."
For his part, President Barack Obama claimed to be optimistic, even saying he believes that a health care denial bill will pass in both houses of Congress by the end of the year.
"We have an opportunity to do something truly historic in 2009," Obama said to a mostly silent crowd during a town hall meeting in Virginia yesterday. "I promise I will only sign a clear and comprehensive health care bill that fully denies coverage to you, your sick mother, her husband, middle-class Americans, single-parent households, the unemployed, and most importantly, anyone in need of emergency medical attention."
"This administration is committed to not providing health care," Obama added. "Not just for this generation of Americans, but for many generations to come."
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