“What we need is Not health insurance,” Dr, Atul Gawande declared at the Families USA conference in Washington D.C. earlier today. “What we need is health care.”
Gawande, who is the author of Complications: A Surgeon’s Notes On An Imperfect Science, went on to make the point that, “even if a person is on Medicare, that doesn’t mean that he is getting healthier.”
What is fundamentally flawed about our system, he added, is that no one is responsible for making sure that healthcare will be better next year than it is this year. “In 1996,” he pointed out, “Americans underwent some 60 million surgeries. In 2008, that number rose to 100 million. Does that mean that Americans are healthier?” he asked. Or does it simply mean that we are paying for more unnecessary surgeries? “No one knows,” said Gawande, “because we never measure how well our healthcare system is performing.”
“We need a Federal Health Board,” Gawande observed, and it should be measuring our system every three months. “Are people in Springfield, Massachusetts getting healthier? We need to know so that
we can experiment and innovate” in an effort to improve the way we deliver care. If we don’t measure, we can’t know if we are making progress.
Gawande argues that health care reform will be meaningful only if we develop a system that holds health care providers responsible for making care better, safer, and less costly.
How do we make healthcare less expensive? “The levers are ugly,” Gawande admitted when talking to a small group following his speech. “We can pay doctors and hospitals less; or we can get them to reduce waste”—i.e . eliminating some of those unnecessary surgeries.
“If someone had arthritis in their hip, we used to treat it with aspirin,” Gawande noted. “Now we do hip replacement surgery” that can cost tens of thousands of dollars.
Is the patient better off? Recovery from hip replacement surgery is not easy. In some cases, probably a combination of aspirin and physical therapy might be a equally effective. How often are these surgeries necessary? No one knows (.Though we do know that when patients are given full information about the side-effects, risks and benefits of joint replacement, and a chance to share in the decision-making processpatients decide against the elective procedure 20 percent to 30 percent of the time.)
This is why “we need a Federal Health Board”, says Gawande, “to hold us [hospitals and doctors] responsible for what we do. It doesn’t have to be a board structured like the Federal Reserve,” he adds. It could be the Secretary of Health and Human Services. Or it could be a National Institute of Health Delivery. However it is structured, we need someone measuring productivity in our health care system.
As I explained in an earlier post, we know that productivity in our healthcare system is very low because we over-use advanced medical technologies (a category which includes cutting-edge drugs, devices, tests,, treatments and surgical procedures.) In other industries, advanced technologies usually improve productivity. But, too often, we use new and expensive medical technologies on a broad swathe of patients when only a few, who fit a very specific profile, actually benefit. .
Errors also reduce productivity. And here, Gawande notes, something as simple as a checklist can reduce complications following surgery by as much as 30 percent. He pointed to a research done by the World Health Organization’s Safe Surgery Saves Lives program. Gawande is a member of the reserach group and the study, which was published in the most recent issue of the New England Journal of Medicine , focused at non-cardiac surgery in a diverse group of hospitals and revealed that when surgical teams used the 19-item checklist , mortalities fell from 1.5% to 0.8% while inpatient complications dropped from 11.0% to 7.0%.
From now on the checklist will be used in a relatively small group of U.S. hospitals and surgeons that choose to use it .In the UK and Ireland, by contrast, the checklist will now be in every hospital,” Gawande observes. The UK has a “health board”: the National Health Service sets guidelines. By contrast, our laissez faire health care system leaves every hospital and every doctor to practice medicine as they see fit.
In the U.S., only well-organized integrated multi-specialty health care centers like Kaiser or the Mayo Clinic can move quickly to put a checklist in place, Gawande observes. When physicians work for Kaiser on salary, they follow its evidence- based rules.
Gawande points out that Kaiser became the first health care system in the world to reduce deaths from cardiac disease to a point that this disease is longer the #1 killer among its patients . How did Kaiser do it? By instituting a system that guarantees that every cardiac patient is offered the care or drugs that he needs. Checklists work.
At this point, I asked Gawande a question: “You point out that the VA practices evidence-based medicine and, as a result, achieves better outcomes than fee-for-service Medicare, while costing 30% less than Medicare. Yet, when people talking about setting up a public sector health care plan, they speak of creating “Medicare for All”. Why not open up the VA to everyone? We have good evidence that patients would be getting better care. The only downside,” I added, “is that patients would be confined to the VA network of doctors. But is it really worth spending 30 percent more so that people are free to choose doctors and hospitals that don’t practice evidence-based medicine?”
Gawande agreed: the VA –for- all might well be an excellent idea. But how could it be implemented? For one, not everyone lives close to a VA hospital.
I suggested that a National Health Plan might make the VA one option, alongside “Medicare for All” and tightly regulated private insurance plans. Patients could choose whichever model they preferred. But since the VA can offer better care for less, the premiums, deductibles and co-pays under the VA system would be lower—encouraging patients to choose the VA model if it were convenient. Gawande, who has practiced medicine within the VA as well as in the private sector, liked the idea. “Most people don’t realize how successful the VA is,” the Harvard-trained surgeon observed.
“Giving people more choices is a good idea. Then we’ll have a chance to see which delivery system works best. When I was practicing in a VA hospital,” Gawande added, I was performing surgeries in Boston and our catchman extended all the way to Northern Maine. Vets had a choice; they could go to a private hospital in Maine, or talk the bus all the way down to Boston. Many chose to take the bus.” Vets know how good VA care can be. And, if the VA were fully funded—the way it was under the Clinton administration—and expanded to accommodate non-veterans, it might indeed be a very good public sector option.
If the insurance industry doesn’t persuade Congressional conservatives to block a public-section health care plan. In my next post I will explain why Families USA Director Ron Pollack believes that, at this point, the biggest, and most intractable difference between the for-profit insurance industry and progressive reformers revolves around the question of whether private insurers should be forced to compete with a public sector health plan.