Sunday, Boston Surgeon Dr. Atul Gawande spoke at the New Yorker Festival about the importance of a hospital being able to “Rescue Success from Profound Failure.” (Long-time Health Beat readers will recognize Gawande as the author of Complications: A Surgeon’s Notes On An Imperfect Science, The Checklist Manifesto and a number of brilliant New Yorker articles that I have written about in the past, including: “Letting Go: What Should Medicine Do When it Can’t Save Your Life?”, “It Will Take Ambition It Will Take Humility,” and “The Fight for the Soul of American Medicine” (Hat-tip to the New Yorker for publishing so many stellar articles illuminating an extraordinarily complicated subject: healthcare and healthcare reform.)
Before Gawande’s talk began, IBM, the event’s sponsor, hosted a small breakfast where Gawande spoke informally to a group of doctors, health plan executives, hospital administrators and people from IBM who are in the vanguard of healthcare reform. The New Yorker was kind enough to invite me to attend the breakfast and blog about the conversation.
Less Expensive Medical Care Can Mean Better Care
At Sunday’s breakfast Gawande began by observing that “in just the past four or five years we have seen a huge shift in the national conservation about health care.” Since 2007 or 2008 many have come to realize that when it comes to medical care in the U.S., “there is no direct relationship between the amount of money spent and positive results.” In other words, although we spend twice as much as many other developed countries on health care, medical care in the U.S. is not twice as good. In some ways it is worse.
Yet this epiphany is not as discouraging at it sounds. As Gawande pointed out, “Recognizing that expensive care does not necessarily equal top-quality care has enabled a decoupling of the two issues in the public mind, and opened up the possibility for real beneficial change in the system. The Affordable Care Act’s goal” of securing high quality care for everyone is, in fact, affordable. “We don’t have to ration care.”
For more than two decades, the researchers at Dartmouth have been telling us that when it comes to healthcare, higher quality and lower costs go hand in hand. And for years, both doctors and patients have resisted the counter-intuitive message that “more care” and more “expensive, intensive care” is not necessarily “better care.” Nevertheless, Dartmouth’s studies offer hard evidence: at our best hospitals outcomes are better because doctors practice what some call “lean medicine.” The Mayo Clinic in Rochester Minnesota illustrates how an efficient healthcare delivery system works: care is coordinated; caregivers communicate with each other. As a result, patients see fewer specialists; they undergo fewer unnecessary tests and procedures; diagnoses doesn’t take as long; there are fewer preventable errors; patients spend fewer days in the hospital and are less likely to be readmitted. Outcomes are better; both patient and physician satisfaction is higher, and the final bill is lower.
But Gawande points out: most Americans are not lucky enough to receive integrated care. “Many people of advanced age can have as many as eight specialists, none of whom talk to each other, resulting in duplication of effort (multiple and redundant testing, for example) and tremendous expense.” Under reform, he explained, this will change. “The doctor” will be replaced by a “medical team” that diagnoses and treats “the whole person” working together, “advising a course of treatment and monitoring results.” From the audience, a representative of the Veterans Administration spoke up to say that already, the VA has begun to change how the organization treats patients, “with primary care teams reviewing caseloads instead of single physicians.” This is the collaborative care that we need.
Rethinking the Goals of a Hospital
Toda, the idea that there is too much waste in our health care system has not “filtered down to day-to-day practice,” Gawande acknowledged. Even at Brigham and Women’s Hospital, where he practices, administrators are distressed when their operating rooms are not full. If physicians perform fewer operations, profits fall. Of course fewer surgeries may mean that doctors are advising patients to try medications or a change of diet before going under the knife. As Gawande and others have explained, too many U.S. patients undergo unnecessary procedures that put them at risk– without benefit.
Yet most hospital CEO’s still believe that it is their job to grow revenues. Reformers point out that these administrators need to stop thinking of a hospital as a “revenue center,” and instead recognize that in the larger scheme of things,hospitals are “cost centers.” As a society, we do not want our hospital industry to be a growth industry: this we cannot afford.
Nevertheless, when hospitals do less, they lose money. If reform is going to work, we will need to find creative ways to reimburse them so that efficiency doesn’t leave them in the red.
In Massachusetts, “We’re Early Adapters”
In fact, that this is already beginning to happen at Brigham & Women’s, Gawande announced. His hospital’s newest contracts with Medicare, BlueCross, BlueShield and others link financial reward to clinical performance. Rather than being paid for volume (fee-for-service) they are paid for value (better outcomes at a lower cost.) This means that providers are taking on some of the risks that are built nto medical care—an uncertain science shot through with ambiguities. .
As Gawande observed in his most recent New Yorker essay, “Historically doctors have been paid for services, not results. In the eighteenth century B.C. Hammurabi’s code instructed that a surgeon should be paid ten shekels of silver every time he performed a procedure for a patrician—opening an abscess or treating a cataract with his bronze lancet. It also instructed that if the patient should die or lose an eye, the surgeon’s hands be cut off.” But, “apparently the Mesopotamian surgeon’s lobby got this results clause dropped,” Gawande writes. “Since then, we’ve generally been paid for what we do, whatever happens.”
At Sunday’s breakfast he explained that, today, reform aims to “reshape that system.” Under Brigham & Women’s new contracts with insurers, if the hospital “exceeds its cost-reduction and quality-improvement targets” (in other words, if it manages to deliver better care for less), it will share in the savings. But “if it misses the targets, it will lose tens of millions of dollars.” Today “70 percent of our revenues depend on accepting risk,” Gawande confided. “This is a radical shift.”
When it comes to health care reform, Massachusetts is six years ahead of the rest of the country. “We’re early adapters,” Gawande said, smiling. He recognizes that health care reform will require enormous upheaval, and that many will resist change. Nevertheless he seemed delighted to be on the frontlines of a revolution. Indeed, he reported that when one of his colleagues gives talks out-of-state, he begins my telling the audience: “’Hi, I’m from Massachusetts, and I’m from the Future!” (Here, Gawande grins.)
Doctors Begin to Talk About Costs
In the past, doctors rarely focused on the cost of medical treatments. Their mandate was to do the best they could for the patient in front of them. How much that might cost society was not their concern. They were not economists. They were not politicians. They were physicians.
So when Massachusetts’ Attorney General released reports in 2010 and again in 2011, revealing enormous disparities in how much the state’s hospitals charge even for simple procedures “we were surprised,” Gawande told his breakfast audience. http://www.healthbeatblog.com/2012/09/the-third-rail-of-payment-reform-tackling-wide-variations-in-how-much-providers-charge/ Gawande and his colleagues knew little about hopsital pricing. They had no idea that insurers were paying their medical center far more than other, less well known hospitals, simply because Brigham had a brand name, and thus, enjoyed market clout..
(Even before the AG’s reports came out, a Boston Globe investigation revealed that when Dr. James D. Alderman opens a patient’s clogged arteries at MetroWest Medical Center in Framingham, insurers pay the hospital $17,000—not counting the physician’s fee. But when Alderman performs the same angioplasty at Brigham, the hospital receives $24,5000—44 percent more —even though the patient is receiving the same care from the same interventional cardiologist.)
Now, under reform, physicians are being forced to think about the cost of care.. If they don’t, Brigham won’t receive bonuses from insurers for “exceeding its cost-reduction and quality-improvement targets.”
Not long ago “we had a meeting at the hospital to talk about costs,” Gawande reported, adding that this was a first.
There was a reason for the meeting. Recently, the state issued a distrubing report about health care inflation. As I explained not long ago, Massachusetts health care spending per patient rose by 13% in 2008 and 2009, and outlays for physicians and other professional services jumped by 21 percent. Insurers’ total reimbursements rose in part because patients were using more services, but the report noted, “higher prices explained 77 percent of the growth in spending from 2007 to 2008, and 88 percent of the increase from 2008 to 2009.”
Responding to levitating medical bills, last month, Massachusetts became the first state in the nation to pass legislation that aims to cap overall healthcare spending so that it grows no faster than the state’s economy. The target for 2013 is just 3.6 percent. (Nationwide, economists are predicting annual increases of 6.5% over the next few years. )
The law also created an independent Health Policy Commission that is charged with monitoring provider organizations with revenues of $25 million or more. If they are exceeding the targets they will be required to “submit plans for corrective action.” Or, as Gawande put it, “a toothless Commission can wag its finger at us.”
Though, in fact, the law goes a little further than that: the Commission may refer cases to the attorney general if commissioners determine that an organization “has abused its market power.” Meanwhile the tension between providers receiving higher payments and those receiving much less for similar services continues. Clearlyl, the issue has not been laid to rest.
Presumably Brigham called the meeting to open a discussion about becoming more cost-conscious. Physicians were shown charts revealing how much spending on hosipital care has risen in recent years —and how much it is projected to rise unless health care providers “break the curve” of medical inflation Gawande indicated that physicians were less than enthusiastic about reining in healthcare spending.
Twice, he referred to “the Anger in the Room.” Some doctors pointed out that U.S. patients are getting older; this, suggests they will need more care, not less. How can doctors possiblly be expected to put a lid on medical bills? Others argued that new medical technologies always are more expensive: should they be expected to ignore life-saving innovations? From what Gawande said, this seemed to be the tenor of the discussion. The doctors were not embracing the mandate to squeeze some of the waste out of hte system. Nevertheless, he suggested, it was a beginning.
In the past most physicians have insisted that cost just isn’t their problem. Now, however, as we move from payment systems that reward health care providers for volume, to new rules that offer bonuses only if providers can achieve better outcomes for less, both physicians and hospitals will have to think about ways to trim how much it costs to deliver care so that the bills that send to patients and insurers recieve don’t continue to climb. .
Still, one can understand why medical professionals would be upset by the idea of putting the nation’s health care system on a budget. After all, many doctors ask, what is more important than our health? Shouldn’t the wealthiest nation on earth be able to spend whatever a doctor believes is necessary in order to provide the best care possible?
Clearly, Gawande does not agree. He understands that we are health care inflation is out of control: we about to hit a wall. But he did not stand up and pound on the table.
Instead, he quietly made the point that health care is not our only priority. Because we spend so much on medical care we are left with less to invest in other, equally important, areas. Consider education: “Because healthcare is so expensive, we have 35 kids in a classroom,” he noted.
(Two years ago Gawande told an interviewer a story about attending a parent-teacher conference at his son’s school. “I was interested in meeting the new school superintendent and asking him what he was working on. I thought he’d say educational reform, how to restructure the educational system. But what he spends his time on, he said, is healthcare. As a result of property tax reform in Massachusetts, his budget for teachers has been slashed. At the same time, the cost of medical benefits for teachers has risen by 9 percent. What is he to do? . . .
“A little later I was talking to my son’s math teacher. He couldn’t quite remember where my son was. With 35 students in the class and one teacher, my son was disappearing somewhere in the middle.”
Clinicians Need to Become Engineers
Throughout his talk, Gawande emphasized that if we want affordable, higher quality care “we need better systems, and people doing clinical work need to become part of inventing and engineering the systems. Otherwise, it will be done by a software guy.”
“The biggest hurdle is to get people to work together to coordinate car.” .In our fragmented system, many doctors practice solo or in small groups. Working in separate silos, Gagwande noted, they wind up “chasing each other’s faxes.
”What other industry besides medicine still uses fax machines?” he asked. “Doctors on average received 1100 faxes a month.” As every patient knows, many are lost. “But there is no coordinated push for changing inputs,” said Gawande. “ Acceptance of sub-par systems is the biggest problem.
“Doctors have been slow to grasp that the fact that transforming the flow of information can be more lifesaving than any vaccine,” he added. But “there are signs (such as at Cleveland Clinic and in the state of Massachusetts) that doctors are seeing the value of improving information flows.
“Transparency” also is essential Gawande explained. This means making prices transparent—and striving to make infomartion about quality public. Today, he noted, hospitals compete for maternity patients by advertising that they have Jacuzzis. Under reform, a hospital’s infection rates will be published.
At present, “even a doctor doesn’t have much to go on when choosing a hospital,” Gawande recently admitted when writing about picking out a medical center where his mother would have a knee-replacement operation. “A place may have a great reputation, but it’s hard to know about actual quality of care.
“ Unlike some countries, the United States doesn’t a have a monitoring system that tracks joint-replacement statistics. Even within an institution, I found, surgeons take striking different approaches. They use different makes of artificial joints, different kinds of anesthesia, different regimens for post-surgical pain control and physical therapy.”
Standardizing Medicine and the Need for “Hard-Hitting Oversight”
If we want to control both cost and quality, this will have to change, Gawande wrote in the August 13th & 20th issue of the New Yorker. Doctor’s druthers must give way to what we know about what works best. This, means “studying what the best people are doing” (defining “best” in terms of best outcomes) figuring out how to standardize it, and then trying to get everyone to follow suit.”
For his mother, he found a program that had developed a single, default way of doing knee replacements. Not only was his mother’s operation a success, her recovery was extraordinary. “Three days after her operation, she was getting in and out of bed on her own. She was on virtually no narcotic medication. She was starting to climb stairs.”
At the very end of his talk, Gawande declared that if we want better, safer, more affordable care, we are going to need “hard-hitting oversight.” At that point, to my great disappointment, the breakfast ended. It was time for Gawande go across the street and deliver his talk on how hospitals can “Rescue Success from Failure” to the Festival’s larger audience.
“Essentially,” Gawande wrties, “we’re moving from a Jeffersonian ideal of small guilds and independent craftsmen to a Hamiltonian recognition of the advantages that size and centralized control can bring. . . . For the changes to live up to our hopes –lower costs and better care for everyone—liberals will have to accept the growth of Big Medicine, and conservatives will have to accept the growth of strong public oversight.” He makes it clear that government will have to require “transparency about performance and costs, and enact rules and limitation to protect the ordinary citizen.
“Those of us who work in healthcare . . . will have to contend with new protocols and technology rollouts every six months, supervisors and project managers, and detailed metrics on our performance. Patients won’t just look for the best specialist anymore; they’ll look for the best system. Nurses and doctors will have to get used to delivering care in which our own convenience counts for less and the patients’ experience counts for more. “
Coming from a soft-spoken man, these are tough words. Gawande is never strident .He doesn’t raise his voice. But as he puts it, “change is long overdue, and many people recognize that.” He is certain that on the ground, a revolution has begun. There is no turning back.
Gawande ends his essay: “Some will see danger in this. Many will see hope. And that’s probably the way it should be.”